Rectal prolapse

Rectal prolapse and rectal intussuception correspond to two stages of the same disease. Rectal prolapse is unusual but requires surgical treatment. Abdominal rectopexy is the most effective procedure but increases the risk of postoperative constipation. This risk decreases when the lateral sides are not touched during rectal dissection. The Delorme procedure is associated with a higher rate of recurrence and must be reserved for patients presenting a high risk of postoperative complications. Rectal intussuception is more frequent and is pathological only when arising in the anal sphincter. Rectal intussuception may lead to solitary rectal ulcer and has in this case to be treated by rectopexy. Rectal intussuception involvement in terminal constipation is not yet proved. Internal mucosectomy seems to be the best treatment for terminal constipation.     

Rectal prolapse.

One hundred and twenty-seven patients with complete rectal prolapse have been reviewed. The condition occurred more commonly in females than males (105 to 22), and at an older age in females (mean age 55 years compared with 40 years for males). Although the diagnosis is usually obvious, the importance of recognizing occult prolapse is stressed, especially in association with benign rectal ulcer, localized proctitis and colitis cystica profunda. Examination of the patient in the squatting position may assit in showing occult prolapse. Associated incontinence occurred in 33 patients (26%). Since 1971 the policy of this Unit has been to perform a Ripstein repair for complete rectal prolapse wherever possible. One hundred and two Ripstein repairs have not been performed. A minimum follow-up period of two years is available for 53 patients, of whom 50 (94%) have had their prolapse cured. Control of prolapse usually improves continence; however, seven (13%) remained incontinent despite surgery. The Ripstein repair is strongly advocated as the most effective operation for cure of complete rectal prolapse.     

Rectal prolapse. Clinical studies on rectal prolapse

A series of 164 patients with procidentia recti has been studied. Symptoms are sensation of obstruction, difficulties in emptying the bowel, proctitis, incontinence, reduced tonus of anal sphincters, and complete rectal prolapse. During I the rectum prolapses only under increased intraabdominal pressure and retracts spontaneously. Massive prolapse (stage II) often occurs without increased intraabdominal pressure and has to be reposited manually. Best results are obtained by fixing the mobilised rectum in the hollow of the sacrum as described by Wells in 1959 or by Ripstein in 1969. In bad risk patients a sublevatoric wire can be used. Most patients have satisfactory continence postoperatively without a corresponding physiological tonus of anal sphincters.     

Rectal prolapse and sphincter operations

The surgical management of rectal prolapse and sphincter injuries is complex. These conditions are benign and generally not life-threatening; however they significantly impact on patients’ quality of life. A large number of operations have been described, but often without thorough follow-up or clearly defined outcomes. The challenge for the surgeon is to balance the patient’s symptom severity and quality of life against the risks of surgery, which include making the anal incontinence worse and recurrence of the prolapse.Neuromodulation with sacral nerve stimulation provides good symptom control in up to 75% of selected patients with anal incontinence irrespective of whether there is a sphincter defect or not. Full thickness rectal prolapse is traditionally treated with a perineal operation such as a Delorme’s procedure, but this is associated with a high recurrence rate. Laparoscopic ventral mesh rectopexy is increasingly used to treat rectal prolapse even in the elderly.     

Rectal prolapse. Surgical techniques

The varied operative procedures available for the treatment of rectal prolapse can be confusing. Most of the maneuvers are relatively esoteric and can be performed successfully only by the few surgeons who have developed the specialized techniques. It is recommended, therefore, that the surgeon who is less experienced with rectal prolapse adopt one of the standard operations. A rectopexy or suspension procedure without resection can be performed safely with good results, low morbidity, and a low mortality rate. Anterior resection with or without sacral fixation, an operation familiar to most surgeons, also offers an excellent cure rate. The Thiersch-type approach should probably be reserved for those patients who cannot tolerate laparotomy. The material chosen should be one of the commercially available synthetic products; wire should not be used. The Silastic-impregnated Dacron prosthesis for this operation has some potential benefit, especially for the incontinent patient. Results of further studies are awaited.     

