International Journal of Colorectal Disease

, Volume 28, Issue 7, pp 1027–1030

Impact of prolapse mass on Contour® Transtar™ technique for third-degree rectal prolapse

Authors

    • Department of General and Visceral SurgeryAsklepios Hospital Altona
  • Björn Schinkel
    • Department of General and Visceral SurgeryAsklepios Hospital Altona
  • Sven Jürgens
    • Pelvic Floor UnitAltonaer Tagesklinik
  • Curosh Taylessani
    • Department of General and Visceral SurgeryAsklepios Hospital Altona
  • Wolfgang Schwenk
    • Department of General and Visceral SurgeryAsklepios Hospital Altona
Original Article

DOI: 10.1007/s00384-013-1649-1

Cite this article as:
Petersen, S., Schinkel, B., Jürgens, S. et al. Int J Colorectal Dis (2013) 28: 1027. doi:10.1007/s00384-013-1649-1

Abstract

Purpose

Contour® Transtar™ procedure for rectal prolapse is a promising technique according to safety and efficacy. One potential surgical problem is failure of the stapler due to the thick rectal wall. In order to evaluate the practicability and the impending limitations of the Contour® Transtar™ technique, we reviewed our data with special respect to the necessity of additional anastomosis suturing.

Methods

A prospective analysis of 25 consecutive patients, which underwent Contour® Transtar™ procedure from January 2009 to July 2012, was performed. For statistic analysis, the groups with and without additional suturing of the anastomosis were evaluated according to patient characteristics and surgical outcome.

Results

Twenty-five patients, three men and 22 women, underwent transanal Contour® Transtar™ stapling procedure for rectal prolapse. Due to stapling failure, additional suturing of the anastomosis was necessary in 4 of 25 procedures (16 %). Age (74.1 vs. 83.1 years) and body mass index (30.8 vs. 22.7 kg/m2) were significantly different with and without additional suturing. Operative time was longer (62 vs. 31 min), more cartridges were used (12 vs. 6), and the specimen weight was higher (220 vs. 107 g) in patients with additional suturing. Early postoperative complications were observed in two patients without anastomosis suturing including one patient with bleeding and systemic inflammatory reaction in one case. Postoperative stay did not differ between both groups.

Conclusion

Patients with extensive obesity, which present with a substantial rectal prolapse, may need additional suturing of the rectal anastomosis after Contour® Transtar™ stapling. This causes prolonged operative time. However, this does not correlate with complications and it is not related to significant longer hospital stay.

Keywords

Rectal prolapsePerineal procedureSurgeryComplication

Introduction

The treatment of rectal prolapse differs significantly between surgeons, countries, and regions [1]. According to the guidelines of the American Society of Colorectal Surgeons, patients with a full-thickness rectal prolapse who are not candidates for an abdominal operation may be treated with a perineal rectosigmoidectomy [2]. Especially in elderly patients with increased risk of perioperative morbidity, which may not be suitable for transabdominal rectopexy (with or without resection), transanal resection procedure for rectal prolapse is recommended [3]. During the last decade, beside the well-known Altemeier procedure, transanal stapling procedures have been established [4]. Although Contour® Transtar™ procedure is a promising technique according to its technical feasibility and safety, this technique still needs to be evaluated in comparison to the established transanal procedures [5]. In order to evaluate the practicability and the impending limitation of Contour® Transtar™ technique, we reviewed our data with special respect to the necessity of additional anastomosis suturing.

Methods

Between January 2009 and July 2012, 35 patients were treated surgically for third-degree rectal prolapse at the Department of General and Visceral Surgery at the Asklepios Hospital Hamburg-Altona in cooperation with the Pelvic Floor Unit of the Altonaer Tagesklinik. It was our policy to recommend laparoscopic anterior rectosigmoid resection for all patients who were eligible for abdominal resection and anastomosis. Twenty-five patients who were not suitable for abdominal procedure due to age, comorbidity, and/or patients attitude underwent perineal Contour® Transtar™ procedure and were included in the prospective study. Patient characteristics and operative details, such as the amount of cartridges used and the specimen weight, were evaluated prospectively. The length of rectal prolapse was measured prior to surgery in lithotomy position, measuring the length on the ventral aspect by a ruler. All patients underwent Contour® Transtar™ stapling procedure. The procedure has been described in details previously [6].

