Rectopexia laparoscópica con técnica de Orr-Loygue para el tratamiento del prolapso rectal / Laparoscopic Orr-Loygue rectopexy with mesh for the treatment of rectal prolapse

Introducción: Existen múltiples alternativas para el tratamiento quirúrgico del prolapso rectal mediante procedimientos de fijación, resección o combinados. Si bien el abordaje perineal evita el acceso a la cavidad peritoneal, se acompaña de una tasa de recidiva mayor en relación al abordaje abdominal. Descripción: Se presenta una paciente de 66 años, histerectomizada por vía laparotómica, con un prolapso rectal externo y reductible de 1 año de evolución, sin incontinencia fecal ni constipación. La endoscopia preoperatoria descartó patología colónica asociada. Abordaje laparoscópico en posición de Trendelenburg lateralizado a la derecha. Como es habitual en estos casos se observa la presencia de dolicosigma y fondo de saco de Douglas profundo y se evidencia también la cicatriz de la cesárea. El procedimiento comienza con la apertura peritoneal a nivel del promontorio y la movilización de la unión rectosigmoidea, identificando el uréter izquierdo. Se continua la disección circunferencial tras la apertura de la reflexión peritoneal hasta la altura de la cúpula vaginal. La rectopexia se realiza según la técnica de Orr-Loygue mediante la fijación de la malla por una parte a ambas caras laterales del recto y por otra al promontorio sacro con puntos de polipropileno 2-0, cuidando de no lesionar los vasos ilíacos y los uréteres. Finalmente se cierra la reflexión peritoneal con poliglactina para aislar las mallas protésicas del contenido visceral. La paciente tuvo una buena evolución postoperatoria, otorgándose el alta a las 48 h. Tras 8 meses de seguimiento se encuentra asintomática, con tránsito digestivo y continencia fecal sin alteraciones. Conclusión: El abordaje laparoscópico para el tratamiento del prolapso rectal es seguro y ofrece las ventajas de la cirugía mini-invasiva. La rectopexia con malla protésica es un procedimiento técnicamente desafiante, aunque con mejores resultados alejados. (AU)

Introduction: There are multiple alternatives for the surgical treatment of rectal prolapse through fixation, resection or combined procedures. Although the perineal approach avoids access to the peritoneal cavity, it is associated with a higher recurrence rate than the abdominal approach. Description: The video shows a 66-year-old female patient, hysterectomized by laparotomy, with a 1-year history of reduciblefull-thickness rectal prolapse, without fecal incontinence or constipation. Preoperative endoscopy ruled out associated colonic pathology. The laparoscopic approach is done with the patient placed in Trendelenburg and tilted to the right. As usual in these cases, the presence of dolichosigma and deep Douglas pouch is observed, as well as the cesarean section scar. The procedure begins with the peritoneal opening at the level of the promontory and the mobilization of the rectosigmoid junction, identifying the left ureter. Circumferential dissection is continued after opening the peritoneal reflection up to the level of the vaginal vault. Rectopexy is performed according to the Orr-Loygue technique by fixing the mesh to both lateral aspects of the rectum on one side and to the sacral promontory on the other side with 2-0 polypropylene interrupted sutures, taking care not to injure the iliac vessels and ureters. Finally, the peritoneum is closed with a running suture with polyglactin to isolate the prosthetic mesh from the visceral content. The patient had a good postoperative outcome and was discharged at 48 h. After 8 months of follow-up, she is asymptomatic and has normal colonic transit and fecal continence. Conclusion: the laparoscopic approach for the treatment of rectal prolapse is safe and offers the advantages of minimally invasive surgery. Prosthetic mesh rectopexy is a technically challenging procedure, although has better distant results. (AU)

Prolapso rectal completo / Complete Rectal Prolapse

Introducción: El prolapso rectal completo es la invaginación de las capas del recto a través del canal anal y su protrusión fuera de este. Su incidencia es de 2,5 por 100 000 habitantes con predominio en mujeres de edad avanzada. Es una afección de curso crónico y benigno, cuya presentación clínica y endoscópica es tan variable que puede confundirse con otras entidades como con el cáncer colorrectal. Objetivo: Presentar el caso de una paciente femenina, operada de prolapso rectal completo en la provincia de Cienfuegos. Presentación de caso: Se presenta una paciente femenina de 76 años de edad, blanca, de procedencia rural que acude a la consulta y refiere que lleva 12 días sin defecar. Además, presenta dolor, sangramiento rectal no activo y una masa que protruía a través de la región anal sugestiva al examen físico de un prolapso rectal completo. El tacto rectal confirma el diagnóstico. Se realiza reducción quirúrgica del prolapso por técnica de Delorme. Actualmente lleva 6 meses de operada con evolución favorable. Por lo poco frecuente de esta entidad se considera de interés científico su publicación. Conclusión: Esta entidad es poco común en el entorno médico, el gran cambio que causa en el nivel de vida de aquellos que la portan y sus complicaciones hace que requiera un tratamiento rápido y oportuno(AU)

