Re Khalushi 18 Sept 12 Rectal Prolapse

7/29/2019 Re Khalushi 18 Sept 12 Rectal Prolapse

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RECTAL PROLAPSE

PRESENTER:DR RE KHALUSHI

MODERATOR:PROF LM NTLHE


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CONTENTS

Background

Anatomy

Pathophysiology

Etiology

Clinical presentation Differential diagnosis

Investigations

Non operative management

Surgical management References


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BACKGROUND

Rectal prolapse was reported as early as 400-500 BC byEgyptian and Greek civilization.

The first written report was found in the Ebers Papyrus of1500 BC

Rectal prolapse or procidentia is a protrusion of therectum beyond the anus

Complete (external) or full thickness rectal prolapse isthe protrusion of all of the rectal wall through the analcanal

Occult(internal) rectal prolapse or rectal intussusceptionsis when the rectal wall has prolapsed but does notprotrude through the anus


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HEMORRHOIDS RECTAL PROLAPSE


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BACKGROUND

Grading of prolapse

Grade 1: Occult prolapse

Grade 2: prolapse to but not through the anus

Grade 3: any protrusion though the anus

Annual incidence of 2,5 per 100000 Occurs at extreme age-in pediatrics usually diagnosed

by the age of 3 years with male and female equallyaffected. About 20% associated with cystic fibrosisdisease

In adult the peak incidence is after the 5th

and 7th

decadewith women commonly affected representing 80 to90%(male to female ratio 1:6)


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Rectal prolapse grading


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ANATOMY

Rectum is the distal 12-15 cm of the large intestinebetween the sigmoid colon and the anal canal

It start in front the 3rd sacral vertebra as continuation ofthe sigmoid colon

It passes downward following the curvature of the sacraland coccyx, it ends at tip of the coccyx by piercing thepelvic diaphragm

Divided into 3 parts:1st third is covered by peritoneum onthe anterior and lateral surface, mid third is covered byperitoneum on anterior surface, distal third devoid of

peritoneum It serves as a reservoir for fecal material


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PATHOPHYSIOLOGY

The pathophysiology of rectal prolapse is not

completely understood or agreed upon

There are two main theories:

1. Postulates that rectal prolapse is a slidinghernia through a defect in the pelvic floor

2. The rectal prolapse start as circumferential

internal intussusceptions of the rectum starting

6-8 cm to the anal verge


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Pathophysiology

Prerequisites for the development of rectalprolapse

1. The presence of an abnormal deep pouch ofDouglass

2. The lax and atonic condition of the pelvic floorand anal canal

3. Weakness of both internal and externalsphincter, often evidence by pudendal nerveneuropathy

4. The lack of normal fixation of the rectum, witha mobile mesorectum and lax lateral ligaments


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Etiology

The precise cause is not well defined, however

there are number of associated abnormalities

50% due to chronic straining and constipation

Incontinence Pregnancy-obstetric trauma

Previous surgery

Cystic fibrosis(20% of paediatric rectal prolapse)

Genital prolapse(24%)


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Etiology

Chronic obstructive airway disease

Pertussis

Pelvic floor dysfunction

Neurological disorder- cauda equina syndrome,spinal tumours,multiple sclerosis

Parasitic infection- schistosomiasis, amebiasis

Disorder of defecation

Elevated intra-abdominal pressure


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Clinical presentation

Early symptoms

Protrusion

Mucous discharge

Rectal prolapse associated with bowel movement

TenesmusLate symptoms

bleeding

Incontinence

Rectum spends most of the time prolapsed

cystocele


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Clinical presentation

Physical signs:

Protruding rectal mucosa

Thick concentric mucosal ring

Sulcus noted between anal canal and

rectum

Solitary rectal ulcer (10-25%)

