VIDEO VIGNETTE
Perineal Proctectomy With Bio-Thiersch Procedure for Complete Rectal Prolapse With Fecal Incontinence Jed F. Calata, M.D.1 • Ajit Pai, M.D.2 • Slawomir Marecik, M.D.2 Leela M. Prasad, M.D.2 • John J. Park, M.D.2 1 Department of General Surgery, University of Illinois at Chicago – Metropolitan Group Hospitals, Chicago, Illinois 2 Division of Colon and Rectal Surgery, Advocate Lutheran General Hospital, Park Ridge, Illinois
KEY WORDS: Thiersch; bio-Thiersch; Rectal prolapse; Fecal incontinence; Biological mesh; Proctectomy.
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ectal prolapse occurs in 1% of adults over the age of 65 with fecal incontinence (FI) as the predominant symptom in 50% to 75% of cases.1,2 The Thiersch procedure was first described in 1891 as a treatment for rectal prolapse with the use of a silver wire to encircle the anus.3 Thiersch procedures are not popular owing to the complications from the use of nonabsorbable material, failure of the sling, fecal impaction, recurrence of the prolapse, and incontinence.4 Biological meshes as distinct from nonabsorbable materials are safer and effective in their use to reinforce tissues in the anorectal area.5 This video demonstrates a bio-Thiersch procedure using biological mesh as an adjunct to perineal proctectomy in a patient with procidentia and moderate FI (see Video, Supplemental Digital Content 1, http://links. lww.com/DCR/A179). The rationale is a combined procedure in a group of patients prone to the recurrence of prolapse by either technique. The exact effect on FI, however, can only be determined on long-term follow-up in a Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML and PDF versions of this article on the journal’s Web site (www.dcrjournal.com) Financial Disclosure: None reported. Presented at the meeting of The American Society of Colon and Rectal Surgeons, Phoenix, AZ, April 27 to May 1, 2013. Correspondence: John J. Park, M.D., Division of Colon and Rectal Surgery, 1550 N. Northwest Hwy, Suite 107, Park Ridge, IL 60068. E-mail: [email protected] Dis Colon Rectum 2015; 58: e45 DOI: 10.1097/DCR.0000000000000338 © The ASCRS 2015 Diseases of the Colon & Rectum Volume 58: 4 (2015)
prospective study. A sacral nerve stimulator procedure is an option for persistent or worsening FI after a perineal proctectomy alone. The approach involves completing a standard perineal proctectomy, then performing a bio-Thiersch procedure. Patients gave their consent and were operated on after bowel preparation and 1 g of ertapenem for prophylaxis. A biological mesh rolled into a 1-cm-diameter cylinder is sutured by using 2-0 polydioxanone. The anus is encircled by the use of blunt dissection to create a deep tunnel away from the external sphincter at the level of the ischiorectal fossae by using 3 incisions. The cylinder is passed through the tunnel to surround the anus. The cylinder ends are sutured at the appropriate tension, ensuring a patent anal passage, and internalized. We have used porcine dermal matrix (easy to handle, but disintegrated early once) and bovine pericardium (retained longer, but difficult to handle). The ideal biological mesh for use and long-term outcomes needs further research. REFERENCES 1. Stein EA, Stein DE. Rectal procidentia: diagnosis and management. Gastrointest Endosc Clin N Am. 2006;16:189–201. 2. Snooks SJ, Henry MM, Swash M. Anorectal incontinence and rectal prolapse: differential assessment of the innervation to puborectalis and external anal sphincter muscles. Gut. 1985;26:470–476. 3. Goldman J. Carl Thiersch 1822-1895. Concerning prolapse of the rectum with special emphasis on the operation by Thiersch. Dis Colon Rectum. 1988;31:154–155. 4. Devesa JM, Hervás PL, Vicente R, et al. Anal encirclement with a simple prosthetic sling for faecal incontinence. Tech Coloproctol. 2011;15:17–22. 5. Zutshi M, Hull T, Gurland B. Anal encirclement with sphincter repair (AESR procedure) using a biological graft for anal sphincter damage involving the entire circumference. Colorectal Dis. 2012;14:592–595.
