Delorme’s Procedure for a rectal prolapse

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Introduction
A rectal prolapse is when the normal supports of the bowel become weakened, allowing the muscle of the bowel to drop down through the anus. This is sometimes more noticeable after a bowel
movement. As the condition progresses, a rectal prolapse may occur with everyday activities such as walking or even be present continuously. The recurrence rate with Delorme’s is very high 25%-30%. The prolapse can cause pain, constipation, faecal incontinence, mucus discharge or bleeding.

Treatment Options
The Delorme’s operation is aimed at preventing the lax bowel wall from bulging down through your bottom. This involves the removal of the inner lining from the surface of the prolapsing bowel.
During the healing process scar tissue is formed which then prevents the prolapse returning. With some patients, if the bowel muscles are significantly weakened then it may be necessary to remove the segment of the prolapsing bowel and rejoin the bowel to the anal canal. This is called an Altemeier’s procedure.

Both the Delorme’s and Altemeier’s procedures are done via the anus and no external incision is needed, however there may be some bruising around the anus.

Risks of this operation
As with any other operation, risks with this procedure include:

• Chest infection – This would require antibiotics and physiotherapy.
• Blood clots in the legs (deep vein thrombosis) or in the lung (pulmonary embolism) – We decrease this risk by using compression stockings and blood thinning injections. See page 5 for further
information.
• Anaesthetic – this operation is carried out under a general anaesthetic (you will be asleep) or a spinal anaesthetic. Pre assessment will provide a patient information leaflet about anaesthetics
and the associated risks. If you are at increased risk because of other medical problems, your consultant may refer you to an anaesthetist for a formal assessment.
• Bleeding.
• Patients who are overweight, smoke or have other medical problems are at increased risk of all of the above complications.

What is Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE)?

Your blood flows through your body in blood vessels called veins and arteries. If there is damage to these vessels, for example if you cut yourself, the blood usually forms a plug or ‘clot’ to stop any bleeding. However sometimes the blood’s clotting mechanism goes wrong and can form a blood clot in the veins. When this happens the clot is called a ‘thrombus’. If the clot is deep inside one of the veins it is called a Deep Vein Thrombosis (DVT). A DVT is more likely to happen if you are unwell and inactive or more inactive than usual. Sometimes a clot can become loose and travel through the blood stream to your lungs. This is called a Pulmonary Embolism (PE) and can potentially be fatal.

As you are in hospital and likely to be less mobile than usually due to your illness or an operation you may be at more risk of having a DVT. To reduce the risk of this you will be assessed to see if you are more likely than normal to get a DVT. It is also important that we know all the medicines that you are taking.

What are the signs of DVT and PE?
• Pain or swelling in your leg
• The skin on your leg feels hot or discoloured (red, purple or blue), other than bruising around the area if you have had an operation
• The veins near the surface of your legs appear larger than normal or you notice them more
• You become short of breath
• You feel pain in your chest or upper back
• You cough up blood

What we do to reduce the risk of DVT
If you are at risk you may be given on of the following to reduce the risk of you developing a DVT:
• Anti-embolism stockings. These are tight stockings which squeeze your feet and lower legs and thighs helping your blood to circulate around your legs more quickly. You may not be offered these if you have recently had a stroke, or if you have problems with the veins in your legs
• A medicine called an anti-coagulant which thins the blood and helps prevent clots from forming. This may be an injection just under the skin or a tablet.
• We will encourage you to mobilise as soon as you are able and assist you in doing so. The staff should discuss the benefits and any risks with these treatments, but please ask the staff looking after you if you have any questions.

When you go home
Before you go home you should make sure that you know what to do to reduce the risk of a DVT developing. If you develop any of the symptoms described please seek immediate medical advice.

The risks of this operation also include:
• Urinary retention – unable to pass urine
• Return of rectal prolapse
• Worsening or development of faecal incontinence
• Worsening or development of constipation
• Injury to the pelvic structures
• Failure to open your bowels

If you have the Altemeier’s procedure (resection) a leak may occur at the site where the two cut ends of the bowel are joined and occasionally a re-operation may be required, culminating in a stoma.

Risks of not having surgery
Just as there are risks of having surgery, the risk of not having surgery is that your symptoms may become worse.

Preparation for surgery
You will come into hospital in the morning or for medical reason you may be admitted the day before your operation. Some form of bowel cleansing in the form of enemas or Picolax will be given prior to surgery. It is down to the individual surgeon and procedure which bowel prep you are given. Your pre-assessment nurse will help organise your admission and advise you appropriately.

After Surgery
You may have a drip in your arm and a urinary catheter to drain your bladder. The doctors will decide when the drip can come down and you can eat and drink. The urinary catheter normally stays for 1-2 days. It is quite common to experience some discomfort when you pass urine for the first time. There is a risk of urinary retention (inability to pass urine). You will be given a laxative after your operation to help soften your stools and stimulate a bowel action. At first you may find opening your bowels a little painful this should get easier in time. Regular painkillers should help, however some pain killers can cause constipation. You will be able to shower or have a bath the day after the operation, please ask a member of staff for assistance.

Diet
You should gradually increase the amount of fibre in your diet. It is important that you drink plenty of fluid as well. Try 6-8 cups of anything you like e.g tea, water, juice.

Bowel Actions
Constipation and straining to go to the toilet should be avoided. You may experience a small spotting of blood when you start opening your bowel, some bleeding may continue for up to two weeks. This is normal, however if the bleeding increases you must inform your doctor or nurse immediately or seek urgent attention via Accident and Emergency (A&E). You may also find that you have a small mucus discharge from the anus for about a week. It is advisable that you wear a pad to protect your clothing from soiling.

Exercise
Your symptoms may not improve immediately after the operation, particularly if you have weak muscles around the anus. Sometimes pelvic floor exercise might help to strengthen these muscles. The time taken to get back to normal activities varies from person to person. It can take several months following surgery before full benefit is achieved. You can help yourself by avoiding heavy lifting and straining.

Driving
You can begin to drive when you feel comfortable and confident enough to do an emergency stop safely. Check with your insurance company about any exclusion they may have. This includes being under the influence of some pain medication. You are not excluded form wearing a seat belt.

When you go home
Your stay in hospital is normally 2-4 days. Usually you are discharged when you are medically fit and able to open your bowels. You should have a follow up with the consultant normally 4-6 weeks after the operation. It is quite normal to have ‘good’ and ‘not so good’ days. However, it is important to contact the GP if any of the following occur:

• Discharge
• High temperature
• Uncontrolled shivering/ feeling hot then cold
• Pain when passing urine/frequent need to pass urine or very offensive smelling urine.
• Difficulty with breathing, chestiness or cough with green or yellow phlegm
• Pain in calf, leg or chest
• Vomiting

For urgent out of hour’s problems such as heavy bleeding or prolapse you can go straight to A&E or be referred to the on call surgical registrar via your GP. During normal working hours you can contact the Stoma Care Team who would advise you appropriately or contact the relevant consultant’s team.

This information leaflet is to support and not to replace discussion between you and your clinician. Before you give your consent to any treatment you should raise any questions you have with your clinician.