Current Concepts in Management of Outlet Obstruction

A. Infantino, R. Bellomo, F. Galanti, L. Pisegna Cerone

Outlet is often characterized by dis- ical defects should always be considered. abling symptoms consisting of the strenuous Incidences of 33% of occult , 1.7% effort to expel stools, a feeling of incomplete of sigmoidocele, and 10% of have been evacuation, rectal tenesmus and a repeated call defecographically demonstrated after a clinical to toilet, digitations, and the necessity of enemas diagnosis of and obstructed and/or suppositories [1]. It is related to multiple [4]. This is very important because of the subse- alterations, variously associated and in different quent different approaches: conservative for degrees, of the organs of the pelvis and per- anismus or surgical intervention for other condi- ineum: rectocele, rectal occult-mucosal or full- tions. thickness prolapse, and enterocele. Synchronous anatomic alterations in the urogynecological sector can also be found: uterine, vaginal, and Rectal Intussusception bladder prolapses [2]. A unique pathophysiolog- ic theory has been suggested but not yet demon- Rectal intussusception is often difficult to diag- strated [3]. As a consequence of the variability of nose. Radiological findings that can be indicative the affected organs, great difficulty in reaching a of rectal intussusception can be found also in diagnosis exists, and the management and treat- healthy people [5, 6]. Even the interpretation of ment of outlet constipation is, to date, far from radiological images is still a controversial issue being standardized. [4, 7–10]. There is open discussion as to whether magnetic resonance imaging (MRI) can add more information than cystocolpodefecography Clinical Conditions [9, 10], which remains the most useful and sim- plest test. Rectocele

Rectocele is the most common anatomical alter- Enterocele ation that can be evidentiated through inspec- tion at straining and combined digital rectal and Enterocele has been found by Mellgren et al. [11] vaginal examinations. The presence of a recto- in 19% of 2,816 defecographies, but it can be visu- cele, however, often does not represent by itself alized at a high rate at straining [12, 13]. By itself, it the cause of the symptoms of obstructed defeca- does not necessarily impair defecation [14]; how- tion. In fact, only when it is larger than 3 cm, ever, the presence of the sigma in the dislocated when barium is entrapped after defecographic Douglas pouch can be a cause of compression of evacuation, in the absence of anismus, can it be the rectum at straining [15]. In any case, when a considered a cause of outlet obstruction. The surgical approach for has association between rectocele and other anatom- been chosen, enterocele must be treated. 404 Benign Anorectal Diseases

Solitary Rectal Ulcer quence, an initial conservative approach has been encouraged: high-fiber diet, biofeedback, and In patients with obstructed defecation, a solitary rehabilitation of the pelvic floor muscles can help rectal ulcer can be diagnosed at a rate ranging to reduce symptoms of outlet obstruction [19, 20]. from 6% to 39%. The symptoms improve signifi- cantly after behavioral therapy consisting of biofeedback and attempts to discourage the use of Rectocele laxatives, enemas, and suppositories. The success rate correlates to an increase of rectal mucosal When it has been demonstrated that the predom- blood flow as a consequence of improved activity inant alteration is the rectocele, repair of the ante- of extrinsic innervations of the rectum [16]. rior rectal wall through the different approaches Growing attention has been paid to the psy- described (transvaginal, perineal, or transanal) chological aspect [17]. Fifty patients (eight with should be performed. We believe that transanal slow-transit constipation, 36 with obstructed techniques are to be chosen for simultaneous defecation, and six with mixed symptoms) were repair of exuberant mucosal or full-thickness rec- given biofeedback training: 70% found biofeed- tal wall [21]. The simplest operation is the back helpful, and 62% improved, irrespective of transanal suture of the anterior rectal wall [22], the type of constipation. The results were related with satisfactory results in more than 80% of to psychological state rather than anorectal tests patients [23]. Depending on the size and in [17]. It has been demonstrated that in patients absence of a large rectal intussusception, Sarles with functional intestinal disorders, modification operation may be carried out and combined with of mucosal blood flow depends on the psycholog- an anterior levatorplasty in case of contextual ical state and autonomic innervations [18]. presence of [24]. Improvement of mucosal blood flow could be sec- Taking into consideration new technologies, ondary to both a better psychological equilibrium rectocele and rectal occult mucosal prolapse may and better autonomic nerve stimulation. be also resected with a GIA stapled with satisfacto- ry short-term results [25]. Transanal stapled pro- lapsectomy and anterior levatorplasty have been Management of Obstructed successfully carried out in a small series with short Defecation follow-up [26]. The stapled transanal rectal resec- tion (STARR) for the treatment of symptomatic Treatment of outlet obstruction is often disap- rectocele was presented in 2002 [27]. After 3 pointing, and many authors reported no encour- months, 30% of patients had no complaints, 40% aging results after surgery [19, 20]. As a conse- had only one to two episodes per month of

