doi:10.1111/codi.13015
Original article
Laparoscopic rectopexy is feasible and safe in the emergency admission setting A. L. A. Bloemendaal, A. Mishra, G. A. Nicholson, O. M. Jones, I. Lindsey, R. Hompes and C. Cunningham Department of Colorectal and Pelvic Floor Surgery, Oxford University Hospitals NHS Trust, Oxford, UK Received 10 February 2015; accepted 20 April 2015; Accepted Article online 3 June 2015
Abstract Aim External rectal prolapse may require emergency admission in the elderly and comorbid population. We report the safety and efficacy of laparoscopic ventral rectopexy in patients having an emergency admission with external rectal prolapse. Method A retrospective analysis was performed of a prospective database of all rectopexies performed from 2006. Outcome and follow-up data were assessed. Results Of 812 rectopexies performed, 28 were included for analysis. The mean length of hospital stay was 13.0 days. All operations were completed successfully and without intra-operative complications. Four patients developed a postoperative complication. Two patients developed a recurrence of prolapse.
Conclusion Laparoscopic correction of rectal prolapse following emergency admission is both feasible and safe. It can be considered for both recurring cases and cases with multiple comorbidities. Keywords Laparoscopic ventral mesh rectopexy, emergency admission, rectal prolapse What does this paper add to literature? Many surgeons would choose a perineal repair for external prolapse in an emergency admission setting. We show that performing a laparoscopic rectopexy on frail patients in an emergency admission setting is feasible and safe. The complication and recurrence rates are low.
Introduction
Method
Laparoscopic ventral rectopexy is a safe and cost-effective treatment for external rectal prolapse [1,2] even in the elderly [3]. There is no specific information relating to the average interval from the first onset of symptoms to surgery. Patients who underwent a laparoscopic ventral mesh rectopexy following emergency admission were extracted from our prospective database. Treatment of prolapse was considered emergency treatment if patients underwent preoperative work-up and operation within the same admission. The primary aim of this study was to determine whether emergency operative treatment of a recurrent or persistent rectal prolapse by laparoscopic rectopexy is feasible and safe.
Patients who were admitted as an emergency and underwent laparoscopic repair of rectal prolapse or laparoscopic rectopexy in the Oxford University Hospitals from January 2006 to December 2014 were included for analysis. In addition to baseline demographics, parameters noted at the time of emergency admission leading to a laparoscopic ventral rectopexy within the same admission were included. The following were also included in the analysis: medical history, duration of admission, the interval from the onset of primary prolapse or severe constipation to operation, the interval from admission to operation, the length of postoperative stay and the complications and outcome. Follow-up and the long-term outcome were determined from hospital outpatient visits, nursing home updates and primary care records.
Results Correspondence to: A. L. A. Bloemendaal, MD PhD, Department of Colorectal and Pelvic Floor Surgery, Oxford University Hospitals NHS Trust, Churchill Hospital Old Road, Headington Surgical Admin, Oxford OX3 7LE, UK. E-mail: [email protected]
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Over an 8-year period from 2006 to 2014, 810 laparoscopic rectopexies were performed between 2006 and
Colorectal Disease ª 2015 The Association of Coloproctology of Great Britain and Ireland. 17, O198–O201
