Adult sigmoid intussusception resembling rectal prolapse:A case report

BACKGROUND Rectal prolapse arises from benign etiology.When symptoms of internal intussusception mirror those of rectal prolapse,a misdiagnosis is possible,especially under limited clinical presentation.It is crucial to recognize and differentiate rectal prolapse from internal intussusception because the two diagnoses have different prognoses.Here,we describe a case of adult sigmoid intussusception presenting as rectal prolapse.CASE SUMMARY A 64-year-old woman with no known medical history visited a gastrointestinal outpatient department due to hard bloody stool defecation for 1 wk followed by constipation for 3 d.Colonoscopy revealed a huge polypoid ulcerated tumor at the sigmoid colon with lumen stenosis.The patient was admitted due to postprocedural dull abdominal pain.Due to failed colonoscopy reduction and stent insertion,the patient underwent sigmoid colon resection with primary end-to-end anastomosis,with the transverse colostomy pathological report showing adenocarcinoma,pT3N0M0.She recovered well from the operation and was discharged with regular outpatient clinic follow-up.CONCLUSION Presentation and manifestation of sigmoid intussusception may resemble that of rectal prolapse,necessitating careful observation due to distinct prognostic implications.

Current diagnostic tools and treatment modalities for rectal prolapse

Rectal prolapse is a circumferential,full-thickness protrusion of the rectum through the anus.It is a rare condition,and only affects 0.5%of the general population.Multiple treatment modalities have been described,which have changed significantly over time.Particularly in the last decade,laparoscopic and robotic surgical approaches with different mobilization techniques,combined with medical therapies,have been widely implemented.Because patients have presented with a wide range of complaints(ranging from abdominal discomfort to incomplete bowel evacuation,mucus discharge,constipation,diarrhea,and fecal incontinence),understanding the extent of complaints and ruling out differential diagnoses are essential for choosing a tailored surgical procedure.It is crucial to assess these additional symptoms and their severities using preoperative scoring systems.Additionally,radiological and physiological evaluations may explain some vague symptoms and reveal concomitant pelvic disorders.However,there is no consensus on or standardization of the optimal extent of dissection,type of procedure,and materials used for rectal fixation;this makes providing maximum benefits to patients with minimal complications difficult.Even recent publications and systematic reviews have not recommended the most appropriate treatment options.This review explains the appropriate diagnostic tools for different conditions and summarizes the current treatment approaches based on existing literature and expert opinions.

Rectal prolapse in a 30-year-old bladder stone male patient:A case report

BACKGROUND Rectal prolapse occurs most commonly in children and middle-aged and elderly women and is relatively rare in young men and is occasionally caused by bladder stones.Severe rectal prolapse,bilateral hydronephrosis,and renal insufficiency caused by bladder stones are rare in a 30-year-old man.CASE SUMMARY We report the case of a 30-year-old male patient with cerebral palsy who presented with a large bladder stone that resulted in severe rectal prolapse,bilateral hydronephrosis,and renal insufficiency.Following a definitive diagnosis,the bladder stone was successfully removed,and his kidney function returned to normal.We assessed the patient’s nutritional status and stone composition and concluded that the main cause was malnutrition.CONCLUSION Rectal prolapse is a rare clinical manifestation of bladder stones,particularly in young adults.Cerebral palsy patients are a vulnerable group in society because of their intellectual disabilities and communicative impairments.Accordingly,besides taking care of their daily diet,abnormal signs in their bodies should receive the doctors’attention in a timely manner.

Management of Adult Rectal Prolapse in the Department of Chirurgie A of the University Hospital Center of Point G about 40 Cases

Aim: Reporting the department’s experience in managing adult rectal prolapse. Methods: A descriptive study was conducted in the department of chirurgie A of the chu of point G. All patients operated on for rectal prolapse in the Department of Surgery “A” were included. Technics used were altemeier procedure and anoplasty. Results: 40 cases of complete rectal prolapse were identified. The sex ratio was 1.42. Average age was 50 years. During the study period, rectal prolapse accounted for 0.13% of all pathologies encountered (n = 40) and 3.37% of anorectal pathologies. Locoregional anesthesia was performed in all patients. In the series, 36 patients (90%) were operated on using the Altemeier procedure, anal cerclage was performed in 3 patients (7.5%), and anoplasty was performed in one patient (2.5%). Postoperative mortality was 2.5% (n = 1). The postoperative follow-up was simple in 95% of cases (n = 38). Anal stenosis was found in one patient (2.5%). Conclusion: Low-way surgery remains one of the preferred options for weakened patients exposed to anesthetic risks.