a b Section X • Current Concepts in Management of Outlet Obstruction 405

c d

e f

g h Fig. X.1. A 43-year-old woman with obstructed defecation and digital evacuation. Defecography confirmed the presence of a large rectocele associated to a posterior mucosal rectal prolapse (a). Stapler transanal rectal resection (STARR) procedure was performed. Three series of suture were passed through the anterior rectal wall at a distance of 5 cm from the dentate line (b). Anterior rectal bulging (c). The 33-mm circular stapler (PPH-01, Ethicon EndoSurgery) was then introduced for the anterior rec- tal resection (d). Similarly, two series of sutures were passed through the posterior rectal wall (e). Posterior rectal mucosal pro- lapse (f). The stapler was introduced for the second time for the posterior rectal resection (g). At the end of the operation, the rectum appeared unobstructed (h)

obstructed defecation, 13.3% had evacuation only obstruction; however. 4/25 (16%) patients were using laxatives, and 16.6% were unchanged [27]. complicated by the urge to defecate [28]. In a mul- Afterward, a double stapler technique (Fig. X.1) was ticenter study, 90 patients with rectocele and rectal proposed and compared with STARR plus levator- intussusception were treated by performing the plasty: the results were encouraging on outlet same technique. Symptoms of obstructed defeca- 406 Benign Anorectal Diseases tion improved in 90% of patients, but 17.8% of lapse [35, 36]. Among 20 operated patients, after a patients were complicated with fecal urgency, and follow-up of at least 6 months, only 8.3% (1/12) 8.9% complained of incontinence to flatus [29]. In reported fecal incontinence, and 5% of patients a recent paper, preliminary results on seven with preoperative constipation still complained of patients appeared to be promising after treatment outlet obstruction. The negative predictive preop- with the double stapler procedure [30]. erative data were proximal internal prolapse with Nevertheless, some reports have published dis- rectosacral separation at defecography, chronic appointing results for the STARR procedure , fecal incontinence, and major perineal [31–34]. Anismus and neuroticism were related to descent (>9 cm on straining) [35]. The Delorme severe postoperative pain and recurrent obstruct- procedure for the treatment of rectal outlet ed defecation [31]. In another report from four obstruction can be carried out with minimal mor- Italian centers [32], after performing the STARR bidity and short hospital stay, with good function- technique in 65 patients with obstructed defeca- al results and overall patient satisfaction above tion, more than 60% were still on laxatives after 1- 75% [36]. These are the conclusions of a study on year follow-up. Further studies are needed to clar- 34 patients complaining of outlet obstruction con- ify the usefulness and the proper indications of firmed by defecography. Twenty-six patients the STARR procedure [33] because the diffusion of (76.4%) reported good to excellent overall result the technique is, to date, not justified by the crite- after the Delorme procedure, and eight (23.6%) ria of evidence-based medicine [34]. reported fair to poor results. Symptomatic improvement was observed in 89.7% of patients who had incomplete evacuation and in 88.5% of Rectal Prolapse patients with constipation [37]. Our unpublished results demonstrated that in 27 patients selected Perineal Approach on the basis of the criteria reported in Table X.1 (STARR procedure is not included, as it is awaiting Positive results have been reported by using the scientific placing, which makes valid the most Delorme technique for the treatment of rectal pro- appropriate indication [34]), all symptoms signifi-