Introduction: Complete rectal prolapse is the invagination of the rectal layers through the anal canal and its protrusion out of it. Its incidence is 2.5 per 100,000 inhabitants, predominantly in elderly women. It is a chronic and benign condition, whose clinical and endoscopic presentation is so variable that it can be confused with other entities, such as colorectal cancer. Objective: To present the case of a female patient who underwent surgery for complete rectal prolapse in the province of Cienfuegos. Case presentation: A 76-year-old female patient, white, from a rural area, came to the clinic and reported that she had not defecated for 12 days. In addition, she presents pain, nonactive rectal bleeding and a mass protruding through the anal region suggestive, on physical examination, of a complete rectal prolapse. Digital rectal examination confirmed the diagnosis. Surgical reduction of the prolapse was performed using the Delorme technique. She has undergone surgery for 6 months now, with favorable evolution. Due to the rarity of this entity, its publication is considered as scientifically interesting. Conclusion: This entity is uncommon in the medical environment. The great change that it causes in the living standards of those who carry it and its complications make it require a quick and timely treatment(AU)

Lipoma de recto prolapsado e incarcerado: caso clínico y análisis de la literatura / Prolapsed and incarcerated rectal lipoma: case report and literature review / Prolapso e encarceramento de lipoma do reto: caso clínico e análise da literatura

Los lipomas colónicos son tumores benignos poco frecuentes, extremadamente raros a nivel rectal. A pesar de ello, ocupan el segundo lugar en frecuencia detrás de los pólipos adenomatosos. Aunque la mayoría de los lipomas colorrectales son asintomáticos y se descubren incidentalmente, en ocasiones pueden ser sintomáticos y determinar complicaciones agudas que requieren tratamiento quirúrgico de urgencia. Estas formas de presentación pueden confundirse con las del cáncer colorrectal, constituyendo un desafío diagnóstico y terapéutico. Presentamos el caso de una paciente que consultó en emergencia por una gran masa dolorosa de aparición aguda a nivel del ano, resultando ser un lipoma rectal prolapsado a través del canal anal.

Colonic lipomas are infrequent benign tumors, extremely rare at the rectum. Nevertheless, they follow in frequency polyp adenomas. Even though most colorectal lipomas are asymptomatic and incidental, they can occasionally be symptomatic and develop acute complications that require urgent surgical treatment. This form of presentation can be confounded with colorectal cancer, therefore impairing diagnosis and treatment. We present the case of a female patient who came to the emergency room with an acute painful mass through the anus, that resulted in a prolapsed rectal lipoma.

Os lipomas colônicos são tumores benignos pouco frequentes, extremamente raros no nível retal. Apesar disso, ocupam o segundo lugar em frequência atrás dos pólipos adenomatosos. Embora a maioria dos lipomas colorretais sejam assintomáticos e descobertos incidentalmente, às vezes eles podem ser sintomáticos e levar a complicações agudas que requerem tratamento cirúrgico de emergência. Essas formas de apresentação podem ser confundidas com as do câncer colorretal, constituindo um desafio diagnóstico e terapêutico. Apresentamos o caso de um paciente que consultou na sala de emergência por uma grande massa dolorosa de início agudo ao nível do ânus, que acabou por ser um lipoma retal prolapsado pelo canal anal.

Prolapso rectal completo procedimiento de Delorme / Complete rectal prolapse Delorme procedure / Procedimento completo de prolapso retal Delorme

Introducción: el prolapso rectal es una invaginación del recto que produce su exteriorización a través del ano. Se denomina completo cuando está constituido por todo el espesor de la pared rectal. En su incidencia están vinculados factores como el sexo femenino, los pacientes añosos y el parto. Etiopatogenia: es multifactorial, se plantean varias teorías. Entre ellas, un fondo de saco peritoneal recto vaginal o recto vesical anormalmente profundo, la falta de fijación normal del recto a su lecho, la consecuencia de una invaginación idiopática de la parte superior del recto y un estado de relajación y atonía de la musculatura del suelo de la pelvis y del canal anal. Caso Clínico: mujer, 64 años. Prolapso rectal completo por debilidad de la musculatura del piso pélvico y canal anal. Se plantean la valoración diagnóstica y exámenes paraclínicos preoperatorios. Se describe el procedimiento de Delorme como solución técnica a su prolapso rectal. Se destaca que la paciente evolucionó favorablemente. Conclusiones: el objetivo del tratamiento es solucionar el prolapso y restaurar la función anorrectal sin provocar efectos nocivos. El prolapso que presenta esta paciente es multifactorial e incluye el conjunto de las siguientes anomalías, afecta a las mujeres de edad avanzada y multíparas, está exteriorizado permanentemente y forma parte de una enfermedad degenerativa difusa del periné. El mismo fue solucionado según el procedimiento de Delorme. La evolución de la paciente fue satisfactoria, no se objetivaron complicaciones ni recidiva en el post operatorio precoz o alejado.

