A rectal prolapse
Trans-Anal Evisceration After Perineal Proctectomy
First of all, there is an urban myth that this could happen without previous surgery if one is corpulent and flushes an airplane toilet without first standing up, because of the negative pressure flushing mechanism. This has never been reported. There is one case report in JAMA in 1987 without photographs or an eye witness in which the individual involved said. “It all came out” . Whether this was a small bowel evisceration through a ruptured rectum, or simply a rectal prolapse is not clear in that article. And in any case it was not in an airplane, but a cruise ship. There are documented cases with photographs and detailed clinical histories of children sitting on swimming pool drains with massive trans-anal small bowel eviscerations and massive small bowel loss . There are also case reports of rectal rupture with small bowel evisceration in patients with known rectal prolapse, and no particular triggering event [5, 6] (Fig. 8.2). This seems also not to be rare. Morris cites 53 case reports in 2003 going back to the original report by Brodie in the Lancet in 1827 . Screening PubMed since 2003, 15 more cases would be added for a total of 68 case reports. Not all of these were in patients with rectal prolapse, but at least 70% were.
Eviscerated small intestine in a patient with known rectal prolapse
To these I add one published case report of the same event shortly after a perineal proctectomy with presumed rupture of the anastomosis (, Fig. 8.3), and add an additional case of my own, never published. She was a patient from a mental hospital and prone to rather wild behavior. The photograph of my patient was taken the evening of her surgery, (Fig. 8.4), and immediately repaired by reduction of the small bowel via laparotomy and reinforcement of the anastomotic line, through which the small bowel had come. She had thereafter an uneventful recovery. In the published case report the prolapse did not occur until four days after surgery while straining to defecate in a 42-year-old male. The small bowel was necrotic by the time he made it back to the hospital and to surgery, so the anastomosis was taken down, the ileum resected and an end colostomy formed. A grade 4 surgical complication .
Eviscerated small intestine in a patient who had had an Altemeier 4 days earlier
Eviscerated small intestine in a patient who had had an Altemeier 8 hours earlier
So did these two cases occur due to can anastomotic leak, a poorly constructed anastomosis, or a sudden vast increase in intra-abdominal pressure stressing an anastomosis? The other eviscerations that have been reported have resulted in the absence of an anastomosis. In the case of swimming pools and toilets, there was a large pressure gradient across the rectal wall. In the case of preexisting rectal prolapse, might there have been a solitary rectal ulcer not previously diagnosed? In any case it is not a rare event.
Anastomotic leaks have been often reported after perineal proctectomy, including four in the original paper by Altemeier in 1971 . (Digression. Perineal proctectomies had been done for many years before Altemeier’s 1971 series was published . To the original operation he added a levatorplasty. But with the passage of time virtually all (non-stapled) perineal proctectomies have become known as Altemeiers.) There were eight leaks in a rather massive series of 518 patients reported from the University of Minnesota , a leak rate that compares very favorably with the published risk of leak of colonic anastomoses of between 7 and 8% in Holland . Though some are described as asymptomatic, it is hard to imagine how or why they could have been found in the absence of symptoms. Many were treated by prolonged courses of intravenous antibiotics and bowel rest. A grade 2 complication. If a pelvic abscess results from the leak, trans-anastomosis drainage has been effective. In some cases stomas were done as well, which implies that the patient must have been pretty sick. No additional details were given. One case of massive surgical emphysema was reported extending through the retroperitoneum all the way to the patients face early in the post operative period  (Fig. 8.5a and b).
a Emphysema seen at surgery in a patient with development of subcutaneous emphysema early in the postoperative period. b Mapping on CT of the extent of the patient’s emphysema
Rectal ischemia or infarctions are not an unusual presentation of rectal prolapse that becomes incarcerated . Indeed, perineal proctectomy is well suited to that presentation and as long as both ends after resection are healthy. However, acute ischaemic infarction of the segment of colon above the anastomosis in an Altemeier is also worth mentioning. There are no published case reports of such an event, but there is a case with which I am familiar. A patient had had a perineal proctectomy. She had a lower midline scar on her abdomen that was many years old and she was unable to tell where it came from. It was found too late to be from a previous sigmoid resection for an unknown disease. There was a segment of sigmoid colon that lost its blood supply from both above and below, and nothing available in between. The result of that event, because it was not suspected was not good.