Table X.1. Selection criteria for the choice of surgery in patients with outlet constipation after failure of conser- vative treatment (Modified from [38])

Procedure Selection criteria

Sarles • Predominance of rectocele (distension >2 cm) • Prolapse 1–10 mm (mainly mucosal and anterior) • Absence of rectoanal dyssynergy • Absence of prolapse of the uterus or vaginal vault or absence of enterocele

Delorme • Predominance of rectal intussusception (>10 mm) •High surgical risk • Absence of prolapse of the uterus or vaginal vault or absence of enterocele •Male

Orr • Ample rectosacral space • Enterocele • Descending perineum >9 cm during straining (at defecography) • Genital prolapse

Frykman-Goldberg • Colonic diverticular disease • Colonic associated constipation (prevalently left at transit-times study) Section X • Current Concepts in Management of Outlet Obstruction 407

a b

c d Fig. X.2. Patient complaining of outlet constipation. Cystocolpodefecography at rest (a), during straining (b), and during evac- uation (c). The isolated mucosa of the rectum during the Delorme procedure in this patient was 18 cm (d)

cantly disappeared or dramatically improved, with complications after the Delorme procedure for a high rate (89%) of patient’ satisfaction and no rectal intussusception is reported to be between relapse evident after a medium follow-up of 30 37% and 38.2 % [37, 38]. In our experience, the months. We believe that these results can be justi- complication rate was 29.6% and consisted of fied because we included only rectal intussuscep- anastomotic substenosis (six patients), acute uri- tion and not overt prolapse for the stringent crite- nary retention (two patients), hemorrhagia (one ria of indication for treatment according to patient), and pelvic abscess (one patient). Only this Sielzneff et al. [38] and for the long, isolated cylin- latter complication required reoperation. der of rectal mucosa excised (from 11 cm to 21 cm) (Fig. X.2). Indeed, one possible causes of relapse Abdominal Approach could be the incomplete dissection of the rectal and, in some cases, sigmoid wall. The good func- It is generally asserted that the abdominal tional results on outlet obstruction are in contrast approach is considered to be the choice for to the reduced rectal compliance after the Delorme patients in health conditions while the perineal procedure for full-thickness rectal prolapse [39]. approach is reserved for older patients or patients In our study, no patients complained of postoper- with compromising health conditions [40]. ative fecal incontinence or urgency, and the symp- Ripstein rectopexy, however, can be performed toms of rectal tenesmus, false call to toilet, or inap- with low mortality and recurrence rate. Increased propriate call for a very little amount of rectal con- constipation is a problem with this procedure, tent, was reduced from 21% to 4% postoperatively especially in patients with internal rectal intus- (p<0.003). In the literature, the incidence of minor susception. In a recent study, the number of bowel 408 Benign Anorectal Diseases movements per week significantly decreased sist, principally, in the reduced occurrence of postoperatively (p<0.001) [41]. The section of rec- relapses and in the best functional results for the tal lateral ligaments has been advocated as a cause complete prolapse of the rectum [61, 62]. of prolonged intestinal transit time that occurs Unfortunately, many studies are not comparable after this operation [42, 43], even if this hypothe- due to the different classifications used, the defini- sis has not been confirmed by a more recent paper tions of success, and for the often short follow-up. [44]. In patients with a solitary rectal ulcer, the In 72 patients with intestinal transit time pro- presence of a rectal intussusception at proctogra- longed on the left side, direct rectopexy and resec- phy seems to be a positive predictive factor for tion rectopexy resulted, at an average follow-up of good surgical outcome after sacral rectopexy [45] 30 months, in an improvement or a recovery in (Fig. X.3). The anatomical correction of rectal 76% of cases and a worsening in 9% of cases [63]. intussusception is obtained in almost 100% of Constipation and symptoms of difficult evacua- cases, but postoperative constipation has been tion have been solved or alleviated in 