Clinical Practice Guidelines for the Treatment of Rectal Prolapse

摘要

STATEMENT OF THE PROBLEM Rectal prolapse is a disorder characterized by a full-thickness intussusception of the rectal wall, which protrudes externally through the anus. It is associated with a spectrum of coexisting anatomic abnormalities, such as diastasis of the levator ani, an abnormally deep cul-de-sac, a redundant sigmoid colon, a patulous anal sphincter, and loss or attenuation of the rectal sacral attachments. Some have hypothesized that the condition is associated with (and preceded by) internal rectal intussusception or a traumatic solitary rectal ulcer, although these associations have never been clearly proven.1–3 Rectal prolapse is rare and is estimated to occur in ≈0.5% of the general population overall, although the frequency is higher in females and the elderly, and women aged ≥50 years are 6 times more likely as men to prolapse.4–6 Although it is commonly thought that rectal prolapse is a consequence of multiparity, approximately one third of female patients with rectal prolapse are nulliparous. The peak age of incidence is the seventh decade in women. Interestingly, although fewer men have the condition, the age of incidence for these men is generally ≤40 years. A striking characteristic of younger patients, both male and female, is an increased tendency to have autism, syndromes associated with developmental delay, or psychiatric comorbidities requiring multiple medications.7 Although rectal prolapse is a benign condition, it can be debilitating because of the discomfort of prolapsing tissue both internally and externally, associated drainage of mucus or blood, and the common occurrence of concomitant symptoms of fecal incontinence, constipation, or both.8 Approximately 50% to 75% of patients with rectal prolapse report fecal incontinence, and 25% to 50% of patients report constipation.9–13 Incontinence in the setting of rectal prolapse may be explained by the presence of a direct conduit (ie, the prolapse), which disturbs the sphincter mechanism, the chronic traumatic stretch of the sphincter caused by the prolapse itself, and continuous stimulation of the rectoanal inhibitory reflex by the prolapsing tissue.14 Up to one half of patients with prolapse demonstrate pudendal neuropathy,15 which may be responsible for denervation-related atrophy of the external sphincter musculature.16 Constipation associated with prolapse may result from intussuscepting bowel in the rectum, creating a blockage that is exacerbated with straining, pelvic floor dyssynergia, and colonic dysmotility, although causality versus correlation remains highly debated.11,12 The goals of surgery to correct rectal prolapse are 3-fold: 1) to eliminate the prolapse through either resection or restoration of normal anatomy, 2) to correct associated functional abnormalities of constipation or incontinence, and 3) to avoid the creation of de novo bowel dysfunction. Multiple operations have been developed to achieve this complex 3-fold goal, each with various strengths and weaknesses underscoring the importance of careful patient selection and thorough patient counseling when choosing a surgical approach. METHODOLOGY These guidelines were built based on the last set of The American Society of Colon and Rectal Surgeons (ASCRS) practice parameters for treatment of rectal prolapse published in 2011.17 An organized search of Medline, PubMed, Embase, and the Cochrane Database of Collected Reviews was performed from October 2011 through December 2016. Retrieved publications were limited to the English language and human participants. The search strategies were based on the concepts of rectal prolapse and internal intussusception as primary search terms. Searches were also performed based on various treatments for rectal prolapse, including rectopexy, suture rectopexy, resection rectopexy, ventral rectopexy, D’Hoore rectopexy, Delorme procedure, and Altemeier procedure. An initial search identified 781 unique citations. These were ultimately categorized