External Pelvic Rectal Suspension (The Express Procedure) for Full-Thickness Rectal Prolapse: Evolution of a New Technique

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Abstract
The Délorme's operation for rectal prolapse is a safe procedure but has a high recurrence rate. We aimed to develop an operation akin to it, but designed to reduce this deficit. Thirty-one consecutive patients with rectal prolapse were included in the study. Initially, a conventional Délorme's procedure was performed and sutures or strips of Gore-Tex® were attached circumferentially to the apex of the prolapse, tunneled subcutaneously, and anchored to the external surface of the pelvis. Subsequently, the procedure was modified. Acellular porcine collagen strips were used and buried within the apex without plication of the denuded rectal musculature. Patients were formally assessed preoperatively and four months postoperatively by symptom and quality of life questionnaires and subsequently by regular clinical review. In the Gore-Tex® group (N = 11; males:females = 10:1; mean age, 61 years) three patients underwent suture repair and eight had strip fixation. All suture repairs developed sepsis and one patient had a recurrence. Seven of the strip fixations (88 percent) developed sepsis that resulted in implant extrusion. There was one full-thickness and one mucosal recurrence after a median follow-up of 25 months. In the collagen group (N = 20; males:females = 2:18; mean age, 63 years), sepsis occurred in four patients, requiring surgical intervention in one patient (5 percent) (cf Gore-Tex® group, P = 0.002). There was one mucosal and three full-thickness (15 percent) recurrences after a median follow-up of 14 months (cf Gore-Tex® group, P = not significant). Significant improvements in symptom and quality of life scores were recorded in both groups at four months. A new, minimally invasive perineal procedure for rectal prolapse has been developed and initial data testify to its relative safety provided collagen is used. It remains to be seen whether long-term recurrence rates will be lower than those of conventional perineal procedures.