A 79-year-old woman was referred from another hospital for full-thickness RP measuring 4 cm in length (Figure 1a). She had a habit of straining hard during defecation and had a history of seizures, stroke, subarachnoid hemorrhage, and spondylosis. Considering the patient's age, comorbidities, and preferences, we decided to perform the GMT procedure. The surgery was performed under general anesthesia in the lithotomy position 13 weeks after the first visit due constraints brought about by the coronavirus disease 2019 (COVID-19) pandemic. Intraoperative evaluation revealed that the RP had worsened to >10 cm in length (Figure 1b). The GMT procedure was performed as previously reported, and CV-0 suture (W. L. Gore and Associates, Inc., Elkton, MD) was used as material for the Thiersch procedure. The patient did not develop serious postoperative complications, such as bleeding, perforation, or pelvic abscess. However, 3 weeks after surgery, RP recurred due to loosening of the Thiersch suture. Therefore, an additional CV-0 suture was placed under local anesthesia 5 weeks after the first surgery. Unfortunately, the ligature has also loosened 1 week after reinsertion of the CV-0 suture, and RP recurred. Thus, laparoscopy-assisted suture rectopexy was planned as a third surgery. Nevertheless, due to the outbreak of a new variant of COVID-19, surgery was performed 17 weeks after the initial GMT procedure.
Figure 2a-d show a laparoscopic view during rectal mobilization:with marked edema and rough and membranous adhesions noted in the retrorectal space:between the fascia propria of the rectum and the pre-hypogastric fascia, especially above the upper layer of the rectosacral fascia. In contrast, no adhesions were noted on the serosal side of the rectum. The postoperative course was deemed favorable, and the patient is currently under follow-up. An abdominal-pelvic CT was performed 13 weeks after the initial GMT procedure to assess the perirectal fat tissue using the SYNAPSE VINCENT software (Fujifilm  Co., Tokyo, Japan). The CT attenuation values around the rectum were analyzed by drawing an elliptical region of interest and compared with those recorded in the abdominal subcutaneous fat (Figure 3a, 3b). The CT attenuation values were found to be higher in the mesorectum versus the subcutaneous fat, especially in the posterior area of the mesorectum (P < 0.05) (Figure 4a, 4b). Such an increase in CT attenuation value was not observed except around the rectum where the GMT procedure was performed.