Introduction: rectal prolapse is an invagination of the rectum that produces its exteriorization through the anus. It is called complete when it is constituted by the whole thickness of the rectal wall. Factors such as female sex, elderly patients and childbirth are linked to its incidence. Etiopathogenesis: it is multifactorial, and several theories have been put forward. Among them, an abnormally deep peritoneal rectal vaginal or rectal vesical fornix, the lack of normal fixation of the rectum to its bed, the consequence of an idiopathic invagination of the upper part of the rectum and a state of relaxation and atony of the muscles of the pelvic floor and the anal canal. Case report: female, 64 years old. Complete rectal prolapse due to weakness of the pelvic floor muscles and anal canal. The diagnostic evaluation and preoperative paraclinical examinations are presented. The Delorme procedure is described as a technical solution to her rectal prolapse. It is emphasized that the patient evolved favorably. Conclusions: The goal of treatment is to resolve the prolapse and restore anorectal function without causing harmful effects. The prolapse presented by this patient is multifactorial and includes all of the following anomalies, affects elderly and multiparous women, is permanently externalized and is part of a diffuse degenerative disease of the perineum. It was solved according to the Delorme procedure. The patient's evolution was satisfactory, no complications or recurrence were observed in the early or distant postoperative period.

Introdução: O prolapso retal é uma invaginação do reto que resulta em sua externalização através do ânus. É chamado completo quando consiste de toda a espessura da parede retal. Fatores como sexo feminino, pacientes mais velhos e parto estão ligados a sua incidência. Aetiopatogênese: é multifatorial, e várias teorias foram apresentadas. Estes incluem um fórnix peritoneal rectovaginal ou retal vesical anormalmente profundo, a falta de fixação normal do reto em seu leito, a conseqüência da invaginação idiopática da parte superior do reto e um estado de relaxamento e atonia dos músculos do assoalho pélvico e do canal anal. Relato de caso: mulher, 64 anos de idade. Prolapso retal completo devido à fraqueza dos músculos do assoalho pélvico e do canal anal. São apresentados a avaliação diagnóstica e os exames paraclínicos pré-operatórios. O procedimento Delorme é descrito como uma solução técnica para seu prolapso retal. Observa-se que o paciente evoluiu favoravelmente. Conclusões: O objetivo do tratamento é resolver o prolapso e restaurar a função anorretal sem causar efeitos nocivos. O prolapso apresentado por esta paciente é multifatorial e inclui todas as seguintes anomalias, afeta mulheres idosas e multíparas, é externalizado permanentemente e faz parte de uma doença degenerativa difusa do períneo. Foi tratado de acordo com o procedimento Delorme. A evolução do paciente foi satisfatória, não foram observadas complicações ou recidivas no período pós-operatório precoce ou distante.

Chinese expert consensus on the diagnosis and surgical treatment of rectal prolapse (2022 edition) / 中华胃肠外科杂志

Surgery is currently the only cure for rectal prolapse. Standardized preoperative evaluation and appropriate selection of surgical methods are crucial to the outcome of rectal prolapse surgery. With the development of a series of clinical studies in China and abroad, transabdominal surgery (such as ventral mesh fixation) and transperineal (anal) surgery (such as Altemeier surgery) have been widely recognized. Precise preoperative assessment of rectal prolapse and appropriate selection of surgical approaches has important clinical value in reducing postoperative recurrence rates and surgical-related complications. However, the current rectal prolapse assessment system needs to be improved, and the choice of surgical procedures remains controversal. To guide the diagnosis and surgical treatment of patients with rectal prolapse in China, nationwide specialists of colorectal and pelvic floor surgery have been organized by the of Chinese Medical Doctor Association Anorectal Branch, the Pelvic Floor Surgery Committee, and Clinical Guidelines Committee. Experts have conducted rounds of discussions on the core content of standardized diagnosis and surgical treatment for rectal prolapse, and jointly formulated the "Chinese expert consensus on the diagnosis and surgical treatment of rectal prolapse (2022)". We hope that this consensus will provide useful resources for the colorectal and pelvic floor surgeons, and promote the standardization of diagnosis and surgical treatment for the rectal prolapse in China.

Homeopathic treatment of rectal prolapse in a kitten: a case report

Rectal prolapse be either partial or incomplete in nature and is defined as double layer evagination of the rectum through the anal canal. The common associated causations which can be seen in kittens are severe endoparasitism, enteritis, and associated tenesmus (Fossum, 2002). Rectal prolapse is the one of the most encountered surgical conditions involving the rectum in all domestic animal species (Tyagi and Singh, 1993). Surgical intervention is the most common treatment methodology adopted but however, in cases where surgery is not indicated, required, not opted by the owner, becomes a challenge to treat. Therefore, finding alternative therapies for clinical management is the need of hour. The objective of this study is to report successful management of rectal prolapse in a 5-month-old kitten having 4 episodes of prolapse in five days. The homeopathic medicines used in this case were Sepia 200C and Ruta g. 200C. The patient revealed a favourable response by 2nd day of the treatment and complete healing was observed on 7th day. This therapeutic protocol used was conclusive and it re-established the normal intake of food and energy level. Hence, homeopathic treatment can be considered as an alternative therapy for clinical management of rectal prolapse in a Felines and Canines.