In brief, no preoperative bowel preparation was performed. A single-dose intravenous antibiotic prophylaxis was administered prior to surgery. The patient was operated on under general anesthesia and placed in a lithotomy position. The external prolapse was fully exposed and cut open at three and nine o’clock with a straight stapler. The Contour® Transtar™ stapler was inserted in the prolapse and turned counterclockwise. Care was taken to make sure that the resection line was posed parallel to and above the dentate line; the pin of the stapler was pushed through the rectal wall under digital control. Maintaining the traction on the prolapse, the stapler was closed and fired. This step was performed counterclockwise approximately four to six times. In contrast to previous publications, the stapler line was not oversewn routinely [6]. After firing the complete circumference, the circular stapling line was inspected and checked for integrity. In cases where the stapled line was not intact and perirectal fat was apparent, this part of the stapled anastomosis was sutured by single full-thickness stitches. For this, a Lonestar™ retractor device was inserted and 4/0 monofilament polydioxanone was utilized.

Postoperative care

Patients were started on a low fiber and easily digestible diet on the first postoperative day. Patients received analgesics according to the department’s analgesic protocol (oral NSAIDS plus oxycodone/naloxone). Discharge from hospital was planned on the third to fifth postoperative day depending on the patient’s condition, which was observed closely for any complication.

Follow-up was organized by the outpatient clinics. Patients were ask for reevaluation 3 months and 1 year after surgery. Patients, who were not able to come to the outpatient clinics underwent telephone interview.

Data management and statistical analysis

Statistical analysis was performed using the SPSS 18.0 software package (SPSS Inc., USA). Pearson chi-square test compared the incidence of variables and or t test for comparison of the means for the groups with or without additional anastomotic stapling. Correlation between variables was performed using two-tailed Pearson correlation test. Variables with p value less than 0.05 were considered to be significant.

Results

During the timeframe, a total of 35 patients were treated surgically for rectal prolapse. Of those 25 patients, three men and 22 women underwent transanal procedure for rectal prolapse. Due to patients age, comorbidity, or patient’s attitude, these patients were not suitable for anterior rectosigmoid resection and rectopexy. The mean age was 81.5 years (±6.8 years) and the mean body mass index was 24.1 kg/m2 (±5.3 kg/m2). The mean operative time was 36 min (±20 min); seven (±3) cartridges were used ranging from 4 to 16 cartridges. In four of 25 patients, the stapling procedure caused an insufficient stapling line (16 %).

Biometrical data, length of rectal prolapse, operative time, cartridge used, weight of the specimen, and postoperative stay in the groups with and without additional oversewing of the stapler line are given in Table 1. Patients who required additional handsuture of the stapler line were significantly younger (−9 years) and more obese (BMI +8.1 kg/m2). Twice as many cartridges were used in patients with additional sutures and weight of the specimen was almost twice as high in these patients (+113 g). Furthermore, operative time was twice as long in the latter group of patients.
Table 1

Biometrical data and patient characteristics with and without additional anastomosis suturing

Patient characteristics

 

No additional suturing, n = 21

Additional suturing n = 4

p value

Age

 

83.1 (±5.5)

74.1 (±6.1)

<0.01

Body mass index (kg/m2)

 

22.7 (±4.7)

30.8 (±2.6)

<0.01

Gender

Female

19

3

 

Male

2

1

0.46

Prolapse length (cm)

 

9.3 (±3.1)

9.5 (±0.7)

0.94

Operative time (min)

 

31 (±13)

62 (±31)

0.02

Cartridge

 

6 (±2)

12 (±4)

<0.01

Specimen weight (g)

 

107 (±62)

220 (±44)

<0.01

Hospital stay (days)

 

5 (±2)

7 (±4)

0.18

As shown in Fig. 1, the body mass index correlates significantly the specimen weight (r = 0.62, p < 0.01). Consequently, a correlation was also observed between BMI and operative time (r = 0.68, p < 0.01), specimen weight and operative time (r = 0.77, p < 0.01), and between age and operative time (r = −0.79, p < 0.01).
https://static-content.springer.com/image/art%3A10.1007%2Fs00384-013-1649-1/MediaObjects/384_2013_1649_Fig1_HTML.gif
Fig. 1

Correlation of specimen weight and body mass (r = 0.62, p < 0.01)

Early postoperative complications were observed in two patients including one patient with bleeding and systemic inflammatory reaction in one case, both in the group without hand-sewn anastomosis. No cases of severe skeptical reaction were observed. The mean postoperative hospital stay was not different between both groups.

The mean follow-up was 13 months (±11 months). One patient was lost to follow-up. Two recurrences were observed during the follow-up time. In one patient, the recurrence occurred immediately after surgery; in another patient the prolapse was observed 12 months after surgery. Both patients were treated by a second Contour® Transtar™ stapling.

Discussion

Patients undergoing Transtar™ procedure can be divided in two groups: those with sufficient stapler line and a minority that required manual suturing of the stapled line because of primary failure. Patients that require additional suturing were younger and more obese. Therefore, patients with a BMI >30 kg/m2 should be considered technically more demanding candidates for the Transtar™ procedure.