However before abandoning perineal proctectomy because of the risk of ischemia, be aware that there is also a case of rectosigmoid ischaemia after a Delorme procedure, which is only a very limited mucosectomy . How could such a thing happen? The published case report offers no suggestions beyond a proximal impaction (Fig. 8.6).
Fecal impaction in a previous Delorme who developed rectal ischaemia one month post op
Bleeding is a prominent risk in all of perineal surgery from hemorrhoids to fistulas, and certainly for all perineal procedures for prolapse, with the possible exception of injection sclerotherpy [16, 17] (Injection sclerotherapy is also a procedure for rectal prolapse, especially in children, but with no reported complications). There are individual case reports of the need to return to surgery to suture the bleeding anastomosis but that is not unique to the Altemeier. But there is a special risk related to perineal proctectomy. Once the rectal mucosa and muscularis are divided proximal to the dentate line, mesenteric vessels are serially divided and ligated. As that progresses upwards, every surgeon who does this procedure thinks more and more about how well controlled the mesenteric division is. If a vessel slips away it will retract into the upper pelvis, completely out of reach. Laparotomy is the only option regardless of the fragility of the patient. There are no case reports of this occurring. None of the larger series specifically mention it. It has not happened to me. But I have spent plenty of time worrying about it.
This operation interestingly, in cruising PubMed, is discussed in by far the most publications of all perineal operations for rectal prolapse. Yet it is one with which I have relatively little exposure. It is quite simple: a sleeve mucosectomy and corrugation of the submucosal muscle with anastomosis of the mucosa over the corrugated muscle. So it is sort of an autologous Thiersch. This and all treatments of rectal prolapse, as well as history, anatomy and physiology are discussed at length in the excellent review by Wu et al. .
As written above, what could go wrong with the Delorme? Ischemia did develop 4 weeks after surgery in a patient who had a fecal impaction just above the peritoneal reflection requiring major surgery  (Fig. 8.6). Complications were not mentioned in many publications but as frequent as 45% in others. Suture line dehiscence was perhaps the most common serious complication and again its frequency and severity varied greatly. Several are described as asymptomatic but again, why would one look if there were no symptoms? Still, with an intact muscularis, the danger should have been small. Reoperation was mentioned in several publications, usually to control bleeding but even for fecal diversion after a mucosal suture line separation . How could that happen? Stricture requiring dilation was reported in many publications . The corrugation would in fact function as stated above as a muscular circlage (Fig. 8.7). Delorme in many publications is combined with either levatorplasty or circlage, a sort of belt and suspenders, which, among other things, added subcutaneous wound infection to its possible complications .
Presumably what a barium enema should show in a patient after a Delorme
Reports Comparing Two or More Procedures
Several case series have been published in which there are comparisons of more than one operation in a prolapse population. These are not randomized trials so they are clearly subject to selection bias in allocation of patients to one procedure or another, particularly in those publications comparing an abdominal approach to a perineal one. Efficacy is not really assessable. But it was hoped that these comparative studies could provide information about relative risk of complications from a group of surgeons doing both in the same institution. Of the many, there are two comparing abdominal surgery to a Delorme. Interestingly, in one there were four deaths in the Delorme group, three in the early postoperative period including one small bowel perforation (??), and one six months later after a dilation of a rectal stricture . The second study only reported a post op bleed requiring intervention in the Delorme group . Altemeier was compared to Delorme in two studies. In one there were four leaks in 22 Altemeiers, three requiring stomas (!!) and one small bowel obstruction and in the Delorme group, one anal stenosis, a congestive heart failure, and two urinary tract infections . Complications arose in 22% of Altemeier patients and 7% of those having Delorme. In the second there were no complications in the Delorme group but two leaks in 32 patients, one death early and a hematoma requiring a stoma in the Altemeier meter group. In addition, there were four late strictures .