Outcome of Fecal Incontinence in Patients with Rectal Prolapse Undergoing the Altemeier Procedure with or without Posterior Levatorplasty / Desfecho de incontinência fecal em pacientes com prolapso retal submetidos ao procedimento de Altermeier com ou sem levatorplastia posterior

Abstract Objective To compare the fecal incontinence status of patients submitted to theAltemeier procedure with or without posterior levatorplasty. Materials and Methods Medical records of the patients who underwent the Altemeier procedure at Shahid Faghihi Hospital (in Shiraz, Iran) from 2014 to 2018 were retrospectively studied. Patients older than 17 years of age who underwent the Altemeier procedure due to complete rectal prolapse were considered. In some cases, the operation was performed with posterior levatorplasty. Rectal prolapse due to collagen or connective tissue disorders, anal/sacral anomalies, immunodeficiency, history of rectal surgery, and pelvic radiotherapy were the exclusion criteria of the present study. In addition to the demographics (including age, gender, and body mass index), the fecal incontinence status of each case was determined through theWexner scale preoperatively and 12 months after the surgery. The incontinence scores were then compared against the baseline values of the two groups of patients: those with and those without posterior levatorplasty. The statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS, IBM Corp., Armonk, NY, US), software, version 21. Results In total, 53 patients (17 men and 36 women) with a mean age of 55.23 ± 18.24 years were analyzed. The comparison of the pre- and postoperative scores on theWexner scale between the two groups revealed no statistically significant difference (p >0.05). Conclusion Posterior levatorplasty during the Altemeier procedure did not result in significant improvement of the fecal incontinence outcome of the patients.

Resumo Objetivo Comparar o status de incontinência fecal de pacientes após o procedimento de Altemeier com e sem levatorplastia posterior. Materiais e métodos Os prontuários médicos dos pacientes submetidos ao procedimento de Altemeier no Shahid Faghihi Hospital (em Shiraz, Irã) entre 2014 e 2018 foram avaliados retrospectivamente. Pacientes com idade superior a 17 anos submetidos ao procedimento de Altemeier devido a prolapso retal completo foram considerados. Em alguns casos, a operação foi realizada com levatorplastia posterior. Prolapso retal devido a distúrbios de colágeno ou do tecido conjuntivo, anomalias anais/sacrais, imunodeficiência, histórico de cirurgia retal, e radioterapia pélvica foram os critérios de exclusão deste estudo. Além dos dados demográficos (incluindo idade, sexo, e índice de massa corporal), o status da incontinência fecal de cada caso foi determinado por meio da escala de Wexner antes e doze meses após a cirurgia. Então, as pontuações de incontinência foram comparadas aos valores de referência dos dois grupos de pacientes: com e sem levatorplastia posterior. A análise estatística foi feita usandose o programa Statistical Package for the Social Sciences (SPSS, IBM Corp., Armonk, NY, EUA), versão 21. Resultados No total, 53 pacientes (17 homens e 36 mulheres) com idade média de 55.23 ± 18.24 anos foramavaliados. A comparação entre os grupos das pontuações na escala de Werner no pré e pós-operatório não revelou diferença estatisticamente significativa (p>0.05). Conclusão Levatorplastia superior durante o procedimento de Altemeier não resultou em melhora significativa do desfecho da incontinência fecal dos pacientes.

Management of rectal prolapse (Guda Bhramsa) through Kshara Karma (chemical cauterisation): a case study / Manejo do prolapso retal (Guda Bhramsa) usando Kshara Karma(cauterização química): um estudo de caso

Abstract Rectal Prolapse is a condition where the rectum protrudes beyond the anus. The explanation of this condition can be traced back to ancient Ayurveda text like Susruta Samhita, Ebers Pappyrus of 1500 B.C., etc. The exact cause of rectal prolapse is unclear but it is predominant on female gender and on people having constipation, previous anorectal surgeries etc. Both partial and complete varieties of rectal prolapse are extremely debilitating because of the discomfort of the prolapsing mass and variety of symptoms like rectal bleed, intermittent constipation or fecal incontinence. Although, diverse modalities of surgical management of rectal prolapse are present, no single optimal procedure is proved and the choice of operation is determined by the patient's age, sex, degree of incontinence, operative risk, as well as by the surgeon's experience. In Ayurveda, Guda Bhramsa (Rectal prolapse) is explained by Acharya Susruta under Kshudra Rogas (chapter of minor diseases) and has elaborated it's conservative management very beautifully. In this case, a female with partial rectal prolapse was treated with Kshara application and managed without complications. So, Kshara application can be a safe and effective alternative for the management of rectal prolapse.

Resumo O prolapso retal é uma condição em que o reto se projeta para além do ânus. A explicação desta condição foi relatada em antigos textos Ayurveda como Susruta Samhita e Ebers Pappyrus, datados de 1500 aC. A causa exata do prolapso retal não é clara, mas essa condição é predominante no sexo feminino e nas pessoas com constipação e histórico de cirurgias anorretais anteriores. Tanto o prolapso retal parcial quanto total são extremamente debilitantes devido ao desconforto da massa prolapsante e da variedade de sintomas como sangramento retal, constipação intermitente ou incontinência fecal. Embora diversas modalidades de tratamento cirúrgico para corrigir o prolapso retal tenham sido relatadas na literatura, nenhum procedimento é consensual; a escolha da operação é determinada pela idade, sexo, grau de incontinência, risco operatório e experiência do cirurgião. Na Ayurveda, Guda Bhramsa (prolapso retal) é explicado por Acharya Susruta no Kshudra Rogas (capítulo de doenças menores) e seu manejo conservador é descrito de forma bastante completa. No presente caso, uma paciente do sexo feminino com prolapso retal parcial foi tratada com aplicação de Kshara e administrada sem complicações. Assim, a aplicação de Kshara pode ser uma alternativa segura e eficaz para o manejo do prolapso retal.