70% of described in up to 38–47% of patients [46–48]. patients who underwent sacral rectopexy and in Different authors have reported a statistically 64% of those who underwent colonic resection, significant improvement in constipation and both with a laparoscopic approach [64]. In a retro- incontinence after rectopexy and resection of the spective study comparing use of mesh,direct suture, sigma (Frykman-Goldberg technique) associated and resection rectopexy, the latter offered better with a low complication rate [49–51]. An increase functional results,in particular for the improvement in anal resting and squeezing pressure has been of constipation. The use of mesh did not seem to shown and directly correlated to improvement of add any particular advantage [65], even considering continence [51], which was more evident at 6 the incidence of recurrences of prolapse [66]. A months’ follow-up [52]. The incidence of postop- more empiric approach, based on the preoperative erative constipation in patients who underwent clinical evaluation, seems to give a greater guarantee rectopexy with resection of the sigma was of success; in fact, by performing the Wells tech- reduced when compared with rectopexy without nique in patients with fecal incontinence and the resection [50, 53, 54]. resection rectopexy in those with constipation, after The laparoscopic approach in comparison with an average follow-up of 18 months, anal inconti- the laparotomic approach has shown the following nence and constipation improved in 80% and 91% advantages: reduction of postoperative pain and of cases, respectively [67]. minor use of analgesics, reduction of surgical mor- To avoid the posterior dissection of the rectum, bidity, minor aesthetic damage, minor recovery a possible cause of postoperative constipation due time, and earlier return to work [50]. Similar, how- to lesion of the autonomic nerves, an alternative ever,are the results regarding the cure of a complete technique has recently been proposed consisting rectal prolapse. Access via laparoscopy seems to of a ventral rectopexy performed by a laparoscop- have a minor postoperative morbidity of between ic approach [68]. After a medium follow-up of 61 4% and 9% but presents a more prolonged opera- months, 16/19 patients with obstructed defecation tive time, especially during the learning curve [55, resulted asymptomatic and 28/31 incontinent 56]. Recent studies have confirmed that the retro- patients improved significantly their continence. spective [51, 57–59] or prospective comparison However, two patients developed symptoms of between the “open” technique and laparoscopy is in constipation in the postoperative period [68]. Age favor of the latter. In addition, a study on economic had no influence on the functional results impact demonstrated that laparoscopic rectopexy obtained. The results did not differ in patients who in comparison with the open procedure, other than were older or younger than 70 years [69]. giving better clinical results, cost less [60]. The role of the laparoscopic approach for the Combined Repair treatment of rectal prolapse has been studied extensively since the end of the 1980’s but only As already underlined, the combined repair of recently comparative studies with laparotomy con- anterior and posterior perineum is mandatory in sidering the different procedures (direct suture, order to avoid multiple operations with higher use of a mesh, and resection rectopexy) have been risk of complications [70]. Eighty-nine patients conducted. Most of the literature seems to assert underwent combined surgery, and 60 of these that the benefits of the abdominal approach con- patients had a concurrent vaginal repair. Section X • Current Concepts in Management of Outlet Obstruction 409

a b

c d Fig. X.3. A 62-year-old woman afflicted by obstructed defecation. Cystocolpodefecography confirms suspicion of rectoanal intussusception and a large enterocele (a).Videolaparoscopic view of the very deep pouch of Douglas (b). After isolation of the rectum, sparing the hypogastric nerves, the lateral ligaments, and the uterosacral ligaments, the polypropylene mesh is fixed below the sacral promontorium and distally to the lateral wall of the rectum and the posterior vaginal fornix (c). End of the operation after obliteration of the pouch of Douglas by two purse-string sutures (d)

