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| 번호 | 제목 | 등록일 | 조회수 |
|---|---|---|---|
| 121 | Delorme’s Procedure for Rectal Prolapse [2003년 9월 DCR] | 2011-11-17 | 3537 |
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Clinical and Physiological Analysis
Akira Tsunoda, M.D., Ph.D., Naokuni Yasuda, M.D., Ph.D.,Noboru Yokoyama, M.D., Ph.D., Goichi Kamiyama, M.D., Ph.D.,Mitsuo Kusano, M.D., Ph.D. From the Second Department of Surgery, School of Medicine, Showa University, Tokyo, Japan PURPOSE: Clinical and physiological results of Delorme’s procedure were assessed retrospectively in patients undergoing this procedure for rectal prolapse.
METHODS: A consecutive series of 31 patients (7 males, 24 females; age,14–93, mean 70 years) with full-thickness, rectal prolapse were treated by Delorme’s procedure between 1994 and 2002. Median follow-up was 39 (range, 6–96) months.
RESULTS: Good results were achieved in 27 patients (87 percent),prolapse recurrence was observed in 4 (13 percent), and mean recurrence time was 14 (range, 3–25) months.There were no postoperative deaths. Minor complications occurred in four patients. The median changes in preoperative and postoperative physiologic patterns in 16 patients were as follows: resting pressure from 21.0 (range, 5–48) to 23.5 (range, 12–76) cm H2O (P = 0.030), squeeze pressure from 64.0 (range, 27–248) to 108.0 (range, 32–264) cm H2O (P = 0.041), volume at first sensation from 100 (range,70–180) to 70 (range, 40–130) ml (P = 0.002), maximum tolerated volume from 260 (range, 120–400) to 160 (range,70–400) ml (P = 0.001). Incontinence improved in 63 percent. No patient became constipated, and 38 percent of those constipated preoperatively improved. The preoperative incontinence score improved from 11.5 (range, 1–20) to 6.0 (range, 0–20) after operation (P < 0.0001).
CONCLUSION: Delorme’s procedure had a low morbidity, did not lead to constipation, improved anal continence, and had a reasonably low recurrence rate. Improved anal sphincter and rectal sensation were associated with a reduced incidence of defecatory problems after Delorme’s procedure.
Rectal prolapse is a distressing condition that is encountered more frequently with increasing age; constipation and fecal incontinence often accompany it. Many operations have been reported in the
management of rectal prolapse. Their concepts are based on the correction of anatomical disorders associated with procidentia. Most are successful in terms of control of prolapse. However, once the anatomical disorder is corrected, any remaining problems with obstructed defecation after abdominal procedures or incontinence results in poor patient satisfaction. Because of our incomplete understanding of the pathophysiology of the condition, the most appropriate strategy remains unknown. Delorme’s procedure is peranal mucosal stripping, which can be performed under regional anesthesia
with few postoperative complications, making it suitable for high-risk patients. The operation has resolved fecal incontinence with a variable degree and has not been found to be associated with constipation after operation. The physiological reasons for this improved function involve improved rectal sensation and lowered compliance, but are still controversial. The purpose of this study was to investigate the clinical, functional, and physiologic results of Delorme’s procedure. DISCUSSION
Many operations have been described for full-thickness, rectal prolapse, which may be via the transabdominal or perineal approach. Abdominal rectopexy has become the most commonly performed operation, with a recurrence rate of 0 to 10 percent. The most recent series of the Delorme’s procedure
reports a variable recurrence rate of 5 to 22 percent. Although recurrence rates after Delorme’s procedure are higher than most series of abdominal rectopexies, the advantages of this procedure outweigh this procedure. The main advantage of this technique is a low mortality and morbidity. Mortality of abdominal rectopexy is < 3 percent, and morbidity ranges from 6 to 12 percent. Pelvic sepsis after an implantation rectopexy occurs and can be troublesome. Such a complication is not seen after Delorme’s procedure. The procedure can be performed on patients who have had previous anorectal surgery and those who have failed other procedures for rectal prolapse. The procedure can be easily repeated as with our three patients who underwent a second Delorme’s procedure. Furthermore, the procedure may be recommended for young adult male patients, in whom abdominal rectopexy may cause pelvic (erection) or hypogastric (ejaculation) nerve damage. A partial explanation for recurrence after Delorme’s procedure is technical: it is important to perform a
total mucosectomy as far as the entire length of the prolapse, thereby reaching high into the rectum. An inadequate dissection may result in recurrence. Following the technique is encouraged. On the other hand, the authors found that Delorme’s procedure has good results in younger patients. In elderly patients, 80 years or older, results were disappointing with a 33 percent recurrence rate. Difficulty in defecation and constipation can occur after abdominal rectopexy with a reported incidence
