What is the best management for a patient with rectal prolapse and chronic constipation?

Rectopexy with Sigmoid Resection for Rectal Prolapse with Chronic Constipation

For a patient with rectal prolapse and chronic constipation, rectopexy with sigmoid resection (Option C) is the best management approach, as it addresses both the anatomical defect and the underlying bowel dysfunction while achieving the lowest recurrence rates and improving constipation symptoms. 1, 2, 3

Rationale for Sigmoid Resection in Constipated Patients

The presence of chronic constipation fundamentally changes the surgical decision-making algorithm. When pre-existing constipation is documented, adding sigmoid resection to rectopexy reduces postoperative constipation rates significantly compared to rectopexy alone. 1, 2 The American College of Surgeons specifically recommends this combined approach for patients with significant pre-existing constipation. 2

• Rectopexy alone (Wells rectopexy, Option D) can worsen constipation in up to 50% of patients, making it inappropriate for those already constipated. 1
• Studies demonstrate that rectopexy with sigmoid resection improves constipation complaints from 43.6% to 25.6% postoperatively, while also reducing mean colonic transit time from 47.8 to 38.5 hours and rectosigmoid transit time from 21.1 to 12.7 hours. 3

Superior Outcomes with Abdominal Approach

Abdominal procedures achieve dramatically lower recurrence rates (0-8%) compared to perineal approaches (5-21% to 40%). 1, 4 This translates directly to better long-term quality of life and reduced need for reoperation.

• The American Gastroenterological Association recommends abdominal rectopexy for younger patients with symptomatic rectal prolapse due to these superior recurrence rates. 2
• In a series of 102 patients treated with rectopexy and sigmoid resection, the recurrence rate was only 1.9% with 0% mortality and 4% morbidity. 5
• Another study of 42 patients showed zero recurrences at 54-month follow-up with rectopexy and sigmoid resection. 3

Why Not Perineal Approaches (Altemeire or Delorme)

Perineal procedures (Options A and B) are reserved for elderly or high-risk patients with significant medical comorbidities, not for routine management. 1, 4

• The American Society of Colon and Rectal Surgeons reports recurrence rates as high as 40% with perineal techniques. 1
• These approaches should only be chosen when accepting higher recurrence risk in exchange for lower perioperative morbidity in frail patients. 1

Laparoscopic Technique Preferred

The laparoscopic approach to rectopexy with sigmoid resection offers reduced postoperative complications and shorter hospital stays compared to open surgery. 1, 2

• Mean hospital stay is approximately 4-5 days with laparoscopic approach. 6, 7
• Conversion rates are low (approximately 6.6%) with experienced surgeons. 7
• The Society of American Gastrointestinal and Endoscopic Surgeons recommends laparoscopic rectopexy techniques for their minimally invasive benefits. 2

Critical Caveat: Avoid Resection in Diarrhea/Incontinence

If the patient has pre-existing diarrhea or severe fecal incontinence rather than constipation, bowel resection should be avoided as these symptoms may worsen postoperatively. 4, 2 The American Society of Colon and Rectal Surgeons specifically advises against resection in this population. 2

Additional Functional Benefits

Beyond addressing constipation, rectopexy with sigmoid resection improves fecal incontinence, which affects many patients with rectal prolapse:

• Incontinence improved from 66.6% to 23.1% postoperatively in one series. 3
• Mean resting pressure increased from 36.5 to 46.0 mmHg and maximum squeeze pressure from 90.5 to 103.0 mmHg. 3
• The anorectal angle improved from 102 to 98 degrees, correlating with better sphincter tone and continence. 3

Preoperative Screening Consideration

Patients with rectal prolapse have a 4.2-fold increased risk of colorectal cancer compared to age-matched controls, with rectosigmoid cancer prevalence of 5.7% versus 1.4%. 8 Endoscopic screening should be performed before definitive surgery, particularly given the chronic constipation and bowel habit changes in this population. 8