Improvement occurred in all major symptoms, global alteration of intestinal motility, not only and for all patients, this operation provided con- limited to the function of the large bowel [75]. siderable relief of symptoms, with no evidence of Motility alterations can be, at times, identified by recurrence of rectal or vaginal-vault prolapse at anorectal manometry. Rectal hyposensitivity and follow-up [71]. In case of vaginal-vault prolapse or sensory threshold volumes elevated beyond the enterocele, the associated abdominal col- normal range have been found in 33% of patients posacropexy with mesh has a cure rate of 90 % with rectocele, in 40% of rectal intussusception, and a risk of mesh erosion of 3.3% [72–74]. and in 53% of patients with no mechanical obstruction evident on defecography [76]. This suggests that damage to the rectal wall can be Final Considerations associated with, and not only consequential to, rectal intussusception. The not always encouraging results of surgery for In conclusion, medical treatment must be outlet obstruction are probably not linked only to absolutely considered at the beginning: correction problems of technique. The centrality of the prob- of diet, implementation of fiber and water, and lem is not exclusively mechanic but is also, if not biofeedback, along with great attention to the mostly, biological. This is confirmed by the patients’ psychological aspects. Only after the fail- involvement of the psyche [17, 18] and also by the ure of this phase should a workup for the static 410 Benign Anorectal Diseases and dynamic evaluation of organs of the pelvis ineal access is less aggressive and guarantees good and perineum be carried out. If necessary, surgery functional results in selected patients. If abdomi- should be proposed after a clear discussion with nal rectopexy is chosen, the laparoscopic the patient regarding advantages and disadvan- approach seems to offer a greater probability for tages. If it confirmed that there is no overwhelm- faster physical recovery, minor incidence of mor- ing clinical evidence that tends to suggest one bidity and – other than allowing for the repair of form of surgical procedure over another [77], per- some defects of the anterior perineum – costs less.

References 13. Peters WA 3rd, Smith MR, Drescher CW (2001) Rectal prolapse in women with other defects of pelvic floor 1. Keighley MR (1993) Rectal prolapse. In: Keighley MR, support. Am J Obstet Gynecol 184:1488–1494 Williams NS (eds) Surgery of the anus, rectum and 14. Halligan S, Bartram C, Hall C (1996) Enterocele colon. WB Saunders, London, pp 675–719 revealed by simultaneous evacuation proctography 2. Thakar R, Stanton S (2002) Management of genital and peritoneography: does “defecation block” exist? prolapse. BMJ 324:1258–1262 AJR Am J Roentgenol 167:461–466 3. Petros P (2003) Changes in bladder neck geometry 15. Jorge JM, Yang YK, Wexner SD (1994) Incidence and and closure pressure after midurethral anchoring sug- clinical significance of sigmoidoceles as determined gest a musculoelastic mechanism activates closure. by a new classification system. Dis Colon Rectum Neurourol Urodyn 