LAUSR

Colonic prolapse (CP) is a rare complication after low coloanal anastomosis (CAA), with occurrence ranging from 1.3% to 10%. In addition to its exteriorization through the anus, CP is associated with worsening of anal function, anal pain, soiling, urgency, fragmentation or faecal incontinence. Advanced age, gender, obesity or extent of sphincter resection have been reported to be associated factors related to rectal prolapse. Because CP-related symptoms impair patients’ quality of life, surgical management is often required. We propose to use a novel surgical technique inspired from the Orr-Loygue mesh rectopexy approach for a full-thickness colonic J-pouch prolapse after proctectomy with CAA. A 74-year-old female, with no previous medical history, underwent neoadjuvant chemoradiation for a low T3N+ rectal cancer located 0.5 cm above the dentate line. Eight weeks later, a laparoscopic total mesorectal excision was performed with partial intersphincteric resection and CAA. Reconstruction with a colonic J-pouch was performed and a loop ileostomy was fashioned. She made an eventful recovery. Three months later, she developed a full-thickness colonic J-pouch prolapse, confirmed by an anal examination. Since the prolapse occurred under protective ileostomy and because it was disabling for the patient, surgical treatment was proposed. The surgical procedure was performed through an abdominal midline incision. Previous mobilized left colon was released to view the left and right ureter. The colonic J-pouch was mobilized from the pre-sacral space, then laterally and anteriorly until the pelvic floor was seen. Once the colonic J-pouch was fully mobilized, we took a 1-cm large aponeurotic graft of each side of the rectus muscle. We previously measured the necessary length of the graft from the sacral promontory to the lateral wall of the colonic J-pouch. We sutured with non-resorbable stitches each ‘graft’ to the sacral promontory and the other extremity to the lateral wall of the J-pouch, paying attention that the grafts kept the pouch out of the pelvis with smooth tension (Fig. 1). A pelvic suction drain was left in place. The patient made an uneventful recovery and left hospital on post-operative day 7. She performed biofeedback perineal kinesitherapy for 1 month after the surgery. Ileostomy was closed 3 months later. After a follow-up of 37 months, no recurrence of the CP occurred. She still has fragmentation managed by colonic irrigation with satisfactory result. Surgical management of CP after rectal resection and CAA remains controversial. Small published series reported transanal approaches (circumferential removal with or without posterior anal myorrhaphy, mucosal resection, transanal plication) with low recurrence rates. In all but one surgical details or post-operative outcome were lacking. The major drawback of the transanal approach is the need to remove the pouch and therefore to negatively impact the functional outcome. Through the abdominal ‘colopexy’ the pouch can be retained. Changchien et al. described an abdominal pouch pexy using biological mesh with no recurrence after 9-month follow-up. Given the price of the biological meshes and the logistical difficulties in obtaining them, we did not use this technique and replaced them by solid aponeurotic grafts. It is our hypothesis that non-foreign organic material decreases the risk of mesh migration and sepsis. The present modified Orr-Loygue aponeurotic graft ‘colopexy’ seems efficient, safe and reproducible and could become a useful tool in the colorectal surgeon’s armamentarium. For patients operated on for low rectal cancer with J-pouch CAA and intersphincteric resection, this might represent an alternative to the pouch removal.