Decreased anal tone


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Differential diagnosis

Hemorrhoids

Intussusceptions

Prostates disease

Anal cancer


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RECTAL PROLAPSE


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PROLAPSED HEMORRHOIDS


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THROMBOSED HEMORRHOID


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Investigations

Complete history and physical examination

Screening tool- endoscopy or barium enema isrecommended for adult

Evaluating the rectal prolapse

1. Rigid proctosigmoidoscopy2. Cinedefecography-asses pelvic floor

movement

3. Anorectal manometer-pressure generated bysphincter

4. Electromyography-check denervation andcolon transit


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NON OPERATIVE MANAGEMENT

Sedation, field block with local

unaesthetic

prolapsed rectum can be reduced with

gentle pressure Sprinkling the prolapse with either salt or

sugar

Other modalities-stool softener, enema


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SURGICAL MANAGEMENT

More than 100 procedures were

described for rectal prolapsed

Aim for the treatment:

1. Control the prolapse

2. Restore continence

3. Prevent constipation

Divided in to Abdominal and Pelvicprocedures


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Abdominal procedures

1.Suture Rectopexy-

First described by Cutait in 1959

involves mobilization and upward fixation of the rectum

No mortality, recurrence rate 0-3%(majority) withexception of one series with recurrence of 27%

Clinical outcome- symptoms were better overall in male2.Prosthetic or Mesh Rectopexy

Involves insertion of material like fascia lata,nonabsorbable syntheticmesh,polypropylenemarlex,polyvinyl alcohol,polytef

Two types mesh rectopexy: posterior mesh rectopexyand anterior sling Rectopexy


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Posterior Mesh Rectopexy

After rectal mobilization prosthetic materialis inserted between rectum and sacral

,sutured in to the rectum and suture intothe periosteum of sacral promontory

Mortality rate 0-3%,Recurrence rate 3%,significant pelvis sepsis as major(2-16%)

contributor to post operative complications Clinical outcome-improve continence


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Ripstein Procedure (anterior sling Rectopexy)

First described by Repstein in 1952

After complete mobilization of the rectum,anterior sling of fascia lata or synthetic material

is placed in front of the rectum and sutured tothe sacral promontory

Mortality 0-2,8%,recurrence rate 0-13%

Clinical outcome-yield conflicting result as it

improves continence and causes obstructeddefecation


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3.Resection

Recto sigmoid resection

Mortality 0-6,7%,recurrence rate0-5%

Clinical outcome- there was overall

reduction with constipation, continence

improved and causing less outlet

obstruction


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4.Laparoscopic Rectopexy

The procedure involves either suture or

posterior mesh rectopexy with or without

resection Mortality 0-3%,reccurence rate 0-8% in 8

and 30 months follow up

Clinical outcome depends on the type ofprocedure done


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Perineal procedure

1.Delorme operation

First described Delorme in 1900

Stripping of the prolapsed rectum and

suture plication of the remnant baremuscle, the mucosa is then approximated

to seal the anastomosis

Mortality 0-4%, recurrence rate 4-38%


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continue

2.Perineal Rectosigmoidectomy

First described by Mickulicz in1889

Full thickness excision of the rectum and if

possible portion of sigmoid colon Mortality 0-5%,recurrence rate 0-16%

3.Stapled trans-anal rectal Resection (STARR)

Few published studies

Reported to be safe and effective technique foroutlet obstruction


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REFFERENCES

1. Lechaux D, Trecbuchet G, etal. Laparoscopic rectopexy for fullthickness rectal prolapse.Surg Endosc(2005)19:514-518

2. Madiba T.E, Baig M.K,Wexner S.D.surgical management of rectalprolapse. Archive Surgery(2005)140:63-73

3. Gourgiotis S,Baratsis S.Rectal Prolapse. Int J ColorectalDis(2007)22:231-243

4.Otto S.D,Ritz J.P, Grone J, etal. Abdominal Resection Rectopexywith an Absorbable Polyglactin Mesh:prospective evaluation ofmorphological and functional changes with consecutiveimprovement of patients symptoms. World J Surg(2010)34:2710-2716

5. Kodner IJ, Fry RD, Fleshman JW. Rectal prolapse and other pelvicfloor abnormalities.Ann Surg 1992;24:157190

6.Cirocco WC,Brown AC.Anterior resection for the treatment of rectalprolapse:20 years experience.Am Surg.(1993)59:265-269

7. Snell R.S. Clinical Anatomy by regions.8th edition.335-380

Re Khalushi 18 Sept 12 Rectal Prolapse

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