Prolapso retal em pequenos ruminantes: etiologia, técnicas anestésicas e cirúrgicas e evolução clínica em 12 animais - relato de caso / Rectal prolapse in small ruminants: etiology, anesthetic and surgical techniques, and outcome in 12 animals - case report

Este relato descreve o prolapso retal de grau II intermitente ou permanente em nove ovinos e três caprinos. Para se estabelecer e tratar a causa primária, o histórico clínico foi minuciosamente explorado, sendo complementado pelo atendimento a campo. Nos pacientes predominou sobrepeso e tosse devido à pneumonia e, em menor proporção, verminose e prenhez. Entre os fatores predisponentes identificados na propriedade estavam a inadequada ventilação e o excesso de poeira e amônia nas instalações, o que foi associado à prevalência alta de pneumonia. O tratamento incluiu a redução manual (T1) ou a amputação retal (T2), mediante anestesia epidural sacrococcígea ou lombossacral, respectivamente, com ou sem neuroleptoanalgesia, seguidas de sutura perianal em bolsa de tabaco captonada. Os tratamentos foram eficazes em todos os animais, embora com recidiva e necessidade de nova intervenção em dois pacientes após seu retorno à propriedade. Segundo a literatura consultada, este é o primeiro relato de prolapso em caprinos. Conclui-se que o histórico e a avaliação da propriedade são importantes para identificar e tratar a causa primária do prolapso, evitando-se recidivas, e que a cirurgia e o protocolo anestésico aqui utilizados foram eficientes e podem ser praticados mesmo em condições de campo.(AU)

Nine ovine and three caprine with grade II intermittent or permanent rectal prolapse were treated, with the first report in caprine, according to the consulted literature. The clinical history was deeply explored with the clinical evaluation of the livestock. Among the causative factors identified were the inappropriate ventilation with high levels of dust and ammonia in the facilities, which was correlated to the high incidence of pneumonia and cough. The causative factors identified in the patients were overweight, pneumonia and cough, and, less predominately, verminosis and pregnancy. The treatment was based on manual reduction (T1) or rectal amputation (T2), under sacrococcygeal or lombossacral epidural anesthesia, with or without neuroleptic analgesia. The treatments were efficient in all patients; although there was recurrence in two animals, which needed the repetition of the treatment after their delivery to the farm. Based on the cases reported here, it can be concluded that the history and the livestock clinical evaluation are important to identify the primary causes, avoiding relapses. It also concluded that the surgical treatment and the anesthetic protocol used in the patients reported here were efficient and can be applied even under field conditions.(AU)

Prolapso rectal como presentación inhabitual de enfermedad celiaca. A propósito de 2 casos clínicos / Rectal prolapse as an unusual presentation of celiac disease. Report of two cases

Resumen Introducción: El prolapso rectal (PR) está relacionado a un aumento de presión intrabdominal, patología del piso pélvico o esfínter anal, siendo las causas más frecuentes la constipación, fibrosis quística, tos convulsiva y diarrea disentérica. La enfermedad celiaca no está considerada entre las patologías relacionadas a PR. Objetivo: Dar a conocer una asociación escasamente descrita entre PR y enfermedad celiaca. Casos Clínicos: Se presentan 2 preescolares en quienes el motivo de consulta fue el PR, cuyo estudio se enfocó como diarrea prolongada, debido al antecedente de deposiciones de consistencia pastosa. En los exámenes destacaron títulos de anticuerpos anti-transglutaminasa tisular (Ac anti-tTG) elevados, y biopsias duodenales con atrofia vellositaria y aumento de linfocitos in-traepiteliales, compatible con enfermedad celiaca. Ambos tuvieron una excelente respuesta a la dieta libre de gluten, con rápida normalización de las deposiciones, sin nuevos episodios de PR, desarrollo pondoestatural normal y Ac anti-tTG negativos en los controles anuales a 5 años de seguimiento. Conclusiones: Aunque la asociación entre PR y enfermedad celiaca prácticamente no ha sido descri ta, debe considerarse en pacientes que se presenten con PR.

