Neorectum prolapse after rectal cancer surgery corrected with perineal stapled prolapse resection

Abstract

A 61-year-old woman developed neorectal prolapse after laparoscopic low anterior resection, total mesorectal excision with partial intersphincteric resection and handsewn coloanal anastomosis for rectal cancer. She presented with a 3 cm full thickness reducible prolapse, with associated anal pain and bleeding. A perineal stapled prolapse resection was performed to address the rectal prolapse, with satisfactory results.

Background

An objective in rectal cancer treatment is achieving an oncologically sound resection, while preserving sphincter function.¹ Total mesorectal excision (TME) has become standard for rectal cancer surgery, resulting in decreased rates of local recurrence with complete removal of the rectum and its surrounding lymphatics and vessels, enclosed in a well-defined fascial layer.^{2 3} For low rectal tumours, neoadjuvant treatment in conjunction with intersphincteric resection (ISR) with coloanal anastomosis has allowed sphincter preservation, without compromising oncological and functional outcomes.^4–6 An increase in the conduct of sphincter-saving operations has led to more long-term complications being encountered.^{7 8} Many of these greatly affect function and quality of life but are without standard treatment recommendations.⁹ We share our experience in using a novel approach in managing a rectal prolapse after ISR with coloanal anastomosis for low rectal cancer.

Case presentation

A 61-year-old nulliparous woman was seen on follow-up at the colorectal cancer multidisciplinary clinic for a 16-month history of a prolapsing neorectum, with occasional bleeding and pain. In 2019, she completed short-course radiotherapy (5 Gy for 5 days) 1 week prior to undergoing laparoscopic low anterior resection, total mesorectal excision with partial ISR and handsewn coloanal anastomosis for a Stage IIIB (cT3N1M0) rectal cancer located 4 cm from the anal verge. A loop ileostomy was placed as a means of proximal bowel diversion. She later underwent adjuvant chemotherapy (capecitabine–oxaliplatin ×three cycles, capecitabine ×five cycles). Unfortunately, the patient had poor follow-up on completion of her chemotherapy. She developed neorectum prolapse 8 months after the operation but only sought consultation again after another 8 months because of progressive symptoms associated with the prolapse.

She was of good functional capacity with controlled hypertension and diabetes mellitus and no previous pelvic surgery. On perineal examination, there was a 3 cm full thickness reducible prolapse of the neorectum (figure 1). The sphincter had decreased resting sphincter tone and fair squeeze. (At the time of examination, she still had a diverting ileostomy, hence, symptoms of constipation, diarrhoea, soiling and lifestyle alteration secondary to the prolapse were not evident.) There were no signs of recurrent or metastatic disease on surveillance imaging and endoscopy.

Figure 1.

A full-thickness circumferential prolapse of the neorectum in a 61-year-old woman who underwent low anterior resection with total mesorectal excision and partial intersphincteric resection with for rectal cancer.

Treatment

The patient underwent a perineal stapled prolapse resection (PSPR) 16 months after her first surgery. No bowel preparation was done. Under general anaesthesia, she was placed on lithotomy position with minimal Trendelenburg. Endoanal ultrasonography was done that demonstrated an intact external anal sphincter with normal thickness (0.6 cm) and a thinned out intact internal anal sphincter (<0.1 cm) (figure 2). The full extent of the neorectal prolapse was pulled out using Babcock forceps. Bimanual palpation was used to ensure that nothing was in between the two prolapsing rectal walls. A linear stapler (NTLC75; Ethicon Endo-Surgery, Cincinnati, OH) was deployed along the full length of the prolapse on the left lateral aspect (3 o’clock position) 2 cm away from the dentate line. The same was done on the right lateral side (9 o’clock position) of the prolapse (figure 3). A suture was placed on the apex of both staple lines marking the start and ending point of the circumferential transection. An Echelon Contour Curved Cutter stapler (Ethicon Endo-Surgery) was inserted through the anterior flap starting from the suture at the 3 o’clock position (figure 4). The curved stapler was placed 2 cm away and parallel to the dentate line while maintaining traction on the ends of the prolapse. The stapler pin was guided down through the rectum to secure placement. The vagina was checked before the curved stapler was fired to ensure that it was not caught within it. Circumferential resection of the prolapse was continued with firing of reloaded cartridges of the curved cutter until the stay suture at the 9 o’clock position. The same was done to the posterior flap of the prolapse. The staple line and neorectal mucosa retracted spontaneously on completion of the resection (figure 5) and was inspected using a speculum. Haemostasis was done by oversewing the staple line with interrupted suturing using braided absorbable sutures. The patient was discharged well the following day with good pain control and no bleeding. There was no recurrence on follow-up after 4 months.