In general, two different approaches can be distinguished in the surgical treatment of rectal prolapse, i.e., the transabdominal route and the perineal approach. Perineal procedures are recommended for patients, which may be not suitable for transabdominal rectopexy because of concomitant cardiovascular or pulmonary diseases. In the past, the majority of patients undergoing perineal were treated with either Delorme’s operation or a perineal rectosigmoidectomy, also known as the Altemeier procedure [3]. The transperineal access is safe and improves quality of life substantially [7, 8]. The use of a stapling device, as alternative to the Altemeier procedure, is in debate for decades [9]. In 2008, Scherer et al. presented a new perineal surgical approach, the so-called perineal stapled prolapse resection, for the treatment of external rectal prolapse. The use of the Contour® Transtar™ stapler (Ethicon Endo-Surgery, Norderstedt, Germany) permits safe transanal resection of external rectal prolapse by a technical modification of the Altemeier procedure and allows resection of rectal intussusception under direct view [6]. As suggested by Romano et al., the technique is safe, easier, and faster to perform than the perineal Altemeier rectosigmoidectomy [5]. Since recently no conclusive guidelines for choosing the right perineal procedure for rectal prolapse exist, we choose Transtar™ procedure because of its above-mentioned advantages [1].

The data presented here are comparable to others in terms of operative time and the use of cartridges [10, 11]. Hetzer et al. as well as Mistrangelo et al. used a mean of six cartridges for the stapling procedure. In their series of 32 and five patients, the mean operative time of 40 min was also comparable to the operative time, given by the above-mentioned groups [6]. According to the surgical result, it is remarkable that the weight of the specimens in this series is more than twice as high than reported by Hetzer et al. and Scherer et al. reported with approximately 60 g rectal wall tissue [10].

According to perioperative complications, such as hemorrhage or systemic inflammatory response syndrome, the data presented here are also comparable to others [5, 12]. However, we have to admit that we did not follow the experts’ recommendation for suturing the complete anastomosis [13]. Potentially, this simple technique might inhibit severe bleeding from the stapled line.

In contrast to other publications, we report here about the limitation of Contour® Transtar™ in high volume rectal prolapse. Only Scherer et al. previously reported of 1 out of 15 cases, where they could not finish the operation by Transtar™ procedure [6]. In our series, we finished all four cases by additional hand-sewn anastomosis, which is the same like Scherer et al. did in their case. Martelucci et al. reported of one rectal perforation and four posterior dehiscences in a group of 133 patients, which underwent Contour® Transtar™ procedure not for external rectal prolapse but for obstructed defecation. Two of these were repaired intraoperatively, one required transanal repair on the first postoperative day, and the fourth resolved on conservative treatment. No stoma was required [14]. Martellucci et al. also recently published a series of six patients with Contour® Transtar™ for rectal prolapse. In the discussion, they advised that there should not be too much tissues in the jaws of the Contour® instrument, but it often happens that the rectal wall is very thick, making the complete closure of the stapler agraphes difficult [15]. It is obvious that the attempt to perform a Contour® Transtar™ procedure in patients with BMI >30 kg/m2 caused much higher effort in terms of operative time and costs for cartridges than in patients with BMI <30 kg/m2. In contrast, measuring the length of rectal prolapse did not provide any conclusive data that might predict technical problems with Transtar™ stapling. From our understanding, this is caused by different morphologies of prolapses. A prolapse with a thick and fatty rectal wall is not associated with prolapse length.

The follow-up data show a significant recurrence rate after Transtar™ procedure. The recurrence rate is higher than other reports on Transtar™ surgery of rectal prolapses. However, recurrences are also reported after other perineal procedures. Sailer and colleagues published an overview with a mean recurrence rate of 10–15 % for perineal procedures. Nevertheless, there are also recent data with higher rates available, e.g., Ris et al. published data after Altemeier procedure with a long-term follow-up of 48 months showing a relatively high recurrence rate of 25 % [3, 16]. In this context, it is necessary to state that the oversewing of the stapled anastomosis is not meant to avoid recurrences, but only to close a defect after incomplete stapling to avoid inflammatory response or pelvic sepsis.

Conclusion

With special respect to the Contour® Transtar™ technique, two types of prolapse should be differentiated. The first type is a lightweight rectal prolapse in very old normal weighted women. In these cases, Contour® Transtar™ stapling is a safe and easy technique. The other type of prolapse is a thick prolapse in younger female patients with substantial obesity. In these cases, the perineal Contour® Transtar™ stapling is complicated, needs significant longer operative time and nearly double as much cartridges and an additional suturing of the stapled line may be necessary. The question remains, whether in these cases the classic Altemeier procedure should be regarded as an alternative.

Copyright information

© Springer-Verlag Berlin Heidelberg 2013