LVMR in emergency admission
A. L. A. Bloemendaal et al.
2014. Thirty-seven of these were carried out as an emergency at the time of admission, of whom eight were treated for severe obstructed defaecation and were therefore excluded from the analysis. There were therefore 29 patients with external rectal prolapse and in each case the prolapse was reduced on the emergency ward. There was no case of incarcerated or infarcted prolapse. Twelve cases were not fit for discharge because of rapid recurrence of the prolapse (Fig. 1), severe pain or ongoing rectal bleeding. The remaining 17 patients proceeded to surgery during the same admission. These 29 patients underwent a laparoscopy. One patient was converted to a Delorme’s procedure due to extensive adhesions at laparoscopy. Twenty-eight patients underwent a laparoscopic mesh rectopexy and they are included in this report. During the same period an additional two patients were admitted with an external rectal prolapse who were deemed unfit for laparoscopic surgery on anaesthetic review, owing to the presence of severe chronic obstructive pulmonary disease. They underwent a Delorme’s procedure in the left lateral position under general anaesthesia, as prolonged pneumoperitoneum for a laparoscopic procedure was deemed unsafe. Demographics
All patients were female and the median age was 85.5 years. The average time between the first occurrence of rectal prolapse derived from the records and the emergency operation was 20.6 months (SD 25.5), the longest delay being 84 months. Patients stayed in hospital for an average of 13.1 days of which 6.5 days were preoperative and 6.6 days were postoperative (Table 1). Thirteen patients had cardiovascular disease and four had chronic renal failure. Six patients had hypothyroidism and seven had had a hysterectomy. There was no case of colorectal cancer and three patients had had breast cancer. A psychiatric or neurological disorder was present in seven patients. Four patients experienced a postoperative complication (Table 2), which were all (a)
treated conservatively. No reoperations were necessary and there was no mortality. Preoperative work-up and surgery
All patients underwent a flexible sigmoidoscopy or full colonoscopy unless endoscopy had been performed within the previous year. All patients underwent anaesthetic review to assess their general health and fitness for laparoscopic abdominal surgery. Patients underwent a laparoscopic ventral mesh rectopexy as described by D’Hoore and Penninckx [4]. The peritoneum was opened using diathermy starting at the promontory and the rectovaginal septum was dissected to the pelvic floor. A vaginal speculum was always used to lift the vagina and to clarify the plain. A polypropylene mesh (Prolene; Ethicon, Cincinnati, Ohio, USA) was sutured to the ventral rectum and attached to the promontory using metal tackers (Protack, Covidien, New Javen, Conneticut, USA) under slight tension and the peritoneum was closed. In six cases an additional sacrocolpopexy was performed. In four patients a posterior rectopexy was added. In these cases the surgeon had the impression of a residual posterior prolapse, which necessitated a posterior mesh reinforcement of the rectopexy. Results
Four patients died within 6 months of surgery due to non-surgery related causes (heart failure, two patients aged 88 and 95 years; one pulmonary embolism, 83 years; one undetermined, 89 years). Two patients developed recurrence of prolapse within a year. One underwent a second rectopexy with a good short-term result and the other did not want further surgery. In one patient faecal incontinence worsened, for which no further surgical treatment was undertaken. One patient complained of severe bloating which was treated medically with moderate success. One patient developed back pain postoperatively, which was successfully treated by analgesics. Nineteen patients experienced no recur(b)
Figure 1 External prolapse which was corrected by emergency surgery: (a) preoperative; (b) result directly after laparoscopic ventral mesh rectopexy.
Colorectal Disease ª 2015 The Association of Coloproctology of Great Britain and Ireland. 17, O198–O201
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A. L. A. Bloemendaal et al.
Table 1 Demographics and hospital admission times. Median age in years (range) Mean interval from onset of prolapse to operation in months (SD) Mean total duration of admission in days (SD) Mean interval from admission to operation in days (SD) Mean postoperative stay in days (SD)
85.5 20.6
(30–97) (25.5)
13.1
(7.4)
6.5
(4.5)
6.6
(5.5)
Table 2 Complications within 30 days after emergency rectopexy. Complications
Number
Clavien–Dindo
Pneumonia Urinary tract infection Mild morphine intoxication Hypokalaemia
1 1 1 1
2 2 1 2
rence or treatment-related morbidity. Faecal incontinence was reported to have improved in 17 cases.
