PH Portsmouth Colorectal ACPGBI M62 Meeting Huddersfield April 2005 Perineal Options for Rectal...
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Transcript of PH Portsmouth Colorectal ACPGBI M62 Meeting Huddersfield April 2005 Perineal Options for Rectal...
PHPortsmouth Colorectal
ACPGBI M62 MeetingACPGBI M62 MeetingHuddersfield April 2005Huddersfield April 2005
Perineal Options for Rectal ProlapsePerineal Options for Rectal Prolapse
M.R. Thompson
PHPortsmouth Colorectal
rectal prolapserectal prolapse
non lethal miserable problemnon lethal miserable problem predominantly in the elderlypredominantly in the elderly
PHPortsmouth Colorectal
rectal prolapserectal prolapse
mortalitymortality recurrence raterecurrence rate
~ mucosalmucosal~ full thicknessfull thickness
post-operative functionpost-operative function~ constipationconstipation~ incontinenceincontinence
re-operation ratesre-operation rates
PHPortsmouth Colorectal
rectal prolapserectal prolapse methods of repairmethods of repair
++ resection resection
abdomenalabdomenal laparoscopiclaparoscopic combined with combined with
fixationfixation • anal sphincter repair • anal sphincter repair
• • pelvic floor repairpelvic floor repair AltemeierAltemeier
perinealperineal
Delorme Delorme
PHPortsmouth Colorectal
Altemeier’s procedureAltemeier’s procedure106 cases (19 years)106 cases (19 years)
mortalitymortality 0%0%
morbiditymorbidity 3% (local abscesses)3% (local abscesses)
recurrencerecurrence <3% (3)<3% (3)
functional functional outcomeoutcome
no recordno record
Altemeier Ann Surg 1971
post op
PHPortsmouth Colorectal
Altemeier’s procedureAltemeier’s procedurepre-op preparation (1952)pre-op preparation (1952)
Admitted 7 days preoperativelyAdmitted 7 days preoperatively
Enemas 2 x dayEnemas 2 x day
Liquid or low residue dietLiquid or low residue diet
Sulphonomides or streptomycin etcSulphonomides or streptomycin etc
Hot moist applications to prolapseHot moist applications to prolapse
PHPortsmouth Colorectal
Altemeier’s procedureAltemeier’s procedure63 cases (7 years)63 cases (7 years)(62% day cases)(62% day cases)
mortalitymortality 0%0%
morbiditymorbidity 9.6% (6) anastomotic leak 9.6% (6) anastomotic leak stenosisstenosis
recurrencerecurrence 4.8% (3) (21 months, median)4.8% (3) (21 months, median)
functional functional outcomeoutcome
goodgoodincontinence / constipation incontinence / constipation improvedimproved
post op
Kimmins, Billingham. Dis Colon Rectum 2001
PHPortsmouth Colorectal
Edmond Delorme (1900)Edmond Delorme (1900)
3 young male soldiers3 young male soldiers
1 death1 death 2 good results (11-18 2 good results (11-18 months)months)
““L’étendue de la portion muqueuse à L’étendue de la portion muqueuse à exciser ne peut encore être précisée. exciser ne peut encore être précisée. L’expérience ultérieure nous fixera sur L’expérience ultérieure nous fixera sur ce point d’un intérêt de premier ordre”ce point d’un intérêt de premier ordre”
PHPortsmouth Colorectal
rectal prolapserectal prolapse
type of repairtype of repair mean age mean age yrsyrs
collected Delorme’s seriescollected Delorme’s series 70 - 75 70 - 75
collected abdominal repairscollected abdominal repairs 59 - 65 59 - 65
PHPortsmouth Colorectal
mortalitymortality
type of operationtype of operation incidenceincidence
collected Delorme’scollected Delorme’s 2% (5/250)2% (5/250)
collected abdominal procedurescollected abdominal procedures 0 - 3%0 - 3%
PHPortsmouth Colorectal
recurrencerecurrence
operation typeoperation type mucosalmucosal full full total total
collected Delorme’scollected Delorme’s 0% 0% 13%13% 13% 13%