Figure 2.

Endoanal ultrasonography done on the patient with a thinned out internal anal sphincter (yellow arrows).

Figure 3.

Application of a linear stapler (NTLC75; Ethicon Endo-Surgery, Cincinnati, OH) at the 9 o’clock position of the prolapse. The 3 o’clock position has been previously cut and stapled (yellow circle).

Figure 4.

An Echelon Contour curved cutter stapler (Ethicon Endo-Surgery, Cinicinnati, OH) is applied on the anterior flap that was created after deployment of the linear staplers.

Figure 5.

The patient’s anus at the completion of the procedure. She was sent home the day after surgery.

Discussion

Complete rectal prolapse is characterised by full thickness extrusion of the rectum through the anal muscles and beyond the anal verge.¹⁰ This differs from an occult or internal prolapse where the rectal wall that intussuscepts within the rectum does not protrude beyond the anal verge. A partial or mucosal prolapse, on the other hand, extends out of the anus but only involves the mucosa. Furthermore, it does not involve the entire circumference of the bowel. On physical examination, a complete rectal prolapse appears as a circumferential protrusion of the rectum with concentric rings. It occurs spontaneously, or with slight straining, but can reduce by itself or with gentle pressure. It has an incidence of 2.5 per 100 000, with a female predominance.¹¹ Though it is quite a rare disease, it causes considerable debilitation to patients. Symptoms that have been reported include an anal bulge, pain, bleeding, tenesmus and soiling.¹² This constellation of symptoms results in poor quality of life.¹³

There is no single explanation for the occurrence of rectal prolapse. The levator ani muscle, which comprises the pelvic floor, is attached to the longitudinal conjoint muscles of the rectum providing stability. Widening of the levator hiatus, as well as stretching of the pelvic floor muscles that may arise from pelvic surgery, obstetric trauma, constant straining and ageing, can contribute to development of rectal prolapse. Problems in colonic motility, redundancy of the rectosigmoid, anatomic alterations in the pelvis and the perineum, concurrent pelvic organ prolapse and neurological conditions such as dementia, stroke, spinal cord injuries and cauda equina syndrome are also factors that may predispose to rectal prolapse.^{14 15}

Our patient is a 61-year-old woman who underwent a laparoscopic low anterior resection, total mesorectal excision with partial ISR and handsewn coloanal anastomosis. Because the telling technical challenge is obtaining adequate bowel length to allow for a tension-free coloanal anastomosis, a neorectum prolapse is not often seen after this procedure.⁹ There is often just enough length to fashion the coloanal anastomosis without any redundancy that may predispose to prolapse. Guraieb-Trueba et al⁹ reported an overall incidence of full-thickness neorectal prolapse after transanal transabdominal proctosigmoidectomy (TATA) with a coloanal anastomosis to be 4.6%. The incidence was higher in cases done through minimally invasive means (ie, laparoscopy, robotic) versus open (6.7% vs 2.2%). This was attributed to less adhesion formation after minimally invasive surgery. The same study also noted a significantly higher incidence of neorectal prolapse in women (9.5%) than in men (2.5%). This could be due to their having a wider pelvis, and possible obstetric events (pregnancy, vaginal delivery), which may cause stretching and weakening of the pelvic floor. Another factor identified to carry significant variability in the incidence of prolapse was radiation dose. A higher radiation dose was noted to have lower prolapse incidence. This was attributed to more fibrosis and scarring that cause the neorectum to be fixed to its location in the pelvic cavity as would adhesion formation.⁹ The neorectal prolapse cases were corrected through a Duhamel mucosal excision or a transanal redo of the coloanal end-to-end anastomosis (Altemeier procedure) with or with levatorplasty.⁹

