Rectal prolapse

Less is more: Outcomes of surgical approaches to rectal prolapse in patients with cirrhosis

BACKGROUND

Patients with cirrhosis have increased risk of perioperative complications, and surgical management of concomitant rectal prolapse poses a challenge in these patients. Given the paucity of data informing this, our study aimed to evaluate postoperative outcomes.

METHODS

The National Surgical Quality Improvement Program database was queried for patients undergoing rectal prolapse repair from 2011 to 2019. Patients were stratified by cirrhosis (Model for End-Stage Liver Disease ≥10) and no cirrhosis. Bivariate and multivariable regression analyses were used to compare comorbidities, repair types, and identify predictors of postoperative outcomes.

RESULTS

We identified 2,234 patients: 332 patients with cirrhosis (Model for End-Stage Liver Disease 14 [10-34]). Patients with cirrhosis were older (76 ± 12 years vs 69 ± 17, P < .001) with increased comorbidities (eg, heart failure, lung disease), greater mortality (3.6% vs 0.8%, P < .001), and complication rates compared with patients without cirrhosis. Readmission rates and longer hospital stays also were observed in patients with cirrhosis. A total of 52% of NCPs underwent abdominal repair compared with 62% of patients with cirrhosis who received perineal repair; greater complication rates were observed for abdominal repairs in both groups (patients without cirrhosis 11.4%, patients with cirrhosis 25%). Predictors of greater complication rates in patients with cirrhosis included abdominal repair (odds ratio 2.7, 95% confidence interval 1.4-5, P = .002) and presence of ascites (odds ratio 4.6, 95% confidence interval 1.1-20, P = .04).

CONCLUSION

Overall, abdominal repairs have greater complication rates even when controlling for Model for End-Stage Liver Disease score and presence of ascites. The Delorme procedure had the lowest complication rates. Additional evidence is needed to recommend a preferred surgical approach to rectal prolapse repair in patients with cirrhosis.

Outcomes of Laparoscopic Suture Rectopexy Versus Laparoscopic Mesh Rectopexy: A Systematic Review and Meta-Analysis

The contemporary literature provides conflicting evidence regarding the precedence of laparoscopic mesh rectopexy over laparoscopic suture rectopexy for full-thickness rectal prolapse. This study aimed to compare the clinical outcomes of mesh and suture rectopexy to improve the surgical management of complete rectal prolapse. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed to extract studies based on mesh versus suture rectopexy and published from 2001 to 2023. The articles of interest were obtained from PubMed Central, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Journal Storage (JSTOR), Web of Science, Embase, Scopus, and the Cochrane Library. The primary outcomes included rectal prolapse recurrence, constipation improvement, and operative time. The secondary endpoints included the Cleveland Clinic Constipation Score, Cleveland Clinic Incontinence Score, intraoperative bleeding, hospital stay duration, mortality, overall postoperative complications, and surgical site infection. A statistically significant low recurrence of rectal prolapse (odds ratio: 0.41, 95% confidence interval (CI) 0.21-0.80; p=0.009) and longer mean operative duration (mean difference: 27.05, 95% CI 18.86-35.24; p<0.00001) were observed in patients with mesh rectopexy versus suture rectopexy. Both study groups, however, had no significant differences in constipation improvement and all secondary endpoints (all p>0.05). The laparoscopic mesh rectopexy was associated with a low postoperative rectal prolapse recurrence and a longer operative duration compared to laparoscopic suture rectopexy. Prospective randomized controlled trials should further evaluate mesh and suture rectopexy approaches for postoperative outcomes to inform the surgical management of complete rectal prolapse.

Sigmoido-rectal intussusception anastomosis in the Altemeier procedure for complete rectal prolapse: preliminary results of a new technique

Purpose

Our research introduces an innovative surgical approach, combining the Altemeier Procedure with Sigmoido-rectal Intussusception Anastomosis, effectively reducing recurrence, minimizing complications, and improving postoperative anal function in rectal prolapse patients.