Abstract Introduction: Rectal prolapse (RP) is related to an increase of intra-abdominal pressure, pelvic floor disease or anal sphincter. The most common causes of RP are constipation, cystic fibrosis, whooping cough and dysenteric diarrhea. However, celiac disease is not considered among the pathologies re lated to RP. Objective: To present a scarcely described association between RP and celiac disease. Clinical Cases: We presented 2 preschoolers in whom the reason for consultation was RP, whose study was focused on as prolonged diarrhea, due to the antecedent of pasty consistency of stools. The tests showed elevated anti-tissue transglutaminase (anti-tTG) antibody titers, and duodenal biopsies with villous atrophy and increased intraepithelial lymphocytes, consistent with celiac disease. Both had an excellent response to the gluten-free diet, with rapid normalization of depositions, without presenting any episodes of RP after treatment. Both with normal staturo-ponderal development and anti-tTG-negative controls at the annual 5-year follow-up. Conclusions: Although the association between RP and celiac disease has not been described yet, it should be considered in diagnosis and treatment.

Vigencia y utilidad de la operación de Buie modificada en el tratamiento del prolapso hemorroidal / Validity and usefulness of the modified Buie operation in the treatment of hemorrhoidal prolapse

Introducción: La cirugía del prolapso hemorroidal puede ser controversial, en particular cuando éste es circunferencial o en corona; diversos procedimientos han sido propuestos, algunos de ellos con complicaciones difíciles de solucionar. La técnica de Buie modificada puede resolver esta patología evitando las mismas. Objetivo: Evaluar prospectivamente los resultados obtenidos en la cirugía del prolapso hemorroidal mediante el empleo de la técnica de Buie modificada, sola o combinada con otra técnica. Diseño: Prospectivo observacional. Pacientes y Método: 37 pacientes consecutivos, operados entre agosto de 2007 y mayo de 2014, por prolapso hemorroidal con la técnica de Buie modificada, sola o combinada con otra técnica. Resultados: La edad promedio de la muestra fue 46,48; de los cuales el 62,16% fueron de sexo masculino; todos los pacientes eran portadores de un prolapso hemorroidal parcial o circunferencial o en corona. El sangrado ocasional fue el síntoma más frecuente (75,67%), seguido de la humedad perianal (67,57%). La técnica de Buie modificada se llevó a cabo solo en el 32,43% y combinado con la técnica de Ferguson en el 67,57%. El promedio de días de internación fue de 1,11. Cinco pacientes evidenciaron un sangrado escaso y de presentación irregular siendo la única complicación postoperatoria (13,5%). En el control a 30 días todos los enfermos tuvieron una adecuada cicatrización. No se constataron estenosis anal o ano húmedo por ectropión mucoso. Conclusiones: La técnica de Buie modificada sola o combinada resultó un procedimiento adecuado y efectivo para el tratamiento del prolapso hemorroidal con una estadía sanatorial corta, bajo costo y un índice de complicaciones postoperatorias más que aceptables.

Introduction: Prolapsed hemorrhoid surgery can be controversial, in particular when the surgery involves prolapsed hemorrhoids partial or in “crown”. Several procedures have been proposed, some of which have provided with complications difficult to solve. Buie’s modified technique can resolve this pathology, preventing these complications. Objective: To assess prospectively the acquired results obtained from prolapsed hemorrhoid surgery after Buie’s modified technique, alone or in combination with another technique. Design: Prospective observational. Patients and Method: 37 consecutive patients underwent surgery after Buie’s modified technique alone, or combined with another technique, between August 2007 to May, 2014. Results: The average mean age of the patients was 46,48; from which 62, 16% were males; all carried partial or in “crown” prolapsed hemorrhoids. Occasional bleeding was the most frequent symptom (75, 67%), followed by perianal moisture (67,57%). The Buie’s modified technique was performed alone in 32,43% and in combination with the Ferguson technique in 67, 57%. The average days of patients admission was 1,11. Five patients showed scanty and irregular bleeding, this being the only post-operative complication (13,5%). After a 30-day checkup, all patients presented reasonable scaring. No evidence was found for anal stenosis or moist anus by mucosal ectropion. Conclusions: The Buie’s modified technique, alone or combined, turned out to be the most effective and proper procedure for the treatment of prolapsed hemorrhoids; it is inexpensive, besides the patient is admitted to the hospital for a short period of time with a more acceptable index of post-operative complications.

Tuberculosis of Rectum simulating malignancy and presenting as rectal prolapse - A case report and review.