Discussion Rectal prolapse mainly affects elderly and frail patients. Occasionally it will not be possible to reduce the prolapse and the patient may present to the emergency department. The prolapse is usually successfully reduced and surgical correction is then planned during the same admission. The treatment strategy consisting of outpatient investigations and elective surgery is acceptable in those who are not incapacitated by the external rectal prolapse. This pathway, however, may take months to complete, during which the patient is often still troubled by persistent symptoms of obstructed defaecation, faecal incontinence, pain and rectal bleeding [5]. Immediate surgery is recognized as the only option in truly irreducible or incarcerated external rectal prolapse. A number of case reports have been published on perineal and abdominal approaches to this rare condition [6–10]. Many of the patients reported in this series had suffered from known external rectal prolapse for many months and a proportion were already undergoing outpatient investigation and treatment. Unfortunately, these patients developed persistent incapacitating prolapse in the waiting period during which a number had several hospital admissions. Eleven patients waited more than 2 years for surgery. All patients had been seen in the emergency ward on earlier occasions and were discharged after reduction of the prolapse. A frequently cited reason for not proceeding
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to surgery in frail and elderly patients is the risk of abdominal surgery, such as postoperative confusion and pneumonia. In an acute setting, perineal repair of rectal prolapse may be more appealing than an abdominal approach, but we have demonstrated previously that laparoscopic ventral rectopexy is safe and effective in the elderly with prolapse when managed electively [3]. Our practice has been to offer emergency patients the same corrective procedure with the intention of reducing the rate of recurrence associated with perineal surgery. The PROSPER trial has shown no major difference in recurrence of prolapse between laparoscopic ventral mesh rectopexy and Delorme’s procedure, although the authors of this trial noted a high recurrence rate in the abdominal rectopexy group compared to that reported in the literature [11]. For this reason, given the added morbidity of laparotomy, we chose to convert to Delorme’s procedure in the patient who recurred. In our experience laparoscopic ventral mesh rectopexy during an emergency admission is safe and associated with good functional results. In the emergency setting the patients stayed in hospital for a mean of 13.1 days, which was much longer than the one to two nights that would have been necessary for an elective ventral rectopexy [12]. Even in the elderly this would only have been three inpatient days [3]. An important rate-limiting factor was time required for the preoperative investigation including endoscopy, the anaesthetic review and the cardiological and neurological/psychiatric assessments, where necessary. The postoperative stay was also prolonged due to comorbidity and frailty of the patients. Post-discharge arrangements had to be made, including nursing home care, which lengthened inpatient stay. The number of patients in the study experiencing recurrence was within the expected range reported in a recent metaanalysis [13]. Emergency abdominal surgery in the elderly is associated with increased mortality and morbidity [14]. We have demonstrated excellent results of laparoscopic rectopexy in patients presenting as emergency with external rectal prolapse, however. Taking account of the characteristics of the patients, we believe that laparoscopic rectopexy is safe and feasible and should therefore be performed in patients admitted as emergency, provided the unit has expertise and high volume experience of this technique.
References 1 D’Hoore A, Cadoni R, Penninckx F. Long-term outcome of laparoscopic ventral rectopexy for total rectal prolapse. Br J Surg 2004; 91: 1500–5. 2 Formijne Jonkers HA, Poierrie N, Draaisma WA, Broeders IA, Consten EC. Laparoscopic ventral rectopexy for rectal
Colorectal Disease ª 2015 The Association of Coloproctology of Great Britain and Ireland. 17, O198–O201
LVMR in emergency admission
A. L. A. Bloemendaal et al.
3
4
5 6
7
8
prolapse and symptomatic rectocele: an analysis of 245 consecutive patients. Colorectal Dis 2013; 15: 695–9. Wijffels N, Cunningham C, Dixon A, Greenslade G, Lindsey I. Laparoscopic ventral rectopexy for external rectal prolapse is safe and effective in the elderly. Does this make perineal procedures obsolete? Colorectal Dis 2011; 13: 561–6. D’Hoore A, Penninckx F. Laparoscopic ventral recto(colpo)pexy for rectal prolapse: surgical technique and outcome for 109 patients. Surg Endosc 2006; 20: 1919–23. Fox A, Tietze PH, Ramakrishnan K. Anorectal conditions: rectal prolapse. FP Essent 2014; 419: 28–34. Seenivasagam T, Gerald H, Ghassan N, Vivek T, Bedi AS, Suneet S. Irreducible rectal prolapse: emergency surgical management of eight cases and a review of the literature. Med J Malaysia 2011; 66: 105–7. Ben Ameur H, Rejab H, Beyrouti MI. Altemeier operation for recurred and strangulated rectal prolapse. Indian J Surg 2013; 75: 224–6. Ramanujam PS, Venkatesh KS, Fietz MJ. Perineal excision of rectal procidentia in elderly high-risk patients. A ten-year experience. Dis Colon Rectum 1994; 37: 1027–30.