Materials and methods

This retrospective study, conducted at tertiary referral hospitals including Shandong University of Traditional Chinese Medicine's Affiliated Hospital, Linyi People's Hospital, and Pingyi People's Hospital, examined data from patients undergoing conventional Altemeier surgery or Altemeier combined with Sigmoido-rectal Intussusception Anastomosis. Analyzing hospitalization and follow-up data from January 2009 to December 2022, the study focused on prolapse recurrence, complications, and anal function as primary outcome indicators across these three study centers.

Results

In the study, both groups had an average follow-up of (12.5 ± 2.41) months, and only two traditional group patients experienced mortality. Recurrence rates significantly differed, with 26.47% in the traditional group and 1.54% in the modified group (P < 0.001). The modified group showed no perioperative anastomotic dehiscence, contrasting with a 13.24% occurrence in the conventional group (P = 0.003). Primary complications in the modified group included anastomotic hemorrhage, with rates of 17.65% and 6.15% in the traditional and modified groups, respectively (P = 0.077). At 12 months postoperatively, both groups improved in anal manometry parameters and the Wexner anal incontinence score. Resting pressure was significantly lower in the traditional group (32.50 ± 1.76 mmHg) than the modified group (33.24 ± 2.06 mmHg) (P = 0.027), while the extrusion pressure was higher in the modified group (64.78 ± 1.55 mmHg) than the traditional group (62.85 ± 2.30 mmHg) (P < 0.001). The Wexner anal incontinence score was significantly lower in the modified group (2.69 ± 1.65) than the traditional group (3.69 ± 1.58, P = 0.001).

Conclusion

This retrospective study affirms that adding Sigmoido-rectal Intussusception Anastomosis to the Altemeier procedure reduces recurrence and complications. While both approaches enhance postoperative anal function in complete rectal prolapse patients, the combined method, particularly with Sigmoido-rectal Intussusception Anastomosis, proves more effective.

Ventral mesh rectopexy for recurrent rectal prolapse after Altemeier perineal proctosigmoidectomy: feasibility and outcomes

PURPOSE

Recurrence of rectal prolapse following the Altemeier procedure is reported with rates up to 40%. The optimal surgical management of recurrences has limited data available. Ventral mesh rectopexy (VMR) is a favored procedure for primary rectal prolapse, but its role in managing recurrences after Altemeier is unclear. VMR for recurrent prolapse involves implanting the mesh on the colon, which has a thinner wall, more active peristalsis, no mesorectum, less peritoneum available for covering the mesh, and potential diverticula. These factors can affect mesh-related complications such as erosion, migration, or infection. This study assessed the feasibility and perioperative outcomes of VMR for recurrent rectal prolapse after the Altemeier procedure.

METHODS

We queried our prospectively maintained database between 01/01/2008 and 06/30/2022 for patients who had experienced a recurrence of full-thickness rectal prolapse following Altemeier's perineal proctosigmoidectomy and subsequently underwent ventral mesh rectopexy.

RESULTS

Ten women with a median age of 67 years (range 61) and a median BMI of 27.8 kg/m2 (range 9) were included. Five (50%) had only one Altemeier, and five (50%) had multiple rectal prolapse surgeries, including Altemeier before VMR. No mesh-related complications occurred during a 65-month (range 165) median follow-up period. Three patients (30%) experienced minor postoperative complications unrelated to the mesh. Long-term complications were chronic abdominal pain and incisional hernia in one patient, respectively. One out of five (20%) patients with only one previous prolapse repair had a recurrence, while all patients (100%) with multiple prior repairs recurred.

CONCLUSION

Mesh implantation on the colon is possible without adverse reactions. However, high recurrence rates in patients with multiple previous surgeries raise doubts about using VMR for secondary or tertiary recurrences.

Altemeier procedure for strangulated rectal prolapse: A case report

INTRODUCTION AND IMPORTANCE

Strangled rectal prolapse (RP), also known as incarcerated rectal prolapse, is a condition where the RP cannot be manually reduced.

CASE PRESENTATION

This case report describes a 48-year-old man presenting with a painful and irreducible rectal prolapse. Following failed attempts at manual reduction and the development of necrosis, emergency surgery was performed using the Altemeier procedure. This surgical technique involves resection of the rectum and colon, followed by colo-anal anastomosis and a protective ileostomy.