Another study by Chau et al¹⁶ identified the incidence of neorectal prolapse to be 8% after coloanal anastomosis following laparoscopic TME with ISR. Of the 12 patients who developed prolapse, 3 opted not to undergo surgical correction due to the presence of only moderate symptoms. The remaining nine patients underwent resection of the prolapsed segment with a redo end-to-end coloanal anastomosis done transanally. Three (33%) of the surgically treated patients developed a recurrence of the prolapse. One required an abdominoperineal resection due to poor functional status, while two underwent a repeat transanal correction.¹⁶

A novel perineal approach to rectal prolapse surgery was introduced by Scherer in 2008 using linear staplers (ILA 100; US Surgical, Norwalk, CT) and the Contour Transtar stapler (STR5G; Ethicon Endo-Surgery) to carry out a full thickness resection of the prolapse.¹⁷ A revision of the original technique by Scherer was done by Romano et al¹⁸ in which longitudinal transection of the prolapse was done on both the 3 o’clock and the 9 o’clock position, instead of just the 3 o’clock position. This revision was intended to avoid spiralling when doing the circumferential resection and has been the technique adopted by most surgeons performing PSPR.¹⁹

A systematic review of available literature that included both technical variations found that PSPR has comparable outcomes to the Altemeier and the Delorme procedures.¹² The stapled perineal approach has a recurrence rate of 0%–44% in patients with follow-up of more than 12 months. Together, the Altemeier and the Delorme procedures, on the other hand, have a recurrence rate of 0%–31.3% within the same follow-up period. The stapled approach was also found to improve functional outcomes with postoperative improvement in the Wexner continence score and the obstructed defecation syndrome score.¹⁸

The real advantage of PSPR is in its technical simplicity and reproducibility. This procedure does not require careful, meticulous and extensive dissection, and relies less on surgeon experience as compared with the classic perineal approaches. As the perineal approach is preferred for frail and high-risk patients, this technique is also a quicker procedure running an average of 46.5 min versus the Altemeier and Delorme procedures that take 95.1 and 96.1 min on the average, respectively. Its major disadvantage, however, is the added cost of the staplers.¹²

In our literature search, we did not find any report on the use of the PSPR technique for patients such as ours that developed neorectal prolapse after ISR of low rectal cancer. For a patient post-cancer resection, although done laparoscopically, we did not want to do our surgery transabdominally as we could be met by adhesions in a potentially hostile pelvis. Hence, we proceeded transanally. We decided to apply the stapled technique as it provided a quick and effective procedure that allowed for faster recovery and earlier discharge.

Neorectal prolapse after ISR for low rectal cancer, though a rare late complication, can lead to significant debilitation and poor quality of life. The PSPR technique is a viable option in addressing this complication. Further investigation, however, should be done to assess the long-term outcomes (ie, recurrence, function) of this procedure in this subset of patients.

Learning points.

• Development of rectal prolapse is multifactorial. Predisposing factors may be anatomical (eg, alterations in pelvic floor musculature and redundancy of the rectosigmoid), physiological (eg, pelvic floor muscle myopathies and dyssynergia, and neurological conditions) or a combination of both (eg, ageing, obstetric trauma, pelvic floor surgery and chronic straining from constipation).

• The perineal stapled prolapse resection (PSPR) technique has comparable outcomes to established perineal surgical approaches to rectal prolapse.

• The PSPR technique for rectal prolapse can be applied to prolapse of the neorectum after laparoscopic low anterior resection with total mesorectal excision and partial intersphincteric resection with handsewn coloanal anastomosis for rectal cancer.

Ethics statements

Patient consent for publication

Consent obtained directly from patient(s).