Rectal prolapse (RP) is not fatal but it is a severe problem that can seriously influence the quality of life of patients and most commonly affects older women. There are two types of RP. Type I, which is also called mucosal prolapse, involves the protrusion of the mucosa and is usually less than 3 cm long. Type II, also called full-thickness rectal prolapse (FTRP), involves full-thickness extrusion of the rectal wall characterized by concentric folds in the prolapsed mucosa [6]. This study focused on the treatment of FTRP in older women.
Numerous operative approaches have been described for the treatment of FTRP. The various approaches can be classified into two groups: transabdominal and transperineal [3]. The choice of the initial treatment was based on the assessment, age, comorbidities, and grading of prolapse. Transperineal surgery, which is traditionally reserved for patients who are deemed unsuitable for abdominal operation (the frail and elderly) and those who do not tolerate general anesthesia, consists of Delorme’s, Altemeier’s, STARR, and GMT operations. Delorme’s procedure involves mucosal and submucosal dissection, plication of the remaining muscle layer, and mucosal anastomosis. Delorme’s procedure has been reported to cause significant bleeding and perforation after surgery [7]. Altemeier’s procedure involves excision of the redundant rectum or sigmoid colon. It is more appropriate for obstructive defecation syndrome [8]. It has a risk for fatal complications, such as anastomotic breakdown, rectal bleeding, and perianal abscess. This approach has been reported to have a postoperative mortality rate of 1.6% after surgery [9–10]. The STARR operation involves excision of the redundant rectal mucosa with a colorectal anastomosis that only applies to a mucosal protrusion of less than 5 cm long [11–12]. Since FTRP is a benign disease, the operative method should be simple, has wide adaptation, and has low postoperative mortality rate and cost.
One surgical technique for FTRP is the Gant-Miwa-Thiersch procedure (GMT) (mucosal plication with anal encircling). It can be used irrespective of the length of the rectum and colon prolapse [4]. Iida et al. reported that there were no postoperative complications out of 166 patients who underwent GMT. GMT is not popular in Europe and the United States, while it plays a major role in the treatment of rectal prolapse in China and Japan [4–5]. Possible reasons include anatomical and dietary factors. In Western societies, an elongated sigmoid colon is commonly observed in elderly institutionalized patients with chronic constipation. A redundant, elongated sigmoid colon is prone to rectal prolapse [13]. In China, the pathophysiology of FTRP is usually related to several anatomic concerns, such as obstetric trauma causing weakness of pelvic floor muscles associated with connective tissue, MMP-1 involved in chronic obstructive pulmonary disease that leads to loosely attached rectal mucosa to the underlying muscularis [14] (Table 2), and malnutrition and aging resulting in loss of the normal sacral curvature [15–16]. Due in part to long-term vegetarians in China, constipation seldom occurs [17]. Diarrhea or fecal incontinence was thought to be the common accompanying symptoms of FTRP (Table 1). Clinical results of GMT showed improved defecation with minimal complications [18]. Therefore, selecting surgical approaches should consider the exact causative factors and anatomical variations and tailored according to the patient’s disease characteristics. However, the recurrence rate after GMT was 23.8% within a maximum follow-up period of 14 years [4]. We modified the GMT and combined it with square transfixion with submucosal and ischiorectal space injection sclerotherapy to address this problem.
Compared to GMT,we made the following three improvements in nmGMTSI. First, the grip of the full thickness of the rectal wall was transfixed by 2/0 Vicryl thread at 12, 3, 6, and 9 o’clock positions, 5 cm above the top of the prolapsed mucosa. Similar to GMT, multiple tags were created. After the rectal mucosa, the tissue 1 cm above the dentate line was sutured with the previously uncut Vicryl thread 2/0. The prolapsed rectum was completely restored by tightening the Vicryl thread. This improvement can significantly shorten the operation time and prevent recurrence in the short term after surgery, in which inflammatory adhesions have not yet formed. Second, longitudinal injection of the sclerosant in each of the four quadrants of the rectal submucosal area promotes inflammatory response and scarring, which prevents long-term mucosal prolapse recurrence. Finally, the sclerosant was injected into the pelvic rectal space. This improvement was mainly due to the weakness of the pelvic floor muscles associated with connective tissue. The sclerosant initiates an inflammatory reaction resulting in fibrosis outside the rectal wall and the perirectal tissue that leads to the wall of the rectum adheres to the perirectal tissue, preventing recurrence of prolapse of the rectal wall. Of course, sclerosant should be avoided in the anal sphincter.
Evaluation of the nmGMTSI depends on the results and complications of the surgery. In this study, the WFIS was significantly lower after surgery (Fig. 2a). This study matches the study of Yamana et al. [18], as this study found improvement in incontinence in more than 96.2% of patients (Table 3). One possible explanation is that the ACRP and MASP were significantly increased after anal encircling and the wall of the rectum adhered to the perirectal tissue (Fig. 2a). Constipation was partially improved in this study (Table 3). The AST and MRT were downregulated compared to preoperative values. But the WCS was no significantly different between the preoperative and postoperative (Fig. 2b). One possible reason is that scar formation in the rectal submucosal area would result in outlet obstruction. As shown in Table 3, some patients had complications such as bleeding, colitis, and stenosis, but all recovered satisfactorily with conservative therapies. It is worth noting that the thread used for anal encircling can be infected, and its removal was usually necessary. In such cases, recurrence tends to occur after removal.
In our study, the overall recurrence rate after nmGMTSI was 2.9% during a period of two years with no operative death. The nmGMTSI is effective for diarrhea or fecal incontinence. There are, of course, some limitations in this research. Postoperative follow-up time was not long enough. The nmGMTSI is less effective for constipation or obstructed defecation. The score on patient’s satisfaction score are not validated.