CLINICAL DISCUSSION

The discussion highlights the rarity of RP in young adults and the associated risk factors. It emphasizes the importance of timely intervention in irreducible cases to prevent complications such as strangulation, ulceration, infection, and pain. Various surgical options exist, but in cases of strangulation requiring emergency surgery, the Altemeier procedure is the preferred approach due to its effectiveness and low morbidity. The decision to perform laparoscopic surgery depends on patient factors and surgeon expertise.

CONCLUSION

This case illustrates the successful management of a challenging and uncommon presentation of rectal prolapse, highlighting the value of surgical intervention in cases of strangulation.

Delorme's vs. Altemeier's in the management of rectal procidentia: systematic review and meta-analysis

BACKGROUND

Rectal prolapse is a distressing condition for patients and no consensus exists on optimal surgical management. We compared outcomes of two common perineal operations (Delorme's and Altemeier's) used in the treatment of rectal prolapse.

METHODS

A systematic search of multiple electronic databases was conducted. Peri- and post-operative outcomes following Delorme's and Altemeier's procedures were extracted. Primary outcomes included recurrence rate, anastomotic dehiscence rate and mortality rate. The secondary outcomes were total operative time, volume of blood loss, length of hospital stay and coloanal anastomotic stricture formation. Revman 5.3 was used to perform all statistical analysis.

RESULTS

Ten studies with 605 patients were selected; 286 underwent Altemeier's procedure (standalone), 39 had Altemeier's with plasty (perineoplasty or levatoroplasty), and 280 had Delorme's. Recurrence rate [OR: 0.66; 95% CI [0.44-0.99], P = 0.05] was significantly lower and anastomotic dehiscence [RD: 0.05; 95% CI [0.00-0.09], P = 0.03] was significantly higher in the Altemeier's group. However, sub group analysis of Altemeier's with plasty failed to show significant differences in these outcomes compared with the Delorme's procedure. Length of hospital stay was significantly more following an Altemeier's operation compared with Delorme's [MD: 3.05, 95% CI [0.95 - 5.51], P = 0.004]. No significant difference was found in total operative time, intra-operative blood loss, coloanal anastomotic stricture formation and mortality rates between the two approaches.

CONCLUSIONS

A direct comparison of two common perineal procedures used in the treatment of rectal prolapse demonstrated that the Altemeier's approach was associated with better outcomes. Future, well-designed high quality RCTs with long-term follow up are needed to corroborate our findings.

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.

A novel method for treating complete rectal prolapse with laparoscopic sigmoidopexy to the abdominal wall: A case report

Introduction

Presentation of case

Discussion

Conclusion

•

This is the first reported case of abdominal wall fixation for rectal prolapse.

•

Laparoscopic fixation of the abdominal wall with minimal dissection was performed.

•

Repair is possible without the use of artificial material.

•

The procedure requires only five sutures to fix.

•

This method may be a useful option for patients who can undergo general anaesthesia.

The role of rectal redundancy in the pathophysiology of rectal prolapse: a pilot study

Purpose

Rectal prolapse is hypothesized to be caused due to weakness of the pelvic floor which is related to childbearing. However, half of the female patients with rectal prolapse were reported to be nulliparous and this hypothesis doesn't explain the prolapse in males. The aim of this study is to evaluate the role of rectal redundancy in rectal prolapse pathophysiology.

Methods

This study was conducted prospectively. Fourteen patients who underwent rectopexy were included in the study group. A total of 17 patients who underwent laparotomy for another reason and who have no symptoms regarding rectal prolapse were included in the control group. In order to measure the redundancy of the rectum, we have calculated the ratio of length of intraperitoneal rectum (R) to length of distance between promontorium and peritoneal reflection (PRx). The primary outcome of this study was to evaluate whether the R/PRx ratio is higher in patients with rectal prolapse compared to the control group.

Results

Comparing the anatomic features showed that the length of sigmoid colon and length of PRx were not significantly different between the two groups. However, the length of intraperitoneal rectum was significantly higher in the prolapse group. Furthermore, the median R/PRx ratio in the prolapse group was significantly higher than in the control group.