22:191–197 37:1112–1117 4. Thompson JR, Chen AH, Pettit PD, Bridges MD (2002) 16. Jarrett ME, Emmanuel AV, Vaizey CJ, Kamm MA Incidence of occult rectal prolapse in patients with (2004). Behavioural therapy (biofeedback) for solitary clinical rectoceles and defecatory dysfunction. Am J rectal ulcer syndrome improves symptoms and Obstet Gynecol 187:1494–1499 mucosal blood flow. Gut 53:368–370 5. Shorvon PJ, McHugh S, Diamant NE et al (1989) 17. Wang J, Luo MH, Qi QH, Dong ZL (2003) Prospective Defecography in normal volunteers: results and impli- study of biofeedback retraining in patients with cations. Gut 30:1737–1749 chronic idiopathic functional constipation. World J 6. Ihre T (1990) Intussusception of the rectum and the Gastroenterol 9:2109–2113 solitary rectal ulcer syndrome. Ann Med 22:419–423 18. Emmanuel AV, Mason HJ, Kamm MA (2001) 7. Pomerri F, Zuliani M, Mazza C et al (2001) Relationship between psychological state and level of Defecographic measurements of rectal intussuscep- activity of extrinsic gut innervation in patients with a tion and prolapse in patients and in asymptomatic functional gut disorder. Gut 49:209–213 subjects. AJR Am J Roentgenol 176:641–645 19. Felt-Bersma RJ, Cuesta MA (2001) Rectal prolapse, rec- 8. Muller-Lissner SA, Bartolo DCC, Christiansen J et al tal intussusception, rectocele, and solitary rectal ulcer (1998) Interobserver agreement in defecography – an syndrome. Gastroenterol Clin North Am 30:199–222 international study. Zeit Gastroenterol 36:273–279 20. Malouf AJ, Vaizey CJ, Kamm MA (2001) Results of 9. Kelvin FM, Maglinte DD, Hale DS, Benson JT (2000) behavioral treatment (biofeedback) for solitary rectal Female : a comparison of tripha- ulcer syndrome. Dis Colon Rectum 44:72–76 sic dynamic MR imaging and triphasic fluoroscopic 21. Tjandra JJ, Ooi B-S, Tang C-L et al (1999) Transanal cystocolpoproctography. AJR Am J Roentgenol repair of rectocele corrects obstructed defecation if it 174:81–88 is not associated with anismus. Dis Colon Rectum 10. Rentsch M, Paetzel C, Lenhart M et al (2001) Dynamic 42:1544–1550 magnetic resonance imaging defecography: a diagnos- 22. Block IR (1986) Transrectal repair of rectocele using tic alternative in the assessment of pelvic floor disor- obliterative suture. Dis Colon Rectum 29:707–711 ders in proctology. Dis Colon Rectum 44:999–1007 23. Infantino A, Masin A, Melega E et al (1995) Does 11. Mellgren A, Bremmer S, Johansson C et al (1994) surgery resolve outlet obstruction from rectocele? Int Defecography. Results of investigations in 2816 J Colorectal Dis 10:97–100 patients. Dis Colon Rectum 37:1133–1141 24. Ayabaca SM, Zbar AP, Pescatori M (2002) Anal conti- 12. Bremmer S, Mellgren A, Holmstrom B, Uden R (1998) nence after rectocele repair. Dis Colon Rectum 45:63–69 Peritoneocele and enterocele. Formation and transfor- 25. D’Avolio M, Ferrara A, Chimenti C (2005) Transanal mation during rectal evacuation as studied by means rectocele repair using EndoGIA: short-term results of of defaeco-peritoneography. Acta Radiol 39:167–175 a prospective study. Tech Coloproctol 9:108–114 Section X • Current Concepts in Management of Outlet Obstruction 411