ranging from 27 to 47 percent. Ripstein’s operation results in an increase in difficulty with evacuation from 27 percent before operation to 43 percent after operation. Madden et al. found that 42 percent of patients not constipated preoperatively became so after undergoing posterior rectopexy. Rectal denervation is likely to be an important component in the etiology of defecatory problems. Division of the lateral ligaments results in a high incidence of constipation. Difficult evacuation and constipation have not been reported to be a problem after Delorme’s procedure, as reported in the present series. Continence after prolapse repair often improves regardless of the technique used to correct the prolapse:
between 38 and 100 percent of patients improve after abdominal rectopexy, and up to 83 percent after Delorme’s procedure. Postoperative continence is affected by sphincter and pudendal nerve damage as a result of chronic prolapse. Anal sphincter’s stretch by the anal retractor during the Delorme’s procedure also may affect continence. The reduced resting pressure in patients with rectal prolapse is undoubtedly improved in some after surgery. This might be because the anus is kept open longer by the prolapse, the anal sphincters are no longer kept stretching by the prolapse,or because of abolition of chronic internal relaxation induced by the prolapse itself. Parks et al. demonstrated that there was histologic evidence of denervation in the external anal
sphincter muscle in patients with fecal incontinence and rectal prolapse, and suggested that this may be the result from pudendal neuropathy occurring as a consequence of rectal descent induced during repeated defecation straining. Electromyographic studies supported this suggestion, with increased fiber density in the puborectalis and external sphincter of incontinent patients, compared with normal controls and patients with rectal prolapse who were fully continent. Similarly, PNTML was significantly increased in incontinent patients with rectal prolapse. The present series also showed the increased PNTML in patients with rectal prolapse, even if PNTML was measured only in eight patients compared with that in the control subjects (median, 2.0 ms [1.8–2.2]) reported in our previous study,33 suggesting that pudendal neuropathy may occur in those patients. Evaluation of perioperative physiological changes remains to be established in patients with Delorme’s
procedure. Only a couple of reports appeared in the literature. Plusa et al., on the basis of manometric evaluation before and after Delorme’s procedure, reported an improvement in rectal sensation. The results were in accordance with ours and were likely because of reduced compliance17 and may help those patients in whom the reduced preoperative rectal sensation causes a delay in evacuation. Reduced compliance might be expected to result in incontinence because of urgency, although incontinence was not eliminated in Plusa’s and our series, but its incidence was reduced after operation in both series. Pescatori et al., on the other hand, did not show an improvement in rectal sensation after Delorme’s procedure. A significant increase in MRP and MSP was shown after Delorme’s procedure in the present series, whereas the results of manometric studies reported were not uniform. Pescatori et al. showed improvement in MSP but failed to show improvement in MRP, whereas Plusa et al. showed improvement in neither MRP nor MSP. The explanation for these differing results is not obvious. This may be related to variation in case mix
and patient selection or because of a pudendal neuropathy or, to some degree, perirectal supralevator fibrosis following a subclinical anastomotic dehiscence, if any, with consequent impairment of rectal sensation. However, this may be because of the difference in the postoperative time of physiology study, which was examined six months after operation in each patient in the present series, whereas it was more immediately after operation in other series. The increase in MSP in the present series probably makes an important contribution to improved continence. However, the increase in MRP might not lead to restored continence, because MRP measured postoperatively were extremely inferior to the normal range. Continence improved in 63 percent of our series after operation. Although the improvement in RAIR has not been shown in the present series, the postoperative incontinence in the patients with normal RAIR was significantly less scored than that with absence of RAIR. The absence of RAIR may suggest a defect of discrimination or a relatively low resting pressure, and may be correlated with postoperative incontinence. |
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