9 Sarpel U, Jacob BP, Steinhagen RM. Reduction of a large incarcerated rectal prolapse by use of an elastic compression wrap. Dis Colon Rectum 2005; 48: 1320–2. 10 Voulimeneas I, Antonopoulos C, Alifierakis E, Ioannides P. Perineal rectosigmoidectomy for gangrenous rectal prolapse. World J Gastroenterol 2010; 16: 2689–91. 11 Senapati A, Gray RG, Middleton LJ et al. Prosper: a randomised comparison of surgical treatments for rectal prolapse. Colorectal Dis 2013; 15: 858–68. 12 Powar MP, Ogilvie JW Jr, Stevenson AR. Day-case laparoscopic ventral rectopexy: an achievable reality. Colorectal Dis 2013; 15: 700–6. 13 Cadeddu F, Sileri P, Grande M, De Luca E, Franceschilli L, Milito G. Focus on abdominal rectopexy for full-thickness rectal prolapse: meta-analysis of literature. Tech Coloproctol 2012; 16: 37–53. 14 Louis DJ, Hsu A, Brand MI, Saclarides TJ. Morbidity and mortality in octogenarians and older undergoing major intestinal surgery. Dis Colon Rectum 2009; 52: 59–63.
Colorectal Disease ª 2015 The Association of Coloproctology of Great Britain and Ireland. 17, O198–O201
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Original article
Laparoscopic rectopexy is feasible and safe in the emergency admission setting A. L. A. Bloemendaal, A. Mishra, G. A. Nicholson, O. M. Jones, I. Lindsey, R. Hompes and C. Cunningham Department of Colorectal and Pelvic Floor Surgery, Oxford University Hospitals NHS Trust, Oxford, UK Received 10 February 2015; accepted 20 April 2015; Accepted Article online 3 June 2015
Abstract Aim External rectal prolapse may require emergency admission in the elderly and comorbid population. We report the safety and efficacy of laparoscopic ventral rectopexy in patients having an emergency admission with external rectal prolapse. Method A retrospective analysis was performed of a prospective database of all rectopexies performed from 2006. Outcome and follow-up data were assessed. Results Of 812 rectopexies performed, 28 were included for analysis. The mean length of hospital stay was 13.0 days. All operations were completed successfully and without intra-operative complications. Four patients developed a postoperative complication. Two patients developed a recurrence of prolapse.
Conclusion Laparoscopic correction of rectal prolapse following emergency admission is both feasible and safe. It can be considered for both recurring cases and cases with multiple comorbidities. Keywords Laparoscopic ventral mesh rectopexy, emergency admission, rectal prolapse What does this paper add to literature? Many surgeons would choose a perineal repair for external prolapse in an emergency admission setting. We show that performing a laparoscopic rectopexy on frail patients in an emergency admission setting is feasible and safe. The complication and recurrence rates are low.
Introduction
Method
Laparoscopic ventral rectopexy is a safe and cost-effective treatment for external rectal prolapse [1,2] even in the elderly [3]. There is no specific information relating to the average interval from the first onset of symptoms to surgery. Patients who underwent a laparoscopic ventral mesh rectopexy following emergency admission were extracted from our prospective database. Treatment of prolapse was considered emergency treatment if patients underwent preoperative work-up and operation within the same admission. The primary aim of this study was to determine whether emergency operative treatment of a recurrent or persistent rectal prolapse by laparoscopic rectopexy is feasible and safe.