26. Altomare DF, Rinaldi M, Veglia A et al (2002) 42. Speakman CTM, Madden MV,Nicholls RJ, Kamm MA Combined perineal and endorectal repair of rectocele (1991) Lateral ligament division during rectopexy by circular stapler: a novel surgical technique. Dis causes constipation but prevents recurrence: results Colon Rectum 45:1549–1552 of a prospective randomized study. Br J Surg 27. Boccasanta P,Venturi M, Cioffi U et al (2002) Selection 78:1431–1433 criteria and long-term results of surgery in symp- 43. Scaglia M, Fasth S, Hallgren T et al (1994) Abdominal tomatic rectocele. Minerva Chir 57:157–163 rectopexy for rectal prolapse. Influence of surgical 28. Boccasanta P,Venturi M, Salamina G et al (2004) New technique on functional outcome. Dis Colon Rectum trends in the surgical treatment of outlet obstruction: 37:805–813 clinical and functional results of two novel transanal 44. Mollen RM, Kuijpers JH, van Hoek F (2000) Effects of stapled techniques from a randomised controlled trial. rectal mobilization and lateral ligaments division on Int J Colorectal Dis 19:359–369 colonic and anorectal function. Dis Colon Rectum 29. Boccasanta P, Venturi M, Stuto A et al (2004) Stapled 43:1283–1287 transanal rectal resection for outlet obstruction: a 45. Nicholls RJ (1991) Internal intussusception: the soli- prospective, multicenter trial. Dis Colon Rectum tary rectal ulcer syndrome. In: Goldberg SM, Madoff 47:1285–1296 RD (eds) Semin Colon Rect Surg 2:227–232 30. Mathur P,Ng KH, Seow-Choen F (2004) Stapled muco- 46. Himpens J, Cadière GB, Bruyns J, Vertruyen M (1999) sectomy for rectocele repair: a preliminary report. Dis Laparoscopic rectopexy according to Wells. Surg End Colon Rectum 47:1978–1980 13:139–141 31. Dodi G, Pietroletti R, Milito G et al (2003) Bleeding, 47. Broden G, Dolk A, Holmstrom B (1988) Recovery of incontinence, pain and constipation after STARR the internal anal sphincter following rectopexy: a pos- transanal double stapling rectotomy for obstructed sible explanation for continence improvement. Int J defecation. Tech Coloproctol 7:148–153 Colorectal Dis 3:23–28 32. Binda GA, Pescatori M, Romano G (2005) The dark 48. Mann CV,Hoffman C (1988) Complete rectal prolapse: side of double-stapled transanal rectal resection. Dis anatomical and functional results of treatment with Colon Rectum 48:1830–1831 extended abdominal rectopexy. Br J Surg 75:34–37 33. Pescatori M, Seow-Choen F (2003) Use and abuse of new 49. Briel JW,Schouten WR, Boerma MO (1997) Long-term technologies in colorectal surgery. Tech Coloproctol 7:1–2 results of suture rectopexy in patients with fecal 34. Jayne DG, Finan PJ (2005) Stapled transanal rectal incontinence associated with incomplete rectal pro- resection for obstructed defaecation and evidence- lapse. Dis Colon Rectum 40:1228–1232 based practice. Br J Surg 92:793–794 50. McKee RF, Lauder JC, Poon FW et al (1992) A prospec- 35. Lechaux JP, Lechaux D, Perez M (1995) Results of tive randomized study of abdominal rectopexy with Delorme’s procedure for rectal prolapse.Advantages of and without sigmoidectomy in rectal prolapse. Surg a modified technique. Dis Colon Rectum 38:301–307 Gynec Obstet 174:145–148 36. Berman IR, Harris MS, Rabeler MB (1990) Delorme’s 51. Huber FT, Stein H, Siewert JR (1995) Functional results transrectal excision for internal rectal prolapse: after treatment of rectal prolapse with rectopexy and patient selection, technique, and three-year follow-up. sigmoid resection. World J Surg 19:138–143 Dis Colon Rectum 33:573–580 52. Schultz I, Mellgren A, Dolk A et al (1996) Continence is 37. Liberman H, Hughes C, Dippolito A (2000) Evaluation improved after the Ripstein rectopexy. Different mech- and outcome of the Delorme procedure in the treat- anism in rectal prolapse and rectal intussusception? ment of rectal outlet obstruction. Dis Colon Rectum Dis Colon Rectum 39:300–306 43:188–192 53. Luukkonen P, Mikkonen U, Jarvinen H (1992) 38. Sielzneff I, Malouf A, Cesari J et al (1999) Selection cri- Abdominal rectopexy with sigmoidectomy vs rec- teria for rectal prolapse repair by Delorme’s transrec- topexy alone for rectal prolapse: a prospective, ran- tal excision. Dis Colon Rectum 42:367–373 domized study. Int J Colorectal Dis 7:219–222 39. Plusa SM, Charing LA, Balaji V et al (1995) Physiologic 54. Jacobs LK, Lin YJ, Orkin BA (1997) The best operation changes after Delorme’s procedure for full-thickness for rectal prolapse. Surg Clin North Am 77:49–71 rectal prolapse. Br J Surg 82:1475–1478 55. Kairaluoma MV, Viljakka MT, Kellokumpu IH (2003) 40. Madiba TE, Baig MK, Wexner SD (2005) Surgical man- Open vs. laparoscopic surgery for rectal prolapse: a agement of rectal prolapse. Arch Surg 140:63–73 case-controlled study assessing short-term outcome. 41. Schultz I, Mellgren A, Dolk A et al (2000) Long-term Dis Colon Rectum 46:353–360 results and functional outcome after Ripstein rec- 56. Ashari LH, Lumley JW, Stevenson AR, Stitz RW (2005) topexy. Dis Colon Rectum 43:35–43 Laparoscopically-assisted resection rectopexy for rec- 412 Benign Anorectal Diseases