Conclusion

This study showed that intraperitoneal rectum in patients with rectal prolapse is significantly more redundant than in the normal population. This could be considered reasonable evidence for the role of rectal redundancy on rectal prolapse pathophysiology.

Incarcerated Rectal Procidentia: A Case Report and Review

Rectal procidentia is an uncommon perineal disease that is rare in males. There is no specific medical role in treatment of rectal procidentia and surgical intervention is the treatment of choice. Various surgical approaches have been performed, but there is no consensus on which procedure is most effective in terms of patient condition, recurrence rate, bowel function, and risk. This case presentation of a healthy male patient with experience of uncomplicated reducible rectal prolapse and a history of chronic constipation. Presented with complicated rectal prolapse in the presence of incarcerated rectal prolapse after a failed trial with conservative maneuvers, he ended up with abdominal approach sigmoidectomy and posterior mesh rectopexy.

Longer Prolapsed Rectum Length Increases Recurrence Risk After Delorme's Procedure

Purpose

Risk factors for recurrence of rectal prolapse after surgery remain unclear. Delorme’s procedure is often selected for relatively small-sized rectal prolapse, but there are few reports discussing the association between prolapsed rectum length and prolapse recurrence after Delorme’s procedure. We hypothesized that patients with longer rectal prolapses are at a higher risk of recurrence after Delorme’s procedure.

Methods

The study population comprised patients with rectal prolapse who underwent Delorme’s procedure between January 2014 and December 2019 at Tokyo Yamate Medical Center. We extracted data on patient age, sex, body mass index, previous history of anal surgery, previous history of surgery for rectal prolapse, and length of prolapse, to identify risk factors for prolapse recurrence.

Results

Altogether, 96 patients were eligible for analysis. The median length of the prolapsed rectum was 3.0 cm (range, 1.0–6.6 cm). Twenty-four patients (25.0%) experienced recurrence after Delorme’s procedure after a median of 7.5 months (interquartile range, 3.2–20.9 months). Multivariate analysis revealed that longer prolapsed rectum length increased the risk of recurrence after Delorme’s procedure (hazard ratio, 6.28; 95% confidence interval, 1.83–21.50; P<0.001).

Conclusion

The length of the prolapsed rectum should be measured before Delorme’s procedure for rectal prolapse, because length is associated with a risk of recurrence after the surgery.

Perineal rectosigmoidectomy for rectal prolapse-the preferred procedure for the unfit elderly patient? 10 years experience from a UK tertiary centre

BACKGROUND

Rectal prolapse is a disease presentation with a prevalence of about 1%, mainly affecting older women. It usually presents with symptoms of rectal mass, rectal bleeding, fecal incontinence or constipation, with patients frequently feeling socially isolated as a result. Perineal rectosigmoidectomy is associated with lesser morbidity and mortality than the abdominal procedure, but with a much higher recurrence rate. Therefore, this technique is mainly suitable for the frail elderly patient. Specific outcomes in an elderly population have been described in only a few studies. We evaluated the morbidity, mortality, recurrence rate and functional results after this procedure related to age.

METHODS

All patients who underwent a perineal rectosigmoidectomy over a 10-year period in two tertiary referral centers were included in the study. American Society of Anesthesiology (ASA) grade, pre- and postoperative symptoms, pathology-reported post-fixation specimen length, length of in-patient stay, 30-day morbidity/mortality, and recurrence were measured.

RESULTS

A total of 45 patients underwent a perineal rectosigmoidectomy. Forty-three (95%) were female, with a median age of 82.0 years (IQR 70.5-86.5), ASA grade III and median follow-up of 20 months (range 8.5-45.5 months). Half of the cohort was over 80 years old. Significant symptomatic relief was achieved, predominantly the resolution of rectal mass (8.9% vs. 60.0% preoperatively), fecal incontinence (15.6% vs. 46.7%) and constipation (4.4% vs. 26.7%). The median length of stay was 6 days, while morbidity occurred in 14 patients (31.1%) and recurrence occurred in 6 patients (13%). There were no deaths within 30 days of the procedure and outcomes were comparable in the < 80 and ≥ 80 age group.