Macroligaduras hemorroidales. Tratamiento ideal del prolapso hemorroidario. Seguimiento a 5 años / Hemorrhoidal macro rubber band ligations. Ideal treatment of hemorrhoidal prolapse. Follow-up at 5 years

Introducción: Entre los tratamientos alternativos de las hemorroides se destaca por ser costo-eficientes las ligaduras elásticas convencionales. Las macroligaduras elásticas se hayan en difusión por similares resultados que las bandas elasticas convencionales. La literatura es aun escasa. El objetivo fue analizar los resultados, morbilidad y recidiva a corto y mediano plazo de hemorroides tratadas con macroligaduras. Diseño: Estudio observacional analítico prospectivo. Pacientes: 188 pacientes (110 varones y 78 mujeres). Periodo: 2011-2014. Lugar: Institución privada universitaria. Métodos: Inclusión: pacientes tratados con hemorroides internas sintomáticas. Exclusión: enfermedad anoperineal asociada, tratamiento previo, inmunocompromiso o anticoagulación. Se registraron resultados, complicaciones y recidiva. La técnica empleada fue la descripta por Reis Neto. El Seguimiento fue a 10, 30 días y 6 y 12 meses y 5 años. Resultados: Todos fueron tratados con internación de corta estadía. La edad fue 49,5 años (23-76). Los síntomas fueron prolapso 96, sangrado 44 y ambos 48. Se realizó sólo una sesión en 178 casos (94,6%). Se trataron 2 paquetes en 122 y 3 en 66. El dolor moderado fue en 5 casos y prolongado en 2. El sangrado leve y tenesmo se presentó en la mayoría de los pacientes, pero desapareció en la primera semana. Se registró sangrado inmediato moderado en 5% sin sangrado severo inmediato. Otras complicaciones inmediatas: 2 trombosis y 3 congestión/edema local. En 1 paciente ocurrió un sangrado que requirió de internación sin necesidad de cirugía en forma alejada. Sólo en 3 casos se realizó resección local de plicomas previos. En 139 casos se realizó como único procedimiento. La recidiva fue 6 casos. (2 al primer año y 4 a los 5 años), 5 se trataron con nueva macroligadura y 1 con cirugía. No se registró ninguna complicacion severa, infecciosa o única relacionada al procedimiento. El seguimiento a 1 año fue del 100% y a 5 años del 96%. Discusión y conclusiones: El tratamiento con macroligaduras para el prolapso hemorroidario presentó con baja morbilidad sin complicaciones severas. Los resultados son reproducibles entre diferentes autores. Son el tratamiento ideal para las hemorroides grado III con poco componente externo. (AU)

Introduction: Alternative therapies for internal hemorrhoid plexus are several procedures with specific indications for each grade of hemorrhoid. Due to some major advantages, rubber band ligation has become probably in the most popular between colorectal surgeons. The high-macro rubber band ligation appears to be as the first choice but literature is few. Objective: To analyze results, morbidity and recurrence of internal hemorrhoid disease treated with high-macro rubber band ligation. Design: Observational non-randomized prospective analysis. Patients: 188 patients (110 male). Period: 2011-2014. Setting: Private Institution. Methods: Patients with symptomatic internal hemorrhoid disease (grade II-III-IV). Results, Immediate and late complications and 5 years recurrence were registered. Technique used was the original description by Reis Neto. Patients with immunosuppression, additional perianal disease, previous treatment and anticoagulation were excluded. Results: There was only one session in 178 cases. Two banding were placed in 122 and 3 in 66. Symptoms were prolapse in 96, bleeding in 44 and both in 48. 139 patients were treated as only procedure. Tenesmus and light hemorrhage occurred in most cases. Moderate or late pain was registered in 7 cases, and immediate moderate bleeding in 5%. There was no severe immediate bleeding. Immediate morbidity was 2 thrombosis and 3 anal congestion. There was one moderate late bleeding at day 28 and required admission. Recurrence occurred in six cases, 5 were ligated again and 1 was treated by conventional surgery. There was none severed or unique complication or infection associated. Discussion and conclusion: Macrorubber band presented low morbidity and there are no severe complications at 5 years follow-up. Recurrence of prolapse is low and could be treated by a new session with equal morbidity. Results are equivalent and reproducible by different authors. This procedure might be the ideal treatment for hemorrhoid prolapse. (AU)

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)

Anal position index; can it predict pelvic organ disorders in adults? / O índice de posição anal pode prever doenças de órgãos pélvicos em adultos?