Patients who were admitted as an emergency and underwent laparoscopic repair of rectal prolapse or laparoscopic rectopexy in the Oxford University Hospitals from January 2006 to December 2014 were included for analysis. In addition to baseline demographics, parameters noted at the time of emergency admission leading to a laparoscopic ventral rectopexy within the same admission were included. The following were also included in the analysis: medical history, duration of admission, the interval from the onset of primary prolapse or severe constipation to operation, the interval from admission to operation, the length of postoperative stay and the complications and outcome. Follow-up and the long-term outcome were determined from hospital outpatient visits, nursing home updates and primary care records.
Results Correspondence to: A. L. A. Bloemendaal, MD PhD, Department of Colorectal and Pelvic Floor Surgery, Oxford University Hospitals NHS Trust, Churchill Hospital Old Road, Headington Surgical Admin, Oxford OX3 7LE, UK. E-mail: [email protected]
O198
Over an 8-year period from 2006 to 2014, 810 laparoscopic rectopexies were performed between 2006 and
Colorectal Disease ª 2015 The Association of Coloproctology of Great Britain and Ireland. 17, O198–O201
LVMR in emergency admission
A. L. A. Bloemendaal et al.
2014. Thirty-seven of these were carried out as an emergency at the time of admission, of whom eight were treated for severe obstructed defaecation and were therefore excluded from the analysis. There were therefore 29 patients with external rectal prolapse and in each case the prolapse was reduced on the emergency ward. There was no case of incarcerated or infarcted prolapse. Twelve cases were not fit for discharge because of rapid recurrence of the prolapse (Fig. 1), severe pain or ongoing rectal bleeding. The remaining 17 patients proceeded to surgery during the same admission. These 29 patients underwent a laparoscopy. One patient was converted to a Delorme’s procedure due to extensive adhesions at laparoscopy. Twenty-eight patients underwent a laparoscopic mesh rectopexy and they are included in this report. During the same period an additional two patients were admitted with an external rectal prolapse who were deemed unfit for laparoscopic surgery on anaesthetic review, owing to the presence of severe chronic obstructive pulmonary disease. They underwent a Delorme’s procedure in the left lateral position under general anaesthesia, as prolonged pneumoperitoneum for a laparoscopic procedure was deemed unsafe. Demographics
All patients were female and the median age was 85.5 years. The average time between the first occurrence of rectal prolapse derived from the records and the emergency operation was 20.6 months (SD 25.5), the longest delay being 84 months. Patients stayed in hospital for an average of 13.1 days of which 6.5 days were preoperative and 6.6 days were postoperative (Table 1). Thirteen patients had cardiovascular disease and four had chronic renal failure. Six patients had hypothyroidism and seven had had a hysterectomy. There was no case of colorectal cancer and three patients had had breast cancer. A psychiatric or neurological disorder was present in seven patients. Four patients experienced a postoperative complication (Table 2), which were all (a)
treated conservatively. No reoperations were necessary and there was no mortality. Preoperative work-up and surgery
All patients underwent a flexible sigmoidoscopy or full colonoscopy unless endoscopy had been performed within the previous year. All patients underwent anaesthetic review to assess their general health and fitness for laparoscopic abdominal surgery. Patients underwent a laparoscopic ventral mesh rectopexy as described by D’Hoore and Penninckx [4]. The peritoneum was opened using diathermy starting at the promontory and the rectovaginal septum was dissected to the pelvic floor. A vaginal speculum was always used to lift the vagina and to clarify the plain. A polypropylene mesh (Prolene; Ethicon, Cincinnati, Ohio, USA) was sutured to the ventral rectum and attached to the promontory using metal tackers (Protack, Covidien, New Javen, Conneticut, USA) under slight tension and the peritoneum was closed. In six cases an additional sacrocolpopexy was performed. In four patients a posterior rectopexy was added. In these cases the surgeon had the impression of a residual posterior prolapse, which necessitated a posterior mesh reinforcement of the rectopexy. Results
Four patients died within 6 months of surgery due to non-surgery related causes (heart failure, two patients aged 88 and 95 years; one pulmonary embolism, 83 years; one undetermined, 89 years). Two patients developed recurrence of prolapse within a year. One underwent a second rectopexy with a good short-term result and the other did not want further surgery. In one patient faecal incontinence worsened, for which no further surgical treatment was undertaken. One patient complained of severe bloating which was treated medically with moderate success. One patient developed back pain postoperatively, which was successfully treated by analgesics. Nineteen patients experienced no recur(b)
Figure 1 External prolapse which was corrected by emergency surgery: (a) preoperative; (b) result directly after laparoscopic ventral mesh rectopexy.