CONCLUSIONS

Perineal rectosigmoidectomy is safe for older patients with greater comorbidities resulting in good functional results and is associated with low morbidity and mortality.

Consensus Statement of the Italian Society of Colorectal Surgery (SICCR): management and treatment of complete rectal prolapse

Rectal prolapse, rectal procidentia, "complete" prolapse or "third-degree" prolapse is the full-thickness prolapse of the rectal wall through the anal canal and has a significant impact on quality of life. The incidence of rectal prolapse has been estimated to be approximately 2.5 per 100,000 inhabitants with a clear predominance among elderly women. The aim of this consensus statement was to provide evidence-based data to allow an individualized and appropriate management and treatment of complete rectal prolapse. The strategy used to search for evidence was based on application of electronic sources such as MEDLINE, PubMed, Cochrane Review Library, CINAHL and EMBASE. The recommendations were defined and graded based on the current levels of evidence and in accordance with the criteria adopted by the American College of Gastroenterology's Chronic Constipation Task Force. Five evidence levels were defined. The recommendations were graded A, B, and C.

Full-thickness neorectal prolapse after transanal transabdominal proctosigmoidectomy for low rectal cancer: a cohort study

AIM

Transanal transabdominal proctosigmoidectomy (TATA) with a coloanal anastomosis is an alternative to abdominoperineal excision of the rectum (APR) for low rectal cancer. Neorectal prolapse is an unusual complication following TATA. This study aimed to determine the incidence of neorectal prolapse after TATA for low rectal cancer.

METHOD

This cohort study was conducted in a tertiary referral colorectal centre. From a prospectively maintained database including 1093 patients treated for rectal cancer between 1984 and 2016 we identified those who underwent sphincter-preserving surgery. Data regarding the incidence, management and outcomes of neorectal prolapse were analysed.

RESULTS

A total of 409 patients were identified, of whom 185 underwent open surgery and 224 a minimally invasive surgical procedure (MIS). All received neoadjuvant chemoradiation. Neorectal prolapse occurred in 4.6% (n = 19) with an incidence of 2.2% in the open and 6.7% in the MIS group (P = 0.023), with no difference between MIS techniques. There was one recurrence of neorectal prolapse (5.9%). The incidence of neorectal prolapse was higher in women (9.5%) than men (2.5%) (P = 0.011). There were no differences in local recurrence rates between the neorectal prolapse group (5.3%) and our population without prolapse (3.4%) (P = 0.79).

CONCLUSION

Neorectal prolapse is a rare occurrence following minimally invasive sphincter-saving surgical procedures performed for rectal cancer. It appears to be more frequent in patients who undergo MIS procedures and in women.

Strangulation of giant rectal prolapse

Introduction

Rectal prolapse is the complete protrusion of the rectum through the anal canal, incarceration rarely complicates rectal prolapse. Even more rarely, it becomes strangulated and gangrenous, necessitating emergency surgery.

Case presentation

We present the first reported case of strangulated acute rectal prolapse as the first manifestation of rectal prolapse. The patient was a 26-year-old man who presented with a 20×6 cm semi-spherical mass extra-anally. Rectosigmoidectomy with sacral rectopexy was performed, resecting 20 cm of the incarcerated rectum and sigmoid colon. The postoperative course was uneventful with a good final result after colostomy closure and continuity restoration.

Conclusion

The successful treatment of this patient illustrates the value of surgery in this difficult and unusual case scenario of rectal incarceration.