Perineal rectosigmoidectomy for gangrenous rectal prolapse

Incarceration rarely complicates the chronically progressive form of the full thickness rectal prolapse.Even more rarely,it becomes strangulated,necessitating emergency surgery.We describe an extremely rare case of incarcerated acute rectal prolapse,without a relevant previous history or symptoms of predisposing pathology.The patient underwent emergency perineal proctosigmoidectomy,the Altemeier operation,combined with diverting loop sigmoid colostomy.The postoperative course was quite uneventful with an excellent final result after colostomy closure.The successful treatment of this patient illustrates the value of the Altemeier procedure in the difficult and unusual case scenario of bowel incarceration.

Delorme's operation plus sphincteroplasty for complete rectal prolapse associated with traumatic fecal incontinence

Rectal prolapse associated with traumatic fecal incontinence is a rare clinical combination. This study was designed to assess Delorme＇s operation with sphincteroplasty as a surgical management of this combination in terms of recurrence and improvement of fecal incontinence. In this prospective study, we enrolled patients suffering from short, full-thickness rectal prolapse associated with traumatic fecal incontinence who had been admitted to Alexandria Main University Hospital during the period of May 2010-January 2013. Preoperative data including cause of trauma, duration of symptoms, results of anal manometry, and degree of fecal incontinence using Wexner score were collected from all patients. Delorme＇s procedure with overlap sphincteroplasty was done in all patients. Recurrence of prolapse and improvement of fecal incontinence were assessed after 1, 3, 6 and 12 months. The study included 13 patients aged （32±8.7） years, 9 females and 4 males. Cause of sphincteric injury included previous anal surgery in 7 patients and normal labor in 6 patients. Duration between sphinctefic injury and operation was （8.08±2.47） months. Preoperative Wexner＇s mean score was 16.07±3.4. Early postoperative complications included superficial wound infection （69.2%）, minor wound dehiscence （61.5%）, and postoperative bleeding （7.6%）. Recurrence was detected in 1 patient at 6 month follow-up. Wexner＇s score showed significant improvement for all patients after 6 months （4.00±2.04）. In conclusion, combination of Delorme＇s procedure and sphincteroplasty for treatment of patients with short complete rectal prolapse associated with traumatic fecal incontinence is a safe, effective surgical management with satisfactory results regarding anatomical and functional outcomes.

Therapeutic effects of the TST36 stapler on rectocele combined with internal rectal prolapse

BACKGROUND The most common causes of outlet obstructive constipation(OOC)are rectocele and internal rectal prolapse.The surgical methods for OOC are diverse and difficult,and the postoperative complications and recurrence rate are high,which results in both physical and mental pain in patients.With the continuous deepening of the surgeon’s concept of minimally invasive surgery and continuous in-depth research on the mechanism of OOC,the treatment concepts and surgical methods are continuously improved.AIM To determine the efficacy of the TST36 stapler in the treatment of rectocele combined with internal rectal prolapse.METHODS From January 2017 to July 2019,49 female patients with rectocele and internal rectal prolapse who met the inclusion criteria were selected for treatment using the TST36 stapler.RESULTS Forty-five patients were cured,4 patients improved,and the cure rate was 92%.The postoperative obstructed defecation syndrome score,the defecation frequency score,time/straining intensity,and sensation of incomplete evacuation were significantly decreased compared with these parameters before treatment,and the differences were statistically significant(P<0.05).The postoperative anal canal resting pressure and maximum squeeze pressure in patients decreased compared with before treatment,and the differences were statistically significant(P<0.05).The initial and maximum defecation thresholds after surgery were significantly lower than those before treatment,and the differences were statistically significant(P<0.05).The postoperative ratings of rectocele,resting phase,and defecation phase in these patients were significantly decreased compared with those before treatment,and the differences were statistically significant(P<0.05).CONCLUSION The TST36 stapler is safe and effective in treating rectocele combined with internal rectal prolapse and is worth promoting in clinical work.