Rectal prolapse in autistic children

Rectal prolapse in children is not uncommon, but surgery is rarely indicated. In mentally challenged adults and children, rectal prolapse occurs more frequently than in the general population and often requires surgical intervention in the second to third decade of life. The authors describe 3 children with autism and mental retardation who presented with rectal prolapse at an earlier age than would be anticipated with mental retardation alone. All 3 children required surgical intervention.     

Rectal prolapse and surgery for incontinence

Pelvic floor disorders, which include rectal prolapse (RP) and faecal incontinence (FI), are benign conditions, which are not life threatening but affect the quality of life. This is usually a disease of elderly, mostly frail patients. Management is multidisciplinary based on the symptoms, co-morbidities and patient's expectations.     

Rectal prolapse in infants and children

Rectal prolapse that is intractable to the usual medical therapy was successfully managed without significant complications in 10 patients by simple subcutaneous encirclement of the anus with a heavy nonabsorbable suture, which was in place until the suture was removed or broke after 4 to 6 months. Four patients required two sutures and one needed a third insertion. Since this procedure is simple, has no serious complications, and controls rectal prolapse, it is recommended as the preferred initial surgical treatment of this condition.     

Rectal prolapse: relationship with joint mobility

Joint mobility was assessed in 25 patients who had undergone surgery for complete rectal prolapse and in 25 age- and sex-matched control subjects. A significant increase in extensibility of the fifth finger was found in the patients with rectal prolapse. It was further found that there was a progressive decrease in joint mobility with age in both groups. The pathophysiology of rectal prolapse is complex. Factors considered to be important include rectal intussusception associated with the commonly observed lack of rectal fixation within the sacral hollow, with a deep Pouch of Douglas and weak pelvic floor musculature. The joint hypermobility demonstrated in these patients suggests an underlying connective tissue abnormality which perhaps contributes to the lack of rectal fixation within the pelvis and to the rectal wall intussusception.     

Rectal prolapse and surgery for faecal incontinence

Rectal prolapse and faecal incontinence are relatively common conditions that present to the colorectal and pelvic floor clinics. Both can be complex to treat given they are often multifactorial in origin and tend to present in elderly comorbid patients. Treatment often involves significant patient or family participation, particularly for faecal incontinence, and therefore patients and their families need to understand the risks and benefits of all treatment options available to them. This article outlines the currently available surgical interventions for rectal prolapse and faecal incontinence to allow the surgical trainee to begin these conversations in the clinic.     

Rectal prolapse caused by blunt abdominal trauma

We describe a case of incarcerated rectal prolapse caused by blunt abdominal trauma. Emergency treatment consisted of manual reduction with the patient under general anesthesia, proctosigmoidoscopy, and peritoneal lavage. Subsequent definitive surgical therapy was then performed after bowel preparation and consisted of anterior resection of the sigmoid colon with posterior (sacral) rectopexy.     

吻合器痔上黏膜钉合术后直肠狭窄

目的探讨吻合器痔上黏膜钉合术(PPH)后直肠狭窄的发生情况及处理方法。方法回顾性分析2000年7月至2004年12月共554例行PPH术患者的临床资料和术后随访资料。结果共随访了489例患者,随访率88．3％(489／554),平均随访时间(324±18)d。共12例(12／489, 2．5％)患者在术后89-134(125±5)d出现了直肠狭窄,均可通过肠镜下气囊扩张或切开狭窄环而治愈。术后直肠狭窄的患者术前接受硬化剂治疗(58．3％vs．20．0％,P=0．02)和术后严重疼痛(25．0％vs．6．7％,P=0．003)的比率明显高于术后无直肠狭窄的患者。而两者性别(P=0．32)、既往痔手术史(P=0．11)、手术标本中有鳞形细胞(P=0．77)和术后复发率(P=0．53)的差异无统计学意义。结论PPH术前有硬化剂注射史和术后严重疼痛的患者较易发生术后直肠狭窄,多在术后4个月内发生。