Summary: Tuberculosis of the gastrointestinal tract (GIT) occurs as a primary lesion or secondary to a focus of tuberculosis elsewhere in the body, most commonly in the lungs. Tuberculosis can affect any part of the GIT from the oesophagus to the anal canal. Two main types are – the tuberculous ulcer and the rarer hypertrophic type which is generally found at the ileocecal junction, less commonly in the colon or rectum. Tuberculosis of bowel distal to ileocecal junction is rare and is seldom considered as a differential diagnosis of rectal stricture (2%).1,6 We report a case of rectal tuberculosis presenting with rectal prolapse and masquerading as malignancy, clinically, radiologically as well as on colonoscopy. The diagnosis was confirmed by repeated histopathological examination. The patient underwent definitive surgery along with anti-tuberculous therapy.

Procidencia aguda rectal complicada: alternativas en el tratamiento quirúrgico / Acute complicated rectal prolapse: alternatives for the surgical management

Rectal prolapse is protrusion of the rectum throuhg the anal sphincter. If the protrusion is made up to the entire thickness of the rectal wall, it constitutes a complete prolapse; is called partial, incomplete or mucosal. Rectal prolapse was described in the Ebers Papyrus, 1500 years B.C. is an uncommon pathology frequently incapacitating, and many aspects are still ignored. Complete rectal prolapse predominantly affects adults and usually is associated to fecal incontinence, but also can affect children, generally before five years of age. Rectal prolapse is several times more common in women than in men. The symptoms that patients with complete rectal prolapse present are the actual prolapse itself, with fecal incontinence and altertion of bowel habits. Numerous procedures are available to treat complete rectal prolapse, which can be done through the abdominal or the perineal approaches. Before subjecting these patients to surgery, they should be carefully evaluated to select the surgical procedure to be used. Abdominal procedures are the most usually used and offer beter results. The numerous surgical procedures by the abdominal approach can be synthesized as follows: the Orr procedure or lateral fixation, the Muir procedure (resection without fixation), Dissection of the sigmoid with sacral fixation (Frykmann & Goldberg), De Wells procedure or posterior fixation. The anterior rectopexy or the Ripstein procedure is the preferred technique, especially in the U.S.A., and shows good results; the Ripstein procedure consists in mobilization of the rectum down to the elevator ani muscles. The rectum is fixed to the sacral cavity by means of a piece of Marlex mesh which surrounds the anterior and lateral rectal walls.

Relato Oficial: prolapso rectal / Offcial lecture: rectal prolapse

El prolapso rectal continúa siendo una patología que genera controversias a pesar del tiempo trascurrido. La etiopatogenia no es aún bien conocida y se manifiesta como un trastorno del piso pelviano asociado a otras patologías, además se suman la incontinencia y la constipación que generan mayor complejidad al momento de decidir el tratamiento adecuado. Durante el desarrollo del relato se analizan las diferentes series y sus resultados, con el objetivo de arribar a conclusiones que definan si la mejor operación existe. Debido a la falta de publicaciones que presenten series numerosas y seguimiento adecuado, como así también a resultados basados en evidencia, el tratamiento ideal del prolapso rectal es aún cuestionado. Concluimos que se evidencia algún cambio respecto a las vías de abordaje, con una reivindicación de las técnicas perineales y un incremento de la vía laparoscópica con tendencia a proyectarse como el estándar oro. Pero creemos todavía que cada cirujano deberá decidir la conducta quirúrgica caso por caso.

Despite the time that has passed, rectal procidencia continues to be an entity that gives rise to controversy. Pathogenesis is not yet well know and is manifested as a disorder of the pelvic floor associated with other diseases, besides incontinence and constipation are added that generate even higher complexity when having to decide on the appropriate treatment. Along this review, different series and its results have been analyzed with the objective of finding out conclusions that define if the best surgery exists. Due to the lack of publications with extensive series and appropriate monitoring, as well as to results based on evidence, the ideal treatment of rectal procidence is still questioned. We conclude that some change is evidenced according to the technique or approach selected with a revindication on perineal techniques and an increase on laparoscopic approach tending to project itself as the gold standard. We still believe that each surgeon must decide the conduct of surgery on a case by case basis.

Non-familial juvenile polyposis in prolapsed rectum.

Juvenile polyposis located solely on prolapsed rectal mucosa is very unusual. We report the case of a 17-year old boy who presented to us with a history of passage of blood and mucus per rectum of a mass protruding through the anus during defecation. Per rectal and colonoscopic examinations revealed numerous polyps located solely on the prolapsed rectal mucosa. Histopathology was consistent with juvenile polyposis. He was managed with repeated sessions of endoscopic polypectomy. Family screening was negative for colonic polyps.

External resection of a giant sigmoid lipoma causing colonic intussusception and prolapse through the anal canal.