Clinical efficacy of integral theory–guided laparoscopic integral pelvic floor/ligament repair in the treatment of internal rectal prolapse in females

BACKGROUND Internal rectal prolapse(IRP)is one of the most common causes of obstructive constipation.The incidence of IRP in women is approximately three times that in men.IRP is mainly treated by surgery,which can be divided into two categories:Abdominal procedures and perineal procedures.This study offers a better procedure for the treatment of IRP.AIM To compare the clinical efficacy of laparoscopic integral pelvic floor/ligament repair(IPFLR)combined with a procedure for prolapse and hemorrhoids(PPH)and the laparoscopic IPFLR alone in the treatment of IRP in women.METHODS This study collected the clinical data of 130 female patients with IRP who underwent surgery from January 2012 to October 2014.The patients were divided into groups A and B.Group A had 63 patients who underwent laparoscopic IPFLR alone,and group B had 67 patients who underwent the laparoscopic IPFLR combined with PPH.The degree of internal rectal prolapse(DIRP),Wexner constipation scale(WCS)score,Wexner incontinence scale(WIS)score,and Gastrointestinal Quality of Life Index(GIQLI)score were compared between groups and within groups before surgery and 6 mo and 2 years after surgery.RESULTS All laparoscopic surgeries were successful.The general information,number of bowel movements before surgery,DIRP,GIQLI score,WIS score,and WCS score before surgery were not significantly different between the two groups(all P>0.05).The WCS score,WIS score,GIQLI score,and DIRP in each group 6 mo,and 2 years after surgery were significantly better than before surgery(P<0.001).In group A,the DIRP and WCS score gradually improved from 6 mo to 2 years after surgery(P<0.001),and the GIQLI score progressively improved from 6 mo to 2 years after surgery(P<0.05).In group B,the DIRP,WCS score and WIS score significantly improved from 6 mo to 2 years after surgery(P<0.05),and the GIQLI score 2 years after surgery was significantly higher than that 6 mo after surgery(P<0.05).The WCS score,WIS score,GIQLI score,and DIRP of group B were significantly better than those of group A 6 mo and 2 years after surgery(all P<0.001,Bonferroni)except DIRP at 2 years after surgery.There was a significant difference in the recurrence rate of IRP between the two groups 6 mo after surgery(P=0.011).There was no significant difference in postoperative grade I-III complications between the two groups(P=0.822).CONCLUSION Integral theory–guided laparoscopic IPFLR combined with PPH has a higher cure rate and a better clinical efficacy than laparoscopic IPFLR alone.

Perineal rectosigmoidectomy for strangled rectal prolapse:A case report

Strangled rectal prolapse, the rare disease, is a proctological emergency. Its management is controversial. When it is not reducible and signs of ischemia are present, the Altemeierperineal rectosigmoidectomy remains the best treatment. This study aimed to report our experience on the management of strangled rectal prolapse about 1 case in a 45-year-old man, a holder of a rectal prolapse for 2 years. On admission, he had strangled prolapse for 24 hours with edema. After a vain attempt of manual reduction and installation of necrosis after 48 hours, he had an Altemeier rectosigmo?dectomy. The postoperative course was uneventful and the patient was discharged on the 6th postoperative day. The results were very good, after one year follow-up.

Rectal prolapse: Diagnosis and clinical management

The exact cause of rectal prolapse is not well addressed,but it is often associated with long standing constipation,advanced age,chronic obstructive pulmonary disease and some neurological disorders.Rectal prolapse is usually only a symptom,which needs a focus on discovery of the underlying pathology or disorder.Three different clinical presentations are often combined and called rectal prolapse.Rectal prolapse can be divided into full thickness rectal prolapse where the entire rectum protrudes beyond the anus,mucosal prolapse where only the rectal mucosa (not the entire wall) prolapses,and internal intussuception wherein the rectum collapses but does not exit the anus.Although constipation and straining may contribute to the development of rectal prolapse,simply correcting these problems may not improve the prolapse once it has developed.There are many different approaches to surgical correction of rectal prolapse.