Diagnosis and Management of Anorectal Disorders in the Primary Care Setting

Anorectal disorders are very common among a wide population of patients. Because patients may be embarrassed about the anatomic location of their symptoms, they may present to care late in the course of their illness. Care should be taken to validate patient concerns and normalize fears. This article discusses the diagnoses and management of common anorectal disorders among patients presenting to a primary care physician.

c-Abl regulates gastrointestinal muscularis propria homeostasis via ERKs

The gastrointestinal tract is responsible for food digestion and absorption. The muscularis propria propels the foodstuff through the GI tract and defects in intestine motility may cause obstruction disorders. Our present genetic studies identified non-receptor tyrosine kinase c-Abl as an important regulator of the muscularis propria homeostasis and a risk factor for rectal prolapse. Mouse deficient for c-Abl showed defects in the muscularis propria of gastrointestinal tract and older c-Abl ^-/- mice developed megaesophagus and rectal prolapse. Inhibition of c-Abl with imatinib mesylate, an anti-CML drug, or ablation of c-Abl using Prx1-Cre, which marks smooth muscle cells, recapitulated most of the muscularis propria phenotypes. The pathogenesis of rectal prolapse was attributable to overproliferation of smooth muscle cells, which was caused by enhanced ERK1/2 activation. Administration of ERK inhibitor U0126 impeded the development of rectal prolapse in c-Abl deficient mice. These results reveal a role for c-Abl-regulated smooth muscle proliferation in the pathogenesis of rectal prolapse, and imply that long-term use of imatinib mesylate may cause gastrointestinal problems in patients while ERK inhibitor may be effective in treating rectal prolapse.

Age and cellular context influence rectal prolapse formation in mice with caecal wall colorectal cancer xenografts

In patients with rectal prolapse is the prevalence of colorectal cancer increased, suggesting that a colorectal tumor may induce rectal prolapse. Establishment of tumor xenografts in immunodeficient mice after orthotopic inoculations of human colorectal cancer cells into the caecal wall is a widely used approach for the study of human colorectal cancer progression and preclinical evaluation of therapeutics. Remarkably, 70% of young mice carrying a COLO320DM caecal tumor showed symptoms of intussusception of the large bowel associated with intestinal lumen obstruction and rectal prolapse. The quantity of the COLO320DM bioluminescent signal of the first three weeks post-inoculation predicts prolapse in young mice. Rectal prolapse was not observed in adult mice carrying a COLO320DM caecal tumor or young mice carrying a HT29 caecal tumor. In contrast to HT29 tumors, which showed local invasion and metastasis, COLO320DM tumors demonstrated a non-invasive tumor with pushing borders without presence of metastasis. In conclusion, rectal prolapse can be linked to a non-invasive, space-occupying COLO320DM tumor in the gastrointestinal tract of young immunodeficient mice. These data reveal a model that can clarify the association of patients showing rectal prolapse with colorectal cancer.

Colonic prolapse after intersphincteric resection for very low rectal cancer: a report of 12 cases

BACKGROUND

There are no published data concerning management of patients with exteriorized colonic prolapse (CP) after intersphincteric rectal resection (ISR) and side-to-end coloanal manual anastomosis (CAA) for very low rectal cancer. The aim of the present study was to report our experience in 12 consecutive cases of CP following ISR with CAA.

METHODS

From 2006 to 2014, all patients with very low rectal cancer who developed CP after ISR and CAA were reviewed. Demographic and surgical data, prolapse symptoms and treatment were recorded. Postoperative morbidity, functional outcomes and results after prolapse surgery were recorded.

RESULTS

Twelve out of 143 patients (8 %) who underwent ISR with side-to-end CAA for low rectal cancer presented CP: 7/107 ISR (7 %) with partial resection of the internal anal sphincter (IAS) and 5/36 ISR (14 %) with subtotal or total resection of the IAS (NS). CP was diagnosed after a median of 6 months (range 2-72 months) after ISR. All patients with CP suffered from pain and fecal incontinence. Median Wexner fecal incontinence score before surgery was 16.5 (range 12-20). Three patients refused reoperation. Nine patients underwent transanal surgery with prolapse resection (including colonic stump and side-to-end anastomosis) and new end-to-end CAA (with posterior myorraphy in 4 cases). After a median follow-up of 30 months (range 8-87 months), 3/9 patients (33 %) had CP recurrence: One with very poor function was treated by abdominoperineal resection and definitive stoma. The 2 others were successfully reoperated on transanally. Median Wexner fecal incontinence score after CP surgery was 9 (range 0-20). No CP recurrence was noted for the 6 other patients, and function improved in all cases. Thus, at the end of follow-up, 8/9 patients (89 %) had no recurrence after surgery.

