Perineal Rectosigmoidectomy

Hemorrhoid No More

Piles Holistic Treatments

Get Instant Access

Although first performed by Mickulicz10 in 1889 and later advocated by Miles11 in 1933 and Gabriel12 in 1948, the perineal rectosigmoidec-tomy is most commonly associated with Altemeier (Fig. 20.3). In 1971, Altemeier et al13

reported the results of a one-stage procedure with 106 patients over a 19-year period. There were no postoperative deaths and only three recurrences in their series. Their results were especially impressive considering the patients were older (average age: 62 years) than the patients in most series of the time, and the majority of the patients had documented psychiatric disease (52%).

The technique of the perineal rectosig-moidectomy is thought to be difficult to conceptualize. With the rectum prolapsed, there are two full-thickness layers of the bowel wall. The outer layer is distal and attaches to the anal canal, while the inner layer is in continuity with the proximal bowel. An incision is made through the outer layer, 2 to 4 cm above the dentate line, which straightens the rectum and sigmoid colon. With traction on the bowel, the mesorectum is divided with suture ligation of the vessels. A surprising amount of proximal rectum and sigmoid colon can be prepared for resection with this technique. When, in the judgment of the surgeon, sufficient bowel has been devascular-ized, the inner layer of bowel is transected and a hand-sewn or stapled anastomosis is created between the two cut ends of bowel. As originally described, Altemeier opened the peritoneal cul-de-sac and obliterated what he considered to be a sliding hernia sac. He also reefed the

Figure 20.3. Perineal rectosigmoidectomy. With the rectum prolapsed,the outer rectal tube is incised circularly (a) and unfolded (b).The mesorec-tum is serially ligated and divided (c). When all redundancy has been removed,the inner tube is divided, which completes the resection (d). From Karulf RE, Madoff RD, Goldberg SM. Rectal prolapse. Curr Probl Surg 2001;38:771-832, with permission from Elsevier.

Figure 20.3. Perineal rectosigmoidectomy. With the rectum prolapsed,the outer rectal tube is incised circularly (a) and unfolded (b).The mesorec-tum is serially ligated and divided (c). When all redundancy has been removed,the inner tube is divided, which completes the resection (d). From Karulf RE, Madoff RD, Goldberg SM. Rectal prolapse. Curr Probl Surg 2001;38:771-832, with permission from Elsevier.

RD, Goldberg SM. Rectal prolapse. Curr Probl Surg 2001;38:771-832, with permission from Elsevier.

puborectalis together anterior to the rectum and performed a sutured anastomosis. Other surgeons often omit these two additional technical points due to lack of proven benefit.

One variation on Altemeier's technique employs an intraluminal stapling device to create the anastomosis (Fig. 20.4).14 Bennett and Geelhoed15 reviewed the subject and advocated the use of a stapler in creating the anastomosis, for three reasons. First, it simplifies the anastomosis. Second, there can be a more extensive resection, since the anastomosis is completed inside the anus. Third, in their opinion, the narrowing that is seen after stapled anastomosis may prevent the later need for sphincter plication. However, superior functional results have never been documented with stapled compared to hand-sewn anastomosis for this procedure.

Because of its minimally invasive nature, per-ineal rectosigmoidectomy has been suggested as an alternative for elderly or high-risk patients. A series at the University of Minnesota reviewed the results of perineal rectosigmoidectomy in 114 patients of a median age of 78 years.16 There were no deaths and a 12% complication rate; hospital stay averaged 4 days. Only 11 of the 104 patients (11%) who were available for follow-up developed recurrent full-thickness rectal prolapse. In a second series from Arizona, 72 patients over age 70 were treated with perineal excision of rectal prolapse.17 In this series, nine of the 72 patients presented with acute incarcerated rectal prolapse. Two anastomotic leaks were noted, both in the acutely incarcerated group, both of which required a diverting colostomy. The length of stay averaged 7 days. In a follow-up of 6 months to 9 years (average 48 months), there were no deaths, and eight complications were noted (11%). Four of the 72 patients, had recurrent full-thickness rectal prolapse (5.6%) and another four had prolapse limited to the mucosa. These studies provide evidence that even in elderly or high-risk patients, rectal prolapse can be treated with perineal rectosig-moidectomy with minimal morbidity.

Other authors have reported their results with the Altemeier procedure with less encouraging results. A high rate of recurrence (58%) was reported in the St. Mark's series, with half of these in the first 3 years.18 Other authors report a recurrence rate as high as 60% with perineal rectosigmoidectomy.19 It is not clear why these early reports are at odds with reports in recent years. It is clear that the recurrence rate is linked to the length of follow-up, and more recent reports have emphasized the use of this technique in older and high-risk patients. It is possible that if the early reports had a greater percentage of younger patients, the recurrence rates could be unfavorably skewed.

In addition, these reports from 50 years ago used a technique in which the colorectal anastomosis was hand sewn well outside of the anal canal. The anastomosis was then reduced through the sphincters. By allowing this amount of redundancy, the patients were leaving the operating room with an inadequate resection. More recent articles have described creating the anastomosis closer to the sphincter complex and allowing more tension on the repair. These small technical points and the difference in patient selection may account for the difference in recurrence rates.

One interesting finding, noted in both the University of Minnesota and the Arizona series, was an improvement in continence after surgery. In the Minnesota series, 67 of the 104 patients were incontinent to solid or liquid stool prior to surgery; 56 of these individuals underwent rec-tosigmoidectomy as a sole procedure and 26 (46%) regained full control. The remaining 11 patients had levatoroplasty at the time of rec-tosigmoidectomy and 10 improved (91%) with seven becoming fully continent (64%). In the Arizona series, 54 of 72 patients were incontinent to feces and all patients were incontinent to flatus prior to surgery. Following surgery, which included perineal excision of the rectum and posterior levator approximation to re-create the anorectal angle, 48 patients (67%) had regained continence of both flatus and feces. A study at the Cleveland Clinic Florida analyzed 20 consecutive elderly patients of a mean age of 82 years who underwent perineal rectosigmoidectomy for full-thickness rectal prolapse.20 Detailed functional assessment and physiologic testing were performed before and after surgery. There was one death, one major complication, and no recurrences in an average of 26 months of follow-up. Before surgery, six of 10 patients had prolonged pudendal nerve terminal motor latency (PNTML) values (longer than 2.5 msec). Continence scores improved, on an average, from 14.5 before surgery to 8.4 after surgery. It is interesting to note that continence scores improved in four of the six patients with evidence of at least unilateral neuropathy. This finding suggests that a prolonged PNTML may not be an accurate predictor of postoperative continence. The low recurrence rate was undoubtedly due to the very short follow-up, as a subsequent series of 61 patients from Cleveland Clinic Florida reported a recurrence rate of 12.5%.21

Was this article helpful?

0 0
Fire Up Your Core

Fire Up Your Core

If you weaken the center of any freestanding structure it becomes unstable. Eventually, everyday wear-and-tear takes its toll, causing the structure to buckle under pressure. This is exactly what happens when the core muscles are weak – it compromises your body’s ability to support the frame properly. In recent years, there has been a lot of buzz about the importance of a strong core – and there is a valid reason for this. The core is where all of the powerful movements in the body originate – so it can essentially be thought of as your “center of power.”

Get My Free Ebook


Post a comment