We depict the case of an 80-year-old female patient who presented to us with a history of protruding mass per anum. Sigmoidoscopy revealed a large globular pedunculated polyp at 22 cm from the anal verge resulting in a sigmoidorectal intussusception. Endoscopic polypectomy was not technically possible due to the large size of the polyp. At the time of prolapse the polyp was tied at its pedicle with thread and resected surgically. The patient is asymptomatic on follow-up.

Adult idiopathic ileosigmoid intussusception prolapsing per rectum.

Ileosigmoid intussusception can lead to ischemia and necrosis of either the ileum or sigmoid colon. Ileosigmoid intussusception as a mass prolapsing per rectum in an adult has not been previously reported. We report a 50-year-old man with such a presentation. He recovered uneventfully after subtotal colectomy.

Prolapso do reto: aspectos clínicos e cirúrgicos / Rectal prolapse: clinical and surgical aspects

O prolapso retal é um transtorno da estática do reto e se manifesta pela invaginação oculta ou visível, quando há saída de segmento variável do reto pelo ânus. Trata-se de uma anomalia relativamente incomum, incapacitante e de etiologia pouco conhecida, para que concorre uma multiplicidade de fatores de diferentes patogenias. É mais freqüente na mulher idosa, com pico acima dos 60 anos de idade, mas pode ser visto na criança, mais comum nos meninos que nas meninas e nos adultos do sexo masculino, com distribuição semelhante em diferentes faixas etárias, em geral mais jovens que nas mulheres. O tratamento é invariavelmente cirúrgico e, para tanto, dispomos de mais de uma centena de técnicas que objetivam corrigir o prolapso e restaurar a função anorretal. Essas técnicas podem ser divididas em dois principais grupos de procedimentos mais usados: os primeiros são aqueles que abordam o problema por via perineal e, os segundos, em que a abordagem é feita por via abdominal, seja por meio das laparotomias ou das vídeos-laparoscopias, envolvendo operações de maior ou menor liberação e fixação do reto, com ou sem a retossigmoidectomia complementar. A multiplicidade de procedimentos cirúrgicos atesta o fato de que nenhum deles satisfaz plenamente.

Prolapso rectal / Rectal prolapse

Se hace una revisión de los conceptos actuales que se aplicaron en el estudio diagnóstico y en el tratamiento del prolapso rectal.

Dos casos de lipoma de colon como causa de prolapso rectal / Two cases of colonic lipoma as a cause of rectal prolapse

Se describen dos casos de lipoma colónico que se presentaron como prolapso rectal: en ambos fue necesaria su resección quirúrgica por laparotomía. La frecuencia de lipomas colónicos es baja y no se han informado casos semejantes a los que describimos

Prolapso rectal / Rectal prolapse

Se describe el prolapso rectal en sus distintas variedades, destacando los factores anatómicos y desencadenantes que participan en su desarrollo. Se analiza la presentación clínica y métodos de estudio que permiten el diagnóstico de esta patología y, finalmente, se presenta una revisión de las modalidades terapéuticas empleadas, haciendo énfasis en las distintas técnicas quirúrgicas propuestas

Procidencia Rectal / Rectum procidentia

Antecedentes: Se han desarrollado numerosas técnicas para tratar la procidencia rectal, enfermedad poco común que es manejada ocasionalmente por el cirujano general. Objetivo: Se realizó este artículo de revisión para discutir los cambios más recientes en la patofisiología, diagnóstico y manejo de la procidencia rectal. Resultados: Se discuten la fisiopatología y características clínicas de la procidencia rectal. Hay numerosas alternativas para tratamiento quirúrgico, pero las técnicas más utilizadas incluyen rectopexia con o sin resección de sigmoides. Conslusión: El mejor entendimiento de la fisiopatología, la cada vez más objetiva evaluación de la función anorrectal de sus alteraciones, aunados al desarrollo de materiales biocompatibles y de técnicas más precisas, han dado como resultado el poder ofrecer al paciente con esta patología el tratamiento que mejor se adapte a su condición particular

Management of complete rectal prolapse.

There are two types of rectal prolapse viz, complete or procidentia and occult. Aetiology and management are usually different in children and adults. Control of prolapse by various methods of rectopexies, re-education of bowel habit and correction of sphincter dysfunction are the three phases of treatment in adults. Correction of malnutrition, digital reposition of the prolapse, submucous injection of 5% phenol in almond oil under general anaesthesia and lastly the Thiersch's operation are the methods of correction in children.