Colorectal Disease ª 2015 The Association of Coloproctology of Great Britain and Ireland. 17, O198–O201
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LVMR in emergency admission
A. L. A. Bloemendaal et al.
Table 1 Demographics and hospital admission times. Median age in years (range) Mean interval from onset of prolapse to operation in months (SD) Mean total duration of admission in days (SD) Mean interval from admission to operation in days (SD) Mean postoperative stay in days (SD)
85.5 20.6
(30–97) (25.5)
13.1
(7.4)
6.5
(4.5)
6.6
(5.5)
Table 2 Complications within 30 days after emergency rectopexy. Complications
Number
Clavien–Dindo
Pneumonia Urinary tract infection Mild morphine intoxication Hypokalaemia
1 1 1 1
2 2 1 2
rence or treatment-related morbidity. Faecal incontinence was reported to have improved in 17 cases.
Discussion Rectal prolapse mainly affects elderly and frail patients. Occasionally it will not be possible to reduce the prolapse and the patient may present to the emergency department. The prolapse is usually successfully reduced and surgical correction is then planned during the same admission. The treatment strategy consisting of outpatient investigations and elective surgery is acceptable in those who are not incapacitated by the external rectal prolapse. This pathway, however, may take months to complete, during which the patient is often still troubled by persistent symptoms of obstructed defaecation, faecal incontinence, pain and rectal bleeding [5]. Immediate surgery is recognized as the only option in truly irreducible or incarcerated external rectal prolapse. A number of case reports have been published on perineal and abdominal approaches to this rare condition [6–10]. Many of the patients reported in this series had suffered from known external rectal prolapse for many months and a proportion were already undergoing outpatient investigation and treatment. Unfortunately, these patients developed persistent incapacitating prolapse in the waiting period during which a number had several hospital admissions. Eleven patients waited more than 2 years for surgery. All patients had been seen in the emergency ward on earlier occasions and were discharged after reduction of the prolapse. A frequently cited reason for not proceeding
O200
to surgery in frail and elderly patients is the risk of abdominal surgery, such as postoperative confusion and pneumonia. In an acute setting, perineal repair of rectal prolapse may be more appealing than an abdominal approach, but we have demonstrated previously that laparoscopic ventral rectopexy is safe and effective in the elderly with prolapse when managed electively [3]. Our practice has been to offer emergency patients the same corrective procedure with the intention of reducing the rate of recurrence associated with perineal surgery. The PROSPER trial has shown no major difference in recurrence of prolapse between laparoscopic ventral mesh rectopexy and Delorme’s procedure, although the authors of this trial noted a high recurrence rate in the abdominal rectopexy group compared to that reported in the literature [11]. For this reason, given the added morbidity of laparotomy, we chose to convert to Delorme’s procedure in the patient who recurred. In our experience laparoscopic ventral mesh rectopexy during an emergency admission is safe and associated with good functional results. In the emergency setting the patients stayed in hospital for a mean of 13.1 days, which was much longer than the one to two nights that would have been necessary for an elective ventral rectopexy [12]. Even in the elderly this would only have been three inpatient days [3]. An important rate-limiting factor was time required for the preoperative investigation including endoscopy, the anaesthetic review and the cardiological and neurological/psychiatric assessments, where necessary. The postoperative stay was also prolonged due to comorbidity and frailty of the patients. Post-discharge arrangements had to be made, including nursing home care, which lengthened inpatient stay. The number of patients in the study experiencing recurrence was within the expected range reported in a recent metaanalysis [13]. Emergency abdominal surgery in the elderly is associated with increased mortality and morbidity [14]. We have demonstrated excellent results of laparoscopic rectopexy in patients presenting as emergency with external rectal prolapse, however. Taking account of the characteristics of the patients, we believe that laparoscopic rectopexy is safe and feasible and should therefore be performed in patients admitted as emergency, provided the unit has expertise and high volume experience of this technique.