abdominal proceduresabdominal procedures 8 - 31% 8 - 31% 0 - 3% 12%0 - 3% 12%
PHPortsmouth Colorectal
Delorme’s procedureDelorme’s procedureAuthorAuthor year patients recurrenceyear patients recurrence %%DelormeDelorme 19001900 33 00 0%0%SwintonSwinton 19601960 1919 66 30%30%NayNay 19721972 3434 77 21%21%MoskalenkoMoskalenko 19731973 1010 00 0%0%UhligUhlig 19791979 4444 33 10%10%ChristiansenChristiansen 19811981 1212 22 16%16%MonsonMonson 19861986 2727 22 7%7%AbulafiAbulafi 19901990 2222 11 4%4%SenapatiSenapati 19941994 32#32# 44 12.5%12.5%OliverOliver 19941994 4141 99 22%22%LechauxLechaux 19951995 8585 1111 13.5%13.5%ThompsonThompson 20012001 113*113* 28%* 28%**complete follow up*complete follow up# 75% males# 75% males
PHPortsmouth Colorectal
rectal prolapserectal prolapse
accurate / true recurrence ratesaccurate / true recurrence rates~ needneed
—large serieslarge series—long follow uplong follow up—use Kaplan Meier curves to use Kaplan Meier curves to
measure rate of recurrence measure rate of recurrence
PHPortsmouth Colorectal
probability of no recurrence probability of no recurrence (Kaplan Meier plots)(Kaplan Meier plots)
Time after surgery (months)
14413212010896847260483624120
Pro
babi
lity
of
no-r
ecu
rre
nce
1.0
.8
.6
.4
.2
1°2°
PHPortsmouth Colorectal
Delorme’s operation for rectal prolapseDelorme’s operation for rectal prolapse
50% chance of recurrence free period50% chance of recurrence free period for for patients who survive. patients who survive.
primary operation 91 mths (CI 77-65) 8yrsprimary operation 91 mths (CI 77-65) 8yrs
secondary operationsecondary operation 27 mths (CI 15-39) 27 mths (CI 15-39) 2yrs2yrs
p 0.004 p 0.004
PHPortsmouth Colorectal
correlation of recurrence with correlation of recurrence with length of mucosal resectionlength of mucosal resection
primary operationsprimary operations 14.5cms14.5cms primary recurrencesprimary recurrences 14.0cms14.0cms secondary operationssecondary operations 10.0cms10.0cms secondary recurrencessecondary recurrences 10.5cms10.5cms
PHPortsmouth Colorectal
Delorme’s operationDelorme’s operation
No effect on rate of recurrenceNo effect on rate of recurrence
ageage
sexsex
high grade incontinencehigh grade incontinence
diverticular diseasediverticular disease
sphincteroplasty sphincteroplasty
Watts BJS 2001 Watts BJS 2001
PHPortsmouth Colorectal
Delorme’s operationDelorme’s operation
continencecontinence
81 patients81 patients
pre-oppre-op post-oppost-op
10%10% 35% 35%
PHPortsmouth Colorectal
Delorme’s operationDelorme’s operationcontinence; pad usagecontinence; pad usage
pre-oppre-op 63% (51/81)63% (51/81)
post-oppost-op 31% (25/81)31% (25/81)
32 stopped32 stopped
19 continued pads19 continued pads
7 started7 started
PHPortsmouth Colorectal
constipationconstipation
type of operationtype of operation incidence incidence
collected Delorme’scollected Delorme’s not a problem not a problem
collected Altemeier collected Altemeier not a problem not a problem
collected abdominal procedurescollected abdominal procedures 25 - 47%25 - 47%
PHPortsmouth Colorectal
perineal operations for perineal operations for rectal prolapserectal prolapse
safesafe
technically simpletechnically simple
functional results satisfactoryfunctional results satisfactory
PHPortsmouth Colorectal
perineal operations for perineal operations for rectal prolapserectal prolapse
first choice for the:first choice for the:
elderly and frailelderly and frail
young womenyoung women
young menyoung men
constipated patientsconstipated patients
PHPortsmouth Colorectal
Delorme’s procedure with Delorme’s procedure with sphincter repairsphincter repair