CONCLUSIONS

We believe surgery must be attempted in these patients who develop CP after ISR with CAA for very low rectal cancer in order to improve function and symptoms. A transanal approach with CP resection and new end-to-end anastomosis appeared to be safe and effective. Larger studies are needed to confirm our results.

Recurrence rate after Delorme's procedure with simultaneous placement of a Thiersch suture

Introduction Rectal prolapse is a debilitating condition usually affecting elderly women. The management is generally surgical but the optimal operation remains unclear. The recurrence rate after Delorme's procedure has been found to be similar to that for an abdominal approach. Thiersch sutures have been associated with high rates of complications and recurrence. The aim of this study was to compare the outcomes of Delorme's procedure with those of a combined Delorme-Thiersch procedure. Methods A retrospective case note review was performed of all patients who underwent Delorme's procedure for rectal prolapse between 2008 and 2014 in a single centre. Results Sixty-seven patients (63 women) underwent Delorme's procedure during the study period. The majority (85%) of patients were over 75 years old. Twelve patients had a Thiersch suture placed at the time of the procedure. The median length of stay was 3 days (range: 0-19 days). Postoperative bleeding requiring either transfusion or readmission occurred in five patients (7.5%) and two patients (3.0%) were readmitted with pain. There was no difference in the rate of complications regardless of whether a Thiersch suture had been placed. Recurrence occurred in 8.3% of those who had a Thiersch suture compared with 21.8% of those who did not (p=0.26). There was no difference in the median time to recurrence between the groups. Conclusions There was no increase in complications after placement of a Thiersch suture with Delorme's procedure. The rate of recurrence could potentially be decreased with this combined technique. Additional studies are required to investigate this further.

Laparoscopic surgery for rectal prolapse and pelvic floor disorders

Pelvic floor disorders are different dysfunctions of gynaecological, urinary or anorectal organs, which can present as incontinence, outlet-obstruction and organ prolapse or as a combination of these symptoms. Pelvic floor disorders affect a substantial amount of people, predominantly women. Transabdominal procedures play a major role in the treatment of these disorders. With the development of new techniques established open procedures are now increasingly performed laparoscopically. Operation techniques consist of various rectopexies with suture, staples or meshes eventually combined with sigmoid resection. The different approaches need to be measured by their operative and functional outcome and their recurrence rates. Although these operations are performed frequently a comparison and evaluation of the different methods is difficult, as most of the used outcome measures in the available studies have not been standardised and data from randomised studies comparing these outcome measures directly are lacking. Therefore evidence based guidelines do not exist. Currently the laparoscopic approach with ventral mesh rectopexy or resection rectopexy is the two most commonly used techniques. Observational and retrospective studies show good functional results, a low rate of complications and a low recurrence rate. As high quality evidence is missing, an individualized approach is recommend for every patient considering age, individual health status and the underlying morphological and functional disorders.

Rectal Prolapse in Women-Outcomes of Perineal and Abdominal Approaches

The aim of the study was to assess the clinical and functional results of surgical treatment of female patients with rectal prolapse. In the period of 2003-2010, the group of 86 female patients (mean age of 67 ± 10) underwent surgery due to rectal prolapse. The group of 24 patients (27.9 %) suffered from mild anal incontinence. They were operated on with open sutured rectopexy (18 pts), Altemeier (45 pts) and Delorme procedure (23 pts). Prior to surgery and after operation, clinical and function results were obtained. The follow-up period amounted to 32 ± 11 months. In perineal approaches, we found mortality in one patient (1.4 %, Delorme) and anastomotic leak in four patients (5.9 %). The recurrence rate in the perineal group was 11.8 % (eight patients). We noted one recurrence in the rectopexy group (5.6 %). The Altemeier procedure revealed the most significant impact on the function of the anal sphincter muscles and resting pressures (42 ± 7 vs 53 ± 9 cm H2O; p = 0.0082). If anterior levatoroplasty was added, the benefits referred also to squeeze pressures (41 ± 8 vs 58 ± 9 cm H2O; p = 0.006 and 42 ± 10 vs 56 ± 9 cm H2O; p = 0.01). In the treatment of rectal prolapse, there is still no consensus about the operation of choice. Selection of the appropriate method should be based on clinical findings and patients' comorbidities to obtain maximal benefits and minimize the postoperative risk and failures.