Altemeier perineal rectosigmoidectomy with indocyanine green fluorescence imaging for a female adolescent with complete rectal prolapse:A case report

BACKGROUND Rectal prolapse in young women is rare.Although laparoscopic ventral mesh rectopexy is the standard procedure because of its lower recurrence rate,postoperative infertility is a concern.Perineal rectosigmoidectomy(Altemeier procedure)is useful for these patients.However,the risk of anastomotic leakage should be considered.Recently,the usefulness of fluorescence imaging with indocyanine green(ICG)to prevent anastomotic leakage was reported.We report a case of an adolescent woman with complete rectal prolapse who underwent ICG fluorescence imaging-assisted Altemeier rectosigmoidectomy.CASE SUMMARY A 17-year-old woman who had a mental disorder was admitted to our hospital for treatment for water intoxication.The patient also suffered from rectal prolapse,approximately 3 mo before admission.She was referred to our surgical department because recurrent rectal prolapse could worsen her psychiatric disorder.Approximately 10 cm of complete rectal prolapse was observed.However,the mean maximum anal resting and constriction pressures were within normal limits on anorectal manometry.Because she had the desire to bear children in the future,she underwent Altemeier perineal rectosigmoidectomy to prevent surgery-related infertility.We performed ICG fluorescence imaging at the same time as surgery to reduce the risk of anastomotic leakage.Her postoperative course was uneventful,and the rectal prolapse was completely resolved.She continued to do well 18 mo after surgery,without recurrence of the rectal prolapse.CONCLUSION ICG fluorescence imaging-assisted Altemeier perineal rectosigmoidectomy is useful in preventing postoperative anastomotic leakage in young as well as elderly patients.

Notaras procedure for incarcerated rectal prolapse

Patients with an incarcerated rectal prolapse usually present in the emergency department where manual reduction is first attempted. If reduction is unsuccessful, an emergency laparotomy and internal reduction is required. Edema in the rectal and perineal tissues and impaired blood flow are the main factors for a high percentage of anastomotic leaks. The traditional single stage perineal rectosigmoidectomy is not a safe surgical procedure for treating incarcerated or strangulated rectal prolapses associated with severe edema. Herein we report a case of an incarcerated rectal prolapse treated with the Notaras procedure.

Rectal Prolapse of the Child at the Center University Hospital of Brazzaville

Summary: The aim of this work was to determine the frequency of rectal prolapse and to describe the therapeutic aspects. Material and Methods: A descriptive study with a retrospective collection was carried out between January 2013 and May 2016 in 29 months in the pediatric surgery department at the Center University Hospital of Brazzaville. Children between the ages of 1 and 15 years of age, treated for rectal prolapse and whose records were exploitable were included. The variables studied were: age, gender, parental socio-economic status, consultation time, preference factors, pre-admission treatment, treatment initiated and progression. Results: In 29 months, 22 cases of rectal prolapse were collected, i.e. a hospital frequency of 0.96%. The mean age was 4.5 years extremes (1 and 11 years). The average time of consultation was 5 days extremes (1 and 21 days). Diarrhea 5 cases (23%), constipation diarrhea 3 cases (14%), constipation 10 cases (45%), bronchopneumopathy 4 cases (18%). The treatment was surgical according to the Thiersch technique in all cases. The evolution was favorable. Conclusion: Rectal prolapse, a benign pathology, is relatively uncommon. Constipation remains the main factor favoring the need to take care of upstream. Treatment by the Thiersch method remains the first choice in children.

Advancing the predictive accuracy of PNTML in rectal prolapse:An ongoing quest

Fecal incontinence is a common symptom among patients with rectal prolapse.Pudendal nerve terminal motor latency(PNTML)testing can serve as a reference indicator for predicting the outcomes of rectal prolapse surgery,thereby assisting surgeons in formulating more appropriate surgical plans.The direct correlation between preoperative PNTML testing results and postoperative fecal incontinence in patients with rectal prolapse remains a contentious issue,necessitating further clarification.Thus,we analyze the existing publications from both clinical and statistical perspectives to comprehensively evaluate the accuracy of preoperative PNTML testing in rectal prolapse and provide some feasible statistical solutions.