no’s of patientsno’s of patients Delorme (1900)Delorme (1900) 11 Adair (1962)Adair (1962) 1919 Nay (1972)Nay (1972) 3030 Uhlig (1979)Uhlig (1979) 2020 Christiansen (1987)Christiansen (1987) 1111 Thompson (1994)Thompson (1994) 1414 Lechaux (1995)Lechaux (1995) 3939
PHPortsmouth Colorectal
Delorme’s operation for rectal prolapseDelorme’s operation for rectal prolapse
functional resultsfunctional results
constipationconstipation
Berman (1985 + 1990)Berman (1985 + 1990)
~ used Delorme’s procedure to treat constipationused Delorme’s procedure to treat constipation
Plusa (1995)Plusa (1995)
~ showed a decrease in rectal compliance after showed a decrease in rectal compliance after Delorme’sDelorme’s
PHPortsmouth Colorectal
Delorme’s operationDelorme’s operation
improves incontinenceimproves incontinence
PHPortsmouth Colorectal
outcome of patients in this seriesoutcome of patients in this series
died with no recurrence
alive with recurrence died with
recurrence
alive with no recurrence
no follow up
13%
43%
3%12%
29%
PHPortsmouth Colorectal
Altemeier’s procedureAltemeier’s procedure20 cases (220 cases (2½) years)½) years)
mortalitymortality 5% (1)5% (1)
morbiditymorbidity 5% (1) (pelvic haematoma)5% (1) (pelvic haematoma)
recurrencerecurrence ? 0%? (26 months, mean)? 0%? (26 months, mean)
functional functional outcomeoutcome
90% improved continence90% improved continence
Johansen, Wesner, Jagelman. Dis Colon Rectum 1993
post op
PHPortsmouth Colorectal
Altemeier’s procedureAltemeier’s procedure72 patients 10 yrs72 patients 10 yrs
mortalitymortality 0%0%
morbiditymorbidity 4% (3) anastomotic leak4% (3) anastomotic leak
recurrencerecurrence 5.3% (4) (48 months, mean)5.3% (4) (48 months, mean)
functional functional outcomeoutcome
improved continenceimproved continence
Ramanujam Dis Colon Rectum 1994
post op
PHPortsmouth Colorectal
Altemeier’s procedureAltemeier’s procedure20 cases (220 cases (2½) years)½) years)
mortalitymortality 5% (1)5% (1)
morbiditymorbidity 5% (1) (pelvic haematoma)5% (1) (pelvic haematoma)
recurrencerecurrence ? 0%? (26 months, mean)? 0%? (26 months, mean)
functional functional outcomeoutcome
90% improved continence90% improved continence
Johansen, Wesner, Jagelman. Dis Colon Rectum 1993
post op
PHPortsmouth Colorectal
probability of no recurrence probability of no recurrence (Kaplan Meier plots)(Kaplan Meier plots)
Time after surgery (months)
14413212010896847260483624120
Pro
babi
lity
of no
-recu
rrenc
e1.0
.9
.8
.7
.6
.5
.4
.3
1st
2nd
3rd
PHPortsmouth Colorectal
Delorme’s operationDelorme’s operation
continencecontinence
81 patients81 patients
89%89%
static or improvedstatic or improved
PHPortsmouth Colorectal
Delorme’s operationDelorme’s operation
decreases constipationdecreases constipation
low rectal compliancelow rectal compliance
improved evacuationimproved evacuation
removal of colonic breakremoval of colonic break
improved rectal fillingimproved rectal filling
PHPortsmouth Colorectal
perineal operations for perineal operations for rectal prolapse rectal prolapse
higher rate of recurrencehigher rate of recurrence
can this be improved:can this be improved:
better techniquebetter technique
better selection of better selection of patientspatients
PHPortsmouth Colorectal
Delorme’s operationDelorme’s operation
varying recurrence ratesvarying recurrence rates
age/sexage/sex casemixcasemix severity of prolapseseverity of prolapse
weakness of pelvic floorweakness of pelvic floor completeness of follow upcompleteness of follow up high death rate in elderly patientshigh death rate in elderly patients