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.

Cura de rectocele por vía transanal: experiencia de la unidad de coloproctología del Hospital Universitario de Caracas / Transanal approach in the treatment of rectocele: experience of the coloproctology unit at the Hospital Universitario of Caracas

Determinar la eficacia de la técnica para cura del rectocele por vía transanal usando la máquina PPH®. Estudio realizado en la Unidad de Coloprotología del Hospital Universitario de Caracas. Estudio prospectivo, descriptivo, realizado entre mayo de 2007 y abril de 2009, cuya población estuvo conformada por 62 mujeres con diagnóstico de rectocele, que presentaban sintomatología importante de síndrome de defecación obstruida (SDO), a las cuales se realizó de estreñimiento tiempo de tránsito colónico (TTC), ciego móvil y defecografía. Fueron intervenidas 20 pacientes haciendo uso de la técnica vía transanal con máquina autosuturadora de 33 mm (PPH). El rectocele grado II ocupó el 77% de los casos. El principal motivo de consulta fue la sensación de evacuación incompleta 74% seguida de la digitalización con 41% ambos síntomas del síndrome de defecación obstruida. Entre las patologías asociadas se encuentran principalmente: hemorroides (59,3%), cistocele (46%), intususcepción o prolapso mucoso (49%). Todos los pacientes intervenidos fueron corregidos por técnica vía transanal haciendo uso de la máquina de PPH 33 mm, de los cuales a 40% se le realizó adicionalmente cura del tiempo posterior, 20% cecopexia y a 5% fistulotomía. El 59% de las pacientes presentó mejoría de los síntomas de defecación obstruida antes de los siete días del postoperatorio, y el resto entre 7 y 15 días. El 45% presentó dolor que cedió con AINES, 25% tuvo urgencia defecatoria y una paciente (5%) presentó estenosis anal resuelta posteriormente. Se demostró que la técnica para cura de rectocele por vía transanal con máquina PPH, tiene una tasa de éxito con resultados satisfactorios de un 95%, con complicaciones menores.

To determinate the efficient of the transanal approach technique to cure rectocele using the PPH machine. Study performed in the Coloproctology Unit at the Hospital Universitario of Caracas. A prospective, descriptive, study carried out on 62 women with rectocele and symptoms of outiet obstruction syndrome (OOS), betwen may 2007 and april 2009. Colonic transit time (CTT), move cecum and defecografy was to each patient. Of these 62 patients, 20 were operated on using the transanal approach technique with the PPH machine and we determited the efficient of that. Of these 62 patients studied, rectocele grade II occupied 77%, the mean symptom was incomplete evacuated sensation (74%), following of digitalization (41%) both symptoms of OOS. We found other pathologies associated like hemorrhoids (59,3%), cistocele (46%), intususcepción or mucosal prolapse (49%). In all the patients operated we used the transanal approach with PPH machine 33 mm; of these patients, 40% we did posterior time cure. 20% cecopexy and 5% fistulotomy. A 59% improved the symptoms of OOS before 7 days and 41% between 7 and 15 days. A 45% of the patients had pain that relieved with AINES, 25% defecatory urgency and one patient stricture that was cure after. We demostrated that the transanal approach technique for rectocele using the PPH machine had low percentage of complications and good results.

Prolapso rectal: abordaje laparoscópico / Rectal prolapse: laparoscopic approach

This study details a comparison between laparoscopic rectopexy with open technique in the treatment of complete rectal prolapse. The surgical technique and the results obtained are commented. The laporoscopic approach of the rectal prolapse combines the good reults of the abdominal procedure with the low postoperative morbility of the mini-invasive surgery. The advantages of the laparoscopic approach are: less postopertive pain, less hospitalization time, diminution of time before return to work, similar results to conventional surgery, independently of the technique employed; the advanced age should not be a contraindications for the laparoscopic approach. All types of rectopexi show similar results. We perform sigmoideal resection only in presence of constipation and justly studied. Many old patients with co-morbilities, previously destinated to perineal procedures, can be suitable candidates to the laparoscopic approach. It is very probable that this procedure will achieve a high level of accuracy in order to define it as "Gold Standard".