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.

Cirugía para prolapso rectal operación de Altemier y otras técnicas: presentación de 9 casos / Surgery for rectal prolapse with altemeier-procedure and other techniques: presentation of 9 cases

Se presentan 9 casos de Prolapso Rectal completo, que fueron sometidos a cirugía durante un período de 10 meses. La Rectosigmoidectomía Perineal o Técnica de Altemeier se realizó en 6 casos,la operación de Ripstein en uno y Cerclaje Anal tipo Thiersch en dos. Todas fueron del sexo femenino. La edad promedio fue 68 años. En cuatro se determinó incontinencia fecal. No hubo mortalidad ni morbilidad. El seguimiento promedio a la fecha es de 10 meses. Se tuvo una recurrencia del Cerclaje Thiersch que fue tratada con la Operación de Altemeier. Se logró continencia fecal en el 80 de los pacientes. Se concluye que la Operación de Altemeier es una buena alternativa quirúrgica para el Prolapso Rectal Completo, con poca morbilidad y bien tolerado por pacientes de edad avanzada y/o con alto riesgo quirúrgico