ABSTRACT Introduction: Anal position index is calculated with a simple formula, which is used to determine the exact position of anus in perineum. This index is currently used only in neonates and infants. Anteriorly displacement of anus is a common cause of chronic constipation. Here we assessed the association between anal position index with patients' characteristics, chronic constipation, rectum prolapse uterine prolapse, and number of delivery. Material and methods: This was a cross-sectional study performed in 2018 on 63 adult admitted to colorectal surgery clinic. Anus-forchuette, coccyx-forchuette and coccyx-scrotum and anal-scrotum were measure by a simple meter tape. Statistical Package for the Social Sciences (SPSS for Windows, ver. 18) was used for data analysis. Independent Student's t-test, correlation coefficient and ANOVA were used. Results: Sixty-three patients within age range of 22-75 years old were recruited. 48 were male (76.2%) and 15 females (23.8%). Twenty-nine (46%) had chronic constipation. The mean ± SD of the index with confidence interval of 95% was 0.5325 ± 0.11861 in males and 0.4510 ± 0.16803 in females. Also the mean of the index was 0.4616 ± 0.14007 in patients with chronic constipation and 0.5570 ± 0.11559 in patients without constipation. Discussion: Anal position index can be a prognostic factor to predict chronic constipation and pelvic floor anatomy disturbance in adults as well as pediatrics.

RESUMO Introdução: O índice de posição anal é calculado com uma fórmula simples, usada para determinar a posição exata do ânus no períneo. Atualmente, esse índice é usado apenas em neonatos e bebês. O deslocamento anterior do ânus é uma causa comum de constipação crônica. No presente estudo, avaliou-se a associação entre o índice de posição anal e as características dos pacientes, constipação crônica, prolapso uterino, prolapso do reto e número de partos. Material e Métodos: Este estudo transversal, realizado em 2018, incluiu 63 adultos admitidos na clínica de cirurgia colorretal. As distâncias ânus-frênulo dos lábios, cóccix-frênulo, cóccix-escroto e ânus-escroto foram medidas com uma fita métrica simples. O SPSS for Windows (v. 18) foi usado para análise dos dados. O teste t de Student para variáveis independentes, o coeficiente de correlação e o teste ANOVA foram usados. Resultados: Sessenta e três pacientes com idade entre 22 a 75 anos foram recrutados; 48 eram do sexo masculino (76,2%) e 15 do sexo feminino (23,8%). Destes, 29 (46%) apresentavam constipação crônica. A média ± DP do índice, com intervalo de confiança de 95%, foi de 0,5325 ± 0,11861 no sexo masculino e 0,4510 ± 0,16803 no sexo feminino. Além disso, a média do índice foi de 0,4616 ± 0,14007 em pacientes com constipação crônica e 0,5570 ± 0,11559 em pacientes sem constipação. Discussão: O índice de posição anal pode ser um fator prognóstico para predizer constipação crônica e alterações da anatomia do assoalho pélvico em pacientes adultos e pediátricos.

Prolapso rectal incarcerado secundario a adenoma velloso gigante / Incarcerated rectal prolapse due to a giant villous adenoma

Los adenomas vellosos pueden manifestarse con sangrado, diarrea, alteraciones hidroelectrolíticas (síndrome Mackittrick-Weelock), obstrucción intestinal, y, muy infrecuentemente, condicionar un prolapso rectal. El prolapso rectal es la protrusión de la pared completa del recto a través del canal anal, su presentación como prolapso rectal incarcerado es poco habitual. Cuando la reducción manual no es posible, la rectosigmoidectomía vía perineal o procedimiento de Altemeier es una buena opción quirúrgica; como alternativa puede realizarse una resección transanal del pólipo y la posterior reducción manual del prolapso rectal. Referiremos el caso de una mujer que acude al Servicio de urgencias presentando un prolapso rectal incarcerado con una masa ulcerada, friable, de 10 × 8 × 5 cm compatible con un pólipo velloso en la cara posterior del recto. Ante la imposibilidad de reducirlo se decide una resección transanal del pólipo con posterior reducción manual del prolapso rectal. Este caso es de interés por la infrecuente asociación entre un prolapso rectal incarcerado y un pólipo velloso gigante, con solo 4 casos comunicados en la literatura.

Villous adenomas may present with bleeding, diarrhea, electrolyte imbalance (Mackittrick-Weelock syndrome), obstruction, being a very rare cause of rectal prolapse. Rectal prolapse is a full thickness protrusion of the rectum through the anal canal and its presentation as an incarcerated rectal prolapse is very infrequent. If manual reduction is deemed impossible, perineal recto-sigmoidectomy, or Altemeier's procedure, is one of the best surgical options, as an alternative transanal excision of the polyp could be performed with subsequent manual reduction of the rectal prolapse. We report the case of a female patient, admitted to the emergency room presenting an incarcerated rectal prolapse with a friable ulcerated mass of 10 × 8 × 5 cm, compatible with a villous polyp in the back side of the rectum. Since manual reduction was considered not feasible, surgery was decided and a transanal excision of the polyp was performed, following a successful manual reduction of the rectal prolapse. This case is of particular interest for its unusual association of incarcerated rectal prolapse due to a giant villous adenoma, having only 4 cases been reported in the literature.