References 1 D’Hoore A, Cadoni R, Penninckx F. Long-term outcome of laparoscopic ventral rectopexy for total rectal prolapse. Br J Surg 2004; 91: 1500–5. 2 Formijne Jonkers HA, Poierrie N, Draaisma WA, Broeders IA, Consten EC. Laparoscopic ventral rectopexy for rectal
Colorectal Disease ª 2015 The Association of Coloproctology of Great Britain and Ireland. 17, O198–O201
LVMR in emergency admission
A. L. A. Bloemendaal et al.
3
4
5 6
7
8
prolapse and symptomatic rectocele: an analysis of 245 consecutive patients. Colorectal Dis 2013; 15: 695–9. Wijffels N, Cunningham C, Dixon A, Greenslade G, Lindsey I. Laparoscopic ventral rectopexy for external rectal prolapse is safe and effective in the elderly. Does this make perineal procedures obsolete? Colorectal Dis 2011; 13: 561–6. D’Hoore A, Penninckx F. Laparoscopic ventral recto(colpo)pexy for rectal prolapse: surgical technique and outcome for 109 patients. Surg Endosc 2006; 20: 1919–23. Fox A, Tietze PH, Ramakrishnan K. Anorectal conditions: rectal prolapse. FP Essent 2014; 419: 28–34. Seenivasagam T, Gerald H, Ghassan N, Vivek T, Bedi AS, Suneet S. Irreducible rectal prolapse: emergency surgical management of eight cases and a review of the literature. Med J Malaysia 2011; 66: 105–7. Ben Ameur H, Rejab H, Beyrouti MI. Altemeier operation for recurred and strangulated rectal prolapse. Indian J Surg 2013; 75: 224–6. Ramanujam PS, Venkatesh KS, Fietz MJ. Perineal excision of rectal procidentia in elderly high-risk patients. A ten-year experience. Dis Colon Rectum 1994; 37: 1027–30.
9 Sarpel U, Jacob BP, Steinhagen RM. Reduction of a large incarcerated rectal prolapse by use of an elastic compression wrap. Dis Colon Rectum 2005; 48: 1320–2. 10 Voulimeneas I, Antonopoulos C, Alifierakis E, Ioannides P. Perineal rectosigmoidectomy for gangrenous rectal prolapse. World J Gastroenterol 2010; 16: 2689–91. 11 Senapati A, Gray RG, Middleton LJ et al. Prosper: a randomised comparison of surgical treatments for rectal prolapse. Colorectal Dis 2013; 15: 858–68. 12 Powar MP, Ogilvie JW Jr, Stevenson AR. Day-case laparoscopic ventral rectopexy: an achievable reality. Colorectal Dis 2013; 15: 700–6. 13 Cadeddu F, Sileri P, Grande M, De Luca E, Franceschilli L, Milito G. Focus on abdominal rectopexy for full-thickness rectal prolapse: meta-analysis of literature. Tech Coloproctol 2012; 16: 37–53. 14 Louis DJ, Hsu A, Brand MI, Saclarides TJ. Morbidity and mortality in octogenarians and older undergoing major intestinal surgery. Dis Colon Rectum 2009; 52: 59–63.
Colorectal Disease ª 2015 The Association of Coloproctology of Great Britain and Ireland. 17, O198–O201
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