tal prolapse: ten years’ experience. Dis Colon Rectum 67. Madbouly KM, Senagore AJ, Delaney CP et al (2003) 48:982–987 Clinically based management of rectal prolapse. Surg 57. Demirbas S, Akin ML, Kalemoglu M et al (2005) Endosc 17:99–103 Comparison of laparoscopic and open surgery for 68. D’Hoore A, Cadoni R, Penninckx F (2004) Long-term total rectal prolapse. Surg Today 35:446–452 outcome of laparoscopic ventral rectopexy for total 58. Lechaux D, Trebuchet G, Siproudhis L, Campion JP rectal prolapse. Br J Surg 91:1500–1505 (2005) Laparoscopic rectopexy for full-thickness rec- 69. Kaiwa Y, Kurokawa Y, Namiki K et al (2004) Outcome tal prolapse: a single-institution retrospective study of laparoscopic rectopexy for complete rectal prolapse evaluating surgical outcome. Surg Endosc 19:514–518 in patients older than 70 years versus younger 59. Rose J, Schneider C, Scheidbach H et al (2002) patients. Surg Today 34:742–746 Laparoscopic treatment of rectal prolapse: experience 70. Nager CW, Kumar D, Kahn MA, Stanton SL (1997) gained in a prospective multicenter study. Management of pelvic floor dysfunction. Lancet 350:1751 Langenbecks Arch Surg 387:130–137 71. Collopy BT, Barham KA (2002) Abdominal colporec- 60. Salkeld G, Bagia M, Solomon M (2004) Economic topexy with pelvic cul-de-sac closure. Dis Colon impact of laparoscopic versus open abdominal rec- Rectum 45:522–526 topexy. Br J Surg 91:1188–1191 72. Timmons MC, Addison WA, Addison SB, Cavenar MG 61. Senagore AJ (2003) Management of rectal prolapse: (1992) Abdominal sacral colpopexy in 163 women with the role of laparoscopic approaches. Semin Laparosc posthysterectomy vaginal vault prolapse and entero- Surg 10:197–202 cele. Evolution of operative techniques. J Reprod Med 62. Solomon MJ, Young CJ, Eyers AA, Roberts RA (2002) 37:323–327 Randomized clinical trial of laparoscopic versus open 73. Fox SD, Stanton SL (2000) Vault prolapse and recto- abdominal rectopexy for rectal prolapse. Br J Surg cele: assessment of repair using sacrocolpopexy with 89:35–39 mesh interposition. Br J Obstet Gynecol 107:1371–1375 63. Bruch HP,Herold A, Schiedeck T,Schwandner O (1999) 74. Visco AG, Weidner AC, Barber MD et al (2001) Vaginal Laparoscopic surgery for rectal prolapse and outlet mesh erosion after abdominal sacral colpopexy. Am J obstruction. Dis Colon Rectum 42:1189–1194 Obstet Gynecol 184:297–302 64. Kellokumpu IH, Vironen J, Scheinin T (2000) 75. Bassotti G, de Roberto G, Sediari L, Morelli A (2004) Laparoscopic repair of rectal prolapse: a prospective Colonic motility studies in severe chronic constipa- study evaluating surgical outcome and changes in tion: an organic approach to a functional problem. symptoms and bowel function. Surg Endosc 14:634–640 Tech Coloproctol 8:147–150 65. Benoist S, Taffinder N, Gould S et al (2001) Functional 76. Gladman MA, Scott SM, Williams NS, Lunniss PJ results two years after laparoscopic rectopexy. Am J (2003) Clinical and physiological findings, and possi- Surg 182:168–173 ble aetiological factors of rectal hyposensitivity. Br J 66. Tsugawa K, Sue K, Koyanagi N et al (2002) Surg 90:860–866 Laparoscopic rectopexy for recurrent rectal prolapse: 77. Bachoo P,Brazzelli M, Grant A (2001) Surgery for com- a safe and simple procedure without a mesh prosthe- plete rectal prolapse in adults (Cochrane Review). In: sis. Hepatogastroenterology 49:1549–1551 The Cochrane Library, 1