The Ethical Committee of The Third People's Hospital of Hangzhou approved the study protocol. Written informed consent for participation was obtained in accordance with institutional review board standards according to the Declaration of Helsinki. Thirty-four patients with full-thickness rectal prolapse, who received either Altemeier or Delorme procedures, between January 2011 and December 2019, at The Third People's Hospital of Hangzhou, China, were recruited in the study. We collected their demographic data, including age at surgical treatment, gender, disease course, BMI, ASA score, squat maximal prolapse length, operative data such as operative time, intraoperative blood loss, postoperative complications, and postoperative length of hospital stay, as well as follow-up data, including recurrence rate, Wexner constipation score and Wexner fecal incontinence scale. Technical safety of eaprocedure was assessed by analyzing operative times, intraoperative blood loss, postoperative complications and postoperative length of hospital stay. Furthermore, we evaluated measures of effectiveness of the interventions, including recurrence rate, Wexner constipation score and Wexner fecal incontinence scale. Furthermore, all patients were subjected to colonoscopy, to exclude other associated pathology, as well as mechanical bowel preparation and prophylactic antibiotic therapy. All operations were performed by the same team of doctors.
All the patients who underwent Delorme procedure were first placed in a lithotomy position, after spinal/epidural anesthesia. Briefly, the surgical area was routinely disinfected and sterile drapes placed. The anal canal was immobilized with a 2-0 traction suture, from the right anterior, right posterior, left anterior, and left posterior directions, and the dentate line identified. The prolapsed rectum was carefully brought out, through the anal orifice, the mucosa removed and assessed (about twice the length of the prolapse part of the rectum). A diluted (1:200,000) epinephrine solution was then injected into the submucosa, near the dentate line, to reduce intraoperative bleeding and facilitate dissection. Thereafter, circumferential resection margin was marked at about 2 cm above the dentate line using an electrocautery (Fig. 1a). The mucosa of outer rectum wall was cut from the anterior, lateral and posterior walls, then its sleeve resection performed from the underlying muscle wall to the apex of the prolapsing bowel submucosal dissection (Fig. 1b-1d). The muscular layer was folded longitudinally, by suturing with absorbable 3.0 vicryl sutures, using simple interrupted stitches (Fig. 1e), then an anal sphincteroplasty also performed using multiple interrupted absorbable sutures (Fig. 1f). Finally, mucosal edges were approximated using simple interrupted stitches (Fig. 1g). No obvious rectal prolapse was observed after Delorme procedure(Fig. 1h).
Patients were positioned in a lithotomy position, and surgery performed under either general or spinal anesthesia. The prolapsed colorectum exhibited a tower-like morphology (Fig. 2a). The anal canal was immobilized using a 2-0 traction suture, from the right anterior, right posterior, left anterior, and left posterior directions, and the dentate line identified. The prolapsed rectum was carefully brought out through the anal orifice, and a circumferential resection margin marked at about 1.5 cm above the dentate line via electrocautery (Fig. 2 b). The outer rectum was then cut from the anterior, lateral and posterior walls using an ultrasonic scalpel (Fig. 2c), then an incision performed through the peritoneum to gain access to the peritoneal cavity (Fig. 2d). The mesorectum, superior rectal artery and sigmoid arteries were also dissected using an ultrasonic scalpel, followed by ligation of the superior rectal and partial sigmoid arteries (Fig. 2e-2f). The peritoneum and the anterior sigmoid wall were sutured at the pouch of Douglas with absorbable 3.0 vicryl sutures using simple interrupted stitches, to reconstruct and elevate the pelvic floor (Fig. 2g). Thereafter, levatorplasty, comprising plication of the levator ani musculature, was performed using interrupted absorbable sutures (Fig. 2h). Cuts were carefully made along the sigmoid wall, about 1 cm above the dentate line, with an end-to-end anastomosis between the rectum and sigmoid also performed simultaneously (Fig. 2i). Finally, the redundant rectum and sigmoid were removed. A drainage tube was placed above the anastomosis for 2 days (Fig. 2j).
Patients were administered with oral liquid intake, at 6 hours post-operation, while a semiliquid diet started 3 days after surgery. Patients were intravenously injected with antibiotics at 3 days post-operation. Those without postoperative complications, such as bleeding, anastomotic stricture, anastomotic leakage, urinary retention, and urinary tract infections were discharged. Follow-up was conducted via outpatient reviews or telephone. Bowel function, including incontinence, and constipation, was reassessed at the clinic at 1 month post-operation, and full thickness prolapse of the rectal wall defined as recurrence of the disease.
All statistical analyses were performed using Statistic Package for Social Science (SPSS) v17.0 software (SPSS Inc., Chicago, IL, USA), and all data presented as means with their respective standard deviations. Kolmogorov-Smirnov and Levene tests were used to test normality and homogeneity of variance. Dichotomous variables were subjected to the McNemar chi-square, Pearson’s chi-square or Fishers’ exact tests. Comparisons between two sample means, before and after treatment, were performed using a paired t-test. Data followed by P<0.05 were considered statistically significant.