External rectal prolapse:abdominal or perineal repair for men?A retrospective cohort study

Background:External rectal prolapse is a relatively rare disease,in which male patients account for a minority.The selection of abdominal repair or perineal repair for male patients has rarely been investigated.Methods:Fifty-one male patients receiving abdominal repair(laparoscopic ventral rectopexy)or perineal repair(Delorme or Altemeier procedures)at the Sixth Affiliated Hospital of Sun Yat-sen University(Guangzhou,China)between March 2013 and September 2019 were retrospectively analysed.We compared the recurrence,complication rate,post-operative defecation disorder,length of stay,and quality of life between the abdominal and perineal groups.Results:Of the 51 patients,45 had a complete follow-up,with a median of 48.5 months(range,22.8–101.8 months).A total of 35 patients were under age 40 years.The complication rate associated with abdominal repair was less than that associated with perineal repair(0%vs 20.7%,P=0.031)and the recurrence rate was also lower(9.5%vs 41.7%,P=0.018).Multivariate analysis showed that perineal repair(odds ratio,9.827;95%confidence interval,1.296–74.50;P=0.027)might be a risk factor for recurrence.Moreover,only perineal repair significantly improved post-operative constipation status(preoperative vs post-operative,72.4%vs 25.0%,P=0.001).There was no reported mortality in either of the groups.No patient’s sexual function was affected by the surgery.Conclusions:Both surgical approaches were safe in men.Compared with perineal repair,the complication rate and recurrence rate for abdominal repair were lower.However,perineal repair was better able to correct constipation.

Changing approaches to rectal prolapse repair in the elderly

Aim:The abdominal approach to rectal prolapse is associated with lower rates of recurrence but a higher chance of complications and has been traditionally reserved for younger patients.However,longer life expectancy and wider use of laparoscopic techniques necessitates another look at the abdominal approach in older patients.Methods:This was a retrospective review of data from patients undergoing abdominal repair of rectal prolapse between 2005 and 2011.Results:Forty-six abdominal repairs(laparoscopic or open suture rectopexy,sigmoidectomy and rectopexy and low anterior resection)were performed during the study period.Twenty-nine repairs(63%)were performed in patients under the age of 70(average age 51)and 17(37%)in patients older than 70(average age 76;range 71-89).Most of the cases performed during the initial 3 years of the study were via laparotomy.However,in the last 4 years,the laparoscopic approach was used in 83%of younger patients and 69%of older patients.Average length of stay was 2.6 days for younger and 3.8 days for older patients.Both groups had similar rates of re-admission:20%vs 23%.The rate of wound infection was higher in the younger patients(5%vs nil).However,rates of urinary tract infection,two instances(10%)vs four(30%),urinary retention,one instance(5%)vs two(15.4%),ileus,one instance(5%)vs two(15.4%)were higher in the older group.Conclusion:Wider use of laparoscopy has precipitated a change in the approach to rectal prolapse in older patients.Although associated with a slightly higher rate of post-operative complications,the abdominal approach to rectal prolapse is feasible,safe and effective in patients older than 70 years.

Stapled Trans-Anal Rectal Resection (STARR) for Obstructive Defecation Syndrome—Functional Outcome and Quality of Life after Two Years