Risk factors and clinical characteristics of rectal prolapse in young patients

BACKGROUND

Rectal prolapse is a relatively common condition in children and elderly patients but uncommon in young adults less than 30 years old. The aim of this study is to identify risk factors and characteristics of rectal prolapse in this group of young patients and determine surgical outcome.

METHODS

Adult patients younger than 30 years old with rectal prolapse treated surgically between September 1994 and September 2012 were identified from an IRB-approved database. Demographics, risk factors, associated conditions, clinical characteristics, surgical management and follow-up were recorded.

RESULTS

Forty-four (females 32) patients were identified with a mean age of 23 years old. Eighteen (41%) had chronic psychiatric diseases requiring treatment and these patients experienced significantly more constipation than non-psychiatric patients (83% vs. 50%; P=0.024). Thirteen (30%) patients had previous pelvic surgery. The most common symptom at presentation was a prolapsed rectum in 40 (91%) and hematochezia in 24 (55%). Twenty-four (55%) underwent a laparoscopic rectopexy, 14 (32%) open abdominal repair, and 6 (14%) had perineal surgery. The most common procedure was resection rectopexy in 21 (48%; 7 open; 14 laparoscopic). At a median follow-up of 11 (range 1-165) months, 6 patients (14%) developed a recurrence.

CONCLUSIONS

Medication induced constipation in psychiatric patients and possible pelvic floor weakness in patients with previous pelvic surgery may be contributing factors to rectal prolapse in this group of patients.

Comparative effects of different sclerosing agents used to treat rectal prolapse: an experimental study in rats

BACKGROUND/PURPOSE

Sclerosing agents injected into the rectal submucosal area produce an inflammatory response and scar that prevent rectal prolapse. This study aimed to investigate the histopathological changes following submucosal injection of different sclerosing agents in rats.

METHODS

Rats (n=35) were divided into control, sham, and five experimental groups, each treated with a different sclerosing agent: cow's milk, 30% saline solution, 30% dextrose solution, 70% ethyl alcohol, and 5% phenol in almond oil (PAO). All agents were injected into the submucosal area. After 4 weeks, all animals were sacrificed. Histopathological evaluation was performed according to a semi-quantitative fibrosis scoring system (grades 0 to 3), by using Masson trichrome and hematoxylin and eosin staining.

RESULTS

Histopathological changes in the 5% phenol in almond oil group were significantly different from other groups (p=0.0001). Prominent submucosal fibrosis (grade 3), lymphatic vascular dilation, foreign body reaction, and lipogranuloma were observed in the 5% PAO group (p=0.007). No significant histopathological differences were seen between the 30% saline, 30% dextrose, and 70% ethyl alcohol groups. Significantly increased mucosal fibroblast proliferation (grade 2) was seen in 60% rats of the 30% dextrose group (p=0.026). The cow's milk and ethyl alcohol groups had mucosal erosions and congestion (grade 1) which were significantly different from the control group (p=0.024). No statically significant difference was observed between the 30% saline group and the control group.

CONCLUSIONS

In this study we showed that 5% PAO can induce some histopathological changes in the submucosal area that increase the mucosal tightness of the mucosa, which are necessary for the treatment of rectal prolapse.

Critical procedures in pediatric emergency medicine

Children comprise approximately one-quarter of all visits to most emergency departments. Children are generally healthier than adults, yet there are similar priorities in assessment and management of pediatric patients. The initial approach to airway, breathing, and circulation still applies and is first and foremost in the evaluation of young infants and children. There are certain anatomic, physiologic, developmental, and social considerations that are unique to this population and must be taken into account during their evaluation and treatment. In this review, we present and discuss an evidence-based approach to high-yield procedures necessary for all emergency physicians taking care of children.