Hemorroidopexia. Nuestra experiencia. Análisis descriptivo de las complicaciones de la técnica de hemorroideopexia con sutura mecánica y el grado de satisfacción / Hemorroidopexy Our experience. Descriptive analysis of the complications of the hemorrhoidepexy technique with mechanical suture and the degree of satisfaction

Introducción: La hemorroidopexia con sutura mecánica, es una técnica eficaz para los prolapsos hemorroidales grado III y IV. Objetivo: Describir nuestra experiencia con dicho método. Material y métodos: Se realizó un análisis descriptivo, retrospectivo sobre una base de datos cargada en forma prospectiva. Se analizaron pacientes con hemorroides grado III y IV, en quienes se realizó hemorroidopexia con PPH- 03, desde enero del 2010 hasta diciembre de 2017. Se evaluaron las variables demográficas, las complicaciones y el grado de satisfacción. Se realizó seguimiento postoperatorio semanal, a los 15 días, al mes, a los 6 meses y finalmente un control telefónico. Resultados: Se estudiaron 452 pacientes. La edad media fue de 46 años (rango: 20-75), siendo el 63% (n=291) del sexo masculino. El 84% (n=387) presentaban hemorroides grado III. El índice de complicación fue del 25% (n=115) durante el periodo de seguimiento, en el postoperatorio inmediato, 60 (52%) pacientes presentaron un evento considerado como complicación, y 55 (48%) pacientes presentaron complicaciones mediatas y tardías. Las complicaciones más frecuentes fueron: dolor en 37 (8%) de los pacientes, seguida por proctorragía en 18 casos (4%) y trombosis hemorroidal externa en 15 pacientes (3,3%). (AU)

Background: Hemorrhoidopexy with mechanical suture is an effective technique for hemorrhoidal prolapses grade III and IV. Objective: Describe our experience with this method. Material and methods: A descriptive, retrospective analysis was performed on a prospectively loaded database. Patients with grade III and IV hemorrhoids were analyzed, in whom hemorrhoidopexy was performed with PPH-03, from January 2010 to December 2017. Demographic variables, complications and degree of satisfaction were evaluated. Weekly postoperative follow-up was performed at 15 days, at month, at 6 months and finally a telephone control. Results: 452 patients were studied. The average age was 46 years (range,: 20 - 75), being 63% (n = 291) of the male sex. 84% (n = 387) had grade III hemorrhoids. The complication rate was 25% (n = 115) during the follow-up period, in the immediate postoperative period, 60 (52%). The most frequent complications were: pain in 37 (8%) patients, follow-up by proctorrhagia in 18 cases (4%) and hemorrhoidal thrombosis external in 15 patients (3.3%). (AU)

Comparison of Delorme-Thiersch Operation Outcomes in Men and Women With Rectal Prolapse

PURPOSE: The laparoscopic rectopexy has become increasingly popular with verified stability, surgical route selection should be tailored to individual patient characteristics rather than operative risk. The perineal approach is useful in young male patients who need to preserve fertility. This study aimed to compare the characteristics of men and women who underwent Delorme-Thiersch procedures and analyze the postoperative outcomes of the perineal approach by sex. METHODS: We retrospectively reviewed the medical records of 293 patients who underwent Delorme-Thiersch operations in Seoul Song Do Colorectal Hospital between January 2011 and September 2017. Patient clinical characteristics and postoperative complications were analyzed by sex. We analyzed surgical outcomes with preoperative and 3-month postoperative incontinence questionnaires, constipation levels, and anal manometry. RESULTS: In this study, men with rectal prolapse were younger than women with the same condition. American Society of Anesthesiologists physical status classifications were higher in women and women had more L-spine X-ray and pudendal nerve terminal motor latency test abnormalities. Anorectal manometry pressures were higher in men. Men also had longer operation times and hospital stays and more postoperative complications (8 T ring infections, 6 patients with bleeding, 3 with strictures, 2 with severe pain, and 2 with rectal perforations). The recurrence rate was higher among women. CONCLUSION: Men with rectal prolapse were younger, healthier, and had relatively better anorectal function than women. The Delorme-Thiersch operation in men promoted lower recurrence rates and was advantageous in preserving the fertility of young patients, but the incidence of complications was also higher in men. Adequate counseling and preparation for the possibility of complications are needed.

Changing Trend of Rectal Prolapse Surgery in the Era of the Minimally Invasive Surgery

With the life span of the general population increased, rectal prolapse in elderly patients became a major concern in terms of the decision of the treatment modalities and quality of life of patients. Most elderly patients with rectal prolapse in the past received a perineal approach with the fear of general anesthetic complications rather than the abdominal approach. However, improvement in perioperative care in anesthesiology and minimally invasive surgery, the trend of surgical management of rectal prolapse is rapidly changing. Minimally invasive surgery including the laparoscopic and robotic surgeries showed comparable short-term outcomes even in elderly patients. Recently published guidelines also recommended a laparoscopic abdominal approach for the management of rectal prolapse.