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Perineal Proctectomy With Bio-Thiersch Procedure for Complete Rectal Prolapse With Fecal Incontinence Jed F. Calata, M.D.1 • Ajit Pai, M.D.2 • Slawomir Marecik, M.D.2 Leela M. Prasad, M.D.2 • John J. Park, M.D.2 1 Department of General Surgery, University of Illinois at Chicago – Metropolitan Group Hospitals, Chicago, Illinois 2 Division of Colon and Rectal Surgery, Advocate Lutheran General Hospital, Park Ridge, Illinois
KEY WORDS: Thiersch; bio-Thiersch; Rectal prolapse; Fecal incontinence; Biological mesh; Proctectomy.
R
ectal prolapse occurs in 1% of adults over the age of 65 with fecal incontinence (FI) as the predominant symptom in 50% to 75% of cases.1,2 The Thiersch procedure was first described in 1891 as a treatment for rectal prolapse with the use of a silver wire to encircle the anus.3 Thiersch procedures are not popular owing to the complications from the use of nonabsorbable material, failure of the sling, fecal impaction, recurrence of the prolapse, and incontinence.4 Biological meshes as distinct from nonabsorbable materials are safer and effective in their use to reinforce tissues in the anorectal area.5 This video demonstrates a bio-Thiersch procedure using biological mesh as an adjunct to perineal proctectomy in a patient with procidentia and moderate FI (see Video, Supplemental Digital Content 1, http://links. lww.com/DCR/A179). The rationale is a combined procedure in a group of patients prone to the recurrence of prolapse by either technique. The exact effect on FI, however, can only be determined on long-term follow-up in a Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML and PDF versions of this article on the journal’s Web site (www.dcrjournal.com) Financial Disclosure: None reported. Presented at the meeting of The American Society of Colon and Rectal Surgeons, Phoenix, AZ, April 27 to May 1, 2013. Correspondence: John J. Park, M.D., Division of Colon and Rectal Surgery, 1550 N. Northwest Hwy, Suite 107, Park Ridge, IL 60068. E-mail: [email protected] Dis Colon Rectum 2015; 58: e45 DOI: 10.1097/DCR.0000000000000338 © The ASCRS 2015 Diseases of the Colon & Rectum Volume 58: 4 (2015)
prospective study. A sacral nerve stimulator procedure is an option for persistent or worsening FI after a perineal proctectomy alone. The approach involves completing a standard perineal proctectomy, then performing a bio-Thiersch procedure. Patients gave their consent and were operated on after bowel preparation and 1 g of ertapenem for prophylaxis. A biological mesh rolled into a 1-cm-diameter cylinder is sutured by using 2-0 polydioxanone. The anus is encircled by the use of blunt dissection to create a deep tunnel away from the external sphincter at the level of the ischiorectal fossae by using 3 incisions. The cylinder is passed through the tunnel to surround the anus. The cylinder ends are sutured at the appropriate tension, ensuring a patent anal passage, and internalized. We have used porcine dermal matrix (easy to handle, but disintegrated early once) and bovine pericardium (retained longer, but difficult to handle). The ideal biological mesh for use and long-term outcomes needs further research. REFERENCES 1. Stein EA, Stein DE. Rectal procidentia: diagnosis and management. Gastrointest Endosc Clin N Am. 2006;16:189–201. 2. Snooks SJ, Henry MM, Swash M. Anorectal incontinence and rectal prolapse: differential assessment of the innervation to puborectalis and external anal sphincter muscles. Gut. 1985;26:470–476. 3. Goldman J. Carl Thiersch 1822-1895. Concerning prolapse of the rectum with special emphasis on the operation by Thiersch. Dis Colon Rectum. 1988;31:154–155. 4. Devesa JM, Hervás PL, Vicente R, et al. Anal encirclement with a simple prosthetic sling for faecal incontinence. Tech Coloproctol. 2011;15:17–22. 5. Zutshi M, Hull T, Gurland B. Anal encirclement with sphincter repair (AESR procedure) using a biological graft for anal sphincter damage involving the entire circumference. Colorectal Dis. 2012;14:592–595.
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