Background: Stapled transanal rectal resection (STARR) has been shown to improve patients’ functional and quality of life outcomes in several studies. Although it is a safe and effective treatment for obstructive defecation syndrome, still data on long-term follow-up are missing. Methods: From January 2010 to July 2014, 46 consecutive patients undergoing STARR using the CONTOUR&reg TRANSTAR&#8482 device, shortly named TRANSTAR (transanal stapler assisted resection), were prospectively followed. Recurrence rate, quality of life (Patient Assessment of Constipation-Quality of Life (PAC-Qol)) and complication were documented at baseline, 12 and 24 months after operation. Two subgroups of patients were compared to assess the impact of resection length on outcome. Results: We included 46 patients (89% female) in the study. The mean age was 65 ± 16 years and the duration of the operation was 48 ± 4 min. Total PAC-QoL score improved from 2.0 (SD 0.3) to 0.9 (1.4) after 12 months, but deteriorated to 1.2 (0.3) after 24 months (p < 0.001 for both comparisons). Complications were noted in 7% of the patients: Urinary retention (2 patients), postoperative bleeding (1 patient). No major complications or mortality were seen. After one year, we had one prolapse recurrence and after 24 month we had another. There was no significant relation between the length of the specimen and the improvement of life quality. Conclusions: The STARR procedure seems to be a safe and fast therapeutic option for patients with ODS and/or rectal prolapse. It is a tailored transanal full-thickness rectal resection improving the patients’ quality of life still two years after the operation.

Abdominal ventral rectopexy with colectomy for obstructed defecation syndrome:An alternative option for selected patients

BACKGROUND Abdominal ventral rectopexy(AVR)with colectomy is controversial in the treatment of obstructed defecation syndrome(ODS).Literature data on this technique for ODS are very limited.AIM To evaluate the safety and efficacy of AVR with colectomy for selected patients with ODS.METHODS Consecutive patients who underwent AVR with colectomy for ODS were identified prospectively from 2016 to 2017 in our department.Patient demographics,perioperative surgical results,and postoperative follow-up outcomes were collected and analyzed.Long-term follow-up was evaluated with standardized questionnaires.The severity of symptoms was assessed by the objective Wexner Constipation Score(WCS)and ODS Score.The quality of life was assessed by the Patients Assessment of Constipation Quality of Life score.Functional outcome was compared pre-and post-operatively for each patient.The primary outcomes were determined by the improvement in symptoms and quality of life.Secondary outcome measures were operating time,postoperative length of stay,morbidity and mortality,improvement of pelvic floor structure,and patient satisfaction.RESULTS Four patients underwent robotic-assisted surgery,and two patients underwent a laparoscopic-assisted procedure.The mean operating time for the robotic approach was 243 min(range 160–300 min),and the mean operating time for the laparoscopic approach was 230 min(range 220-240 min).The mean postoperative length of stay was 8.2 d(range 6-12 d).There was no conversion to open procedure and no postoperative mortality.No urinary retention,wound infection,prolonged ileus,pelvic infection and anastomosis leakage occurred.Six patients were followed up for 36 mo.The WCS,ODS,and Patients Assessment of Constipation Quality of Life score improved significantly postoperatively(P<0.05).The WCS and ODS scores showed the best remission and stabilization at 6 to 12 mo after surgery.There was no recurrence or novel constipation after surgery.None of the patients used laxative medication.CONCLUSION Robotic and laparoscopic-assisted ventral rectopexy with colectomy is a safe and effective procedure for selected patients with ODS.However,comprehensive preoperative evaluation and careful patient selection are essential.

Quality of life after surgery of the alimentary tract

In recent decades, patient-reported outcomes have become important in clinical medicine. Nowadays, health-related quality of life (HRQOL) is considered a primary outcome in many clinical trials, and it is often the major criterion for judging treatment success. At the beginning of the 21st century, morbidity and mortality rates after surgery of the alimentary tract have dropped dramatically and they can no longer be considered the only outcome measures to determine the success of a surgical procedure. QOL can yield a definitely more patient-orientated measure of outcome that provides us with a more formal measure of the patient’s judgment and desires, which can influence treatment decisions. Nevertheless, despite a very large number of published papers on HRQOL, there is some skepticism on the value of HRQOL and other patientrelated outcomes. Therefore, this topic highlight aims to assess how QOL after surgery of the alimentary tract is covered in the medical literature. Different reviews have analyzed the topic according to different points of view: benign and malignant disease; curative and palliative treatment; open and minimally invasive surgical approach; traditional and newly introduced surgical procedures. This topic highlight does not aim to cover all the possible diseases or different surgical procedures, but it does describe the different approaches in order to give the reader a broad spectrum of analysis of QOL after surgery. This quick overview could stimulate the reader to form his/her own opinion about how to use this primary outcome measure.