Surgical Treatment of Rectal Prolapse: A 10-Year Experience at a Single Institution

PURPOSE: Despite the plethora of surgical options, there is no consensus regarding the best treatment for rectal prolapse. This study is aimed at evaluating our experience with its treatment and outcomes.METHODS: We retrospectively reviewed rectal prolapse patients' characteristics, clinical presentation, surgical procedure, average length of hospital stay, morbidity, mortality, and recurrence over a 10 year period at our institution.RESULTS: A total of 46 patients underwent rectal prolapse repair at our institution over a 10 year period. Of the 39 patients with primary rectal prolapse, 18 patients had an abdominal procedure, while 21 patients underwent a perineal approach. Operative duration was significantly longer in abdominal procedures, of which 16 cases were performed laparoscopically. Length of hospital stay and recurrence were not statistically significant between the 2 groups. In patients with recurrent rectal prolapse, more than 80% of the initial surgeries were done using the perineal approach. An abdominal approach was utilized in the management of 75% of recurrences.CONCLUSION: An abdominal repair may be preferable in the treatment of recurrent rectal prolapse. Minimally invasive techniques may be feasible and can provide a safe alternative to perineal procedures in elderly patients.

Rectosigmoidectomía perineal (procedimiento de Altemeier) para el prolapso rectal encarcelado: reporte de un caso / Case report of perineal rectosigmoidectomy (Altemeier's procedure) for incarcerated rectal prolapse

Resumen Los reportes de prolapso rectal encarcelado son infrecuentes y suponen un reto para el cirujano. Para un prolapso encarcelado no estrangulado, los pacientes deben tratarse con analgésicos y colocarse en la posición de Trendelenburg; y deberían aplicarse medidas conservadoras al prolapso con presión manual simultánea. Si la reducción exitosa no se logra, entonces el paciente generalmente requiere una rectosigmoidectomía con abordaje perineal (procedimiento de Altemeier). Caso clínico: hombre de 57 años, sin una historia previa de síntomas o comorbilidades con predisposición para esta patología. Se presenta en el departamento de urgencias con un prolapso rectal encarcelado posterior a realización de esfuerzo 5 horas antes del ingreso. Se inician medidas conservadoras con colocación en Trendelenburg y aplicación de azúcar granulada tópica. Las medidas fueron infructuosas. El paciente requirió una rectosigmoidectomía con abordaje perineal e ileostomía de protección. El curso postoperatorio no tuvo complicaciones, hubo un excelente resultado después del cierre de la ileostomía y no hubo recurrencia. Discusión: el encarcelamiento conlleva a estrangulamiento a lo largo del tiempo, la cirugía generalmente está indicada si la terapia conservadora fracasa. Aunque tradicionalmente recomendada para los pacientes adultos mayores y pacientes con comorbilidades, los procedimientos perineales son una opción para todos los pacientes y la mejor opción para el prolapso rectal encarcelado.

Abstract Reports of incarcerated rectal prolapse are rare and pose a challenge to the surgeon. For a incarcerated prolapse that is not strangulated, patients should be treated with analgesics and placed in the Trendelenburg position. Conservative measures should be applied to the prolapse with simultaneous manual pressure. If successful reduction is not achieved, then the patient usually requires rectosigmoidectomy with a perineal approach (Altemeier's procedure). Case: The patient was a 57-year-old man with no previous history of symptoms or comorbidities that would predispose him to this pathology. He came to the emergency department with an incarcerated rectal prolapse after attempting to have a bowel movement five hours earlier. Conservative measures of placing the patient in the Trendelenburg placement and topical application of granulated sugar were used. These measures were unsuccessful, so the patient required a rectosigmoidectomy with a perineal approach and protective ileostomy. The patient's postoperative recovery was without complications and had excellent results after the ileostomy was closed. There has been no recurrence. Discussion: Incarceration leads to strangulation over time, so surgery is usually indicated if conservative therapy fails. Although traditionally recommended for elderly patients and patients with comorbidities, perineal procedures are an option for all patients, and this is the best option for incarcerated rectal prolapse.

Coloanal intussusception in adults due to lipoma / Intussuscepção colo-anal decorrente de lipoma em adulto

ABSTRACT Adult intussusception is a rare condition. But coloanal intussusception is an exception. Malignant lesions are the most common cause of colonic intussusception, and in this aspect, differ from childhood intussusception. We present a case wherein the patient had a lipoma of the sigmoid colon that caused an immense prolapse through the anus. Very few cases of coloanal intussusception are reported in adults, and we discuss the diagnostic tools and the management of this rare surgical entity.

RESUMO A intussuscepção no adulto é uma entidade rara. Mas a intussuscepção colo-anal é uma exceção. Lesões malignas são a causa mais comum de intussuscepção colônica e, neste aspecto, difere da intussuscepção infantil. Apresentamos um caso de lipoma do cólon sigmoide que causou um prolapso imenso através do ânus. Muito poucos casos de intussuscepção colo-anal foram relatados em adultos e discutimos as ferramentas diagnósticas e o tratamento dessa entidade cirúrgica rara.

Application of Rectal Prolapse Constipation Balloon in Single Auxiliary Defecation / 中国医疗器械杂志

OBJECTIVE@#To explore the application value of rectal prolapse constipation balloon in single auxiliary defecation.@*METHODS@#Forty-one patients with moderate or severe rectocele were treated with a rectocele constipation balloon through the vagina. The defecography and VAS scores were compared before and after implantation.@*RESULTS@#There was a significant difference between the anorectal angle, rectocele, and VAS scores before and after intervention in defecography (<0.01).@*CONCLUSIONS@#A single assisted defecation of the rectocelicular constipation balloon is feasible.