Rectal Prolapse [keywords]
- Giant rectal polyp prolapse in an adult patient with the Peutz-Jeghers syndrome. [Journal Article]
- BMJ Case Rep 2016.
Peutz-Jeghers Syndrome (PJS) is an autosomal dominant intestinal polyposis syndrome characterised by the presence of hamartomatous polyps and mucocutaneous pigmentation. Prolapse of the polyps through the anus is an infrequent manifestation in children with PJS, and this complication is extremely rare in adult patients. We report the case of a 30-year-old man recently diagnosed with PJS who was seen at the emergency department because of the abrupt onset of severe anal pain with a foreign body sensation in the anal canal and rectal bleeding.Physical examination revealed a giant prolapsed polyp.
- A novel technique of introducing the mesh at the distal dissection while performing laparoscopic ventral rectopexy. [JOURNAL ARTICLE]
- Colorectal Dis 2016 Jul 18.
Laparoscopic ventral rectopexy (LVR) is considered an effective treatment for rectal prolapse (RP) and/or rectoanal intussusception (RAI). After the dissection of the rectovaginal septum down to the pelvic floor, a strip of mesh is introduced and should be secured as distally as possible. We have developed a novel technique of introducing the mesh at the distal dissection.A nylon thread with straight needle was passed through the posterior wall of vagina at the distal extent of the dissection, which was caught in the abdominal cavity and fixed at the end of the mesh extracorporeally. The mesh was then introduced, pulled toward the pelvic floor and settled at the pierced site by the perineal operator.Sixty-eight female patients underwent LVR using this technique. There was no intraoperative and postoperative mesh-related complications. The mean distance from the vaginal ostium to the point of passing a nylon thread through the posterior wall of vagina was 2 cm. Postoperative proctography showed the anatomical correction in 47 of the 48 patients who were examined.The surgeon can confirm that the mesh is introduced and secured at the distal dissection by using this technique while performing LVR. This article is protected by copyright. All rights reserved.
- [Laparoscopic resection rectopexy in the treatment of obstructive defecation syndrome]. [English Abstract, Journal Article]
- Rozhl Chir 2016; 95(6):227-30.
Obstructive defecation syndrome (ODS) presents a common medical problem, which can be caused by various pelvic disorders; multiple disorders are frequently diagnosed. At the present, a high number of corrective techniques are available via various surgical approaches. Laparoscopic resection rectopexy is a minimally invasive technique, which comprises redundant sigmoidal resection with rectal mobilisation and fixation.The aim of this paper was to evaluate the safety and effectiveness of laparoscopic resection rectopexy in the treatment of patients with ODS. The evaluation was performed via our own patients data analysis and via literature search focused on laparoscopic resection rectopexy.In total, 12 patients with ODS undergoing laparoscopic resection rectopexy in University Hospital Ostrava during the study period (2012-2015) were included in the study. In our study group, mean age was 64.5 years and mean BMI was 21.9; the group included 11 women (91.6%). ODS was caused by multiple pelvic disorders in all patients. Dolichosigmoideum and rectal prolapse (internal or external) were diagnosed in all included patients. On top of that, rectocoele and enterocoele were diagnosed in several patients. Laparoscopic resection rectopexy was performed without intraoperative complications; mean operative time was 144 minutes. Mean postoperative length of hospital stay was 7 days. Postoperative 30-day morbidity was 16.6%. All postoperative complications were classified as grade II according to Clavien-Dindo classification. Mean preoperative Wexner score was 23.6 points; mean score 6 months after the surgery was 11.3 points. Significant improvement in ODS symptoms was noted in 58.3% of patients, and a slight improvement in 16.6% of patients; resection rectopexy provided no clinical effect in 25% of patients.It is fundamental to carefully select those patients with ODS who could possibly profit from the surgery. Our results, in accordance with published data, suggest that laparoscopic resection rectopexy is a valuable surgical technique in the treatment of patients with ODS caused by multiple pelvic disorders.obstructive defecation syndrome - constipation - resection rectopexy - operative techniques - pelvic floor disorders.
- Perineal Rectosigmoidectomy (Altemeier Procedure) as Treatment of Strangulated Rectal Prolapse. [JOURNAL ARTICLE]
- J Gastrointest Surg 2016 Jul 6.
Incarceration of a rectal prolapse is an unusual entity that represents a surgical emergency. Even more rarely, it becomes strangulated, requiring emergency surgery. When surgery becomes inevitable, the choice of procedure varies. A 57-year-old man who presented with strangulated rectal prolapse is described. The patient underwent emergency perineal proctosigmoidectomy, the Altemeier operation, combined with diverting loop sigmoid colostomy. The postoperative course was uneventful. After a 6-month follow-up, there was no recurrence, but the patient continued with fecal incontinence. This case underlines the importance of the Altemeier procedure as treatment in the patient with a strangulated prolapsed rectal segment.
- Evaluating the Surgeons' Perception of Difficulties of Two Techniques to Perform STARR for Obstructed Defecation Syndrome: A Multicenter Randomized Trial. [JOURNAL ARTICLE]
- Surg Innov 2016 Jul 1.
After initial enthusiasm in the use of a dedicated curved stapler (CCS-30 Contour Transtar) to perform stapled transanal rectal resection (STARR) for obstructed defecation syndrome (ODS), difficulties have emerged in this surgical technique.First, to compare surgeons' perception of difficulties of STARR performed with only Transtar versus STARR performed with the combined use of linear staplers and Transtar to cure ODS associated with large internal prolapse and rectocele; second, to compare the postoperative incidence of the urge to defecate between the 2 STARR procedures.An Italian multicenter randomized trial involving 25 centers of colorectal surgery.Patients with obstructed defecation syndrome and rectocele or rectal intussusception, treated between January and December 2012.Participants were randomly assigned to undergo STARR with a curved alone stapler (CAS group) or with the combined use of linear and curved staplers (LCS group).Primary end-points were the evaluation of surgeons' perception of difficulties score and the incidence of the "urge to defecate" at 3-month follow up. Secondary end-points included duration of hospital stay, rates of early and late complications, incidence of "urge to defecate" at 6 and 12 months, success of the procedures at 12 months of follow-up.Of 771 patients evaluated, 270 patients (35%) satisfied the criteria. Follow-up data were available for 254 patients: 128 patients (114 women) in the CAS group (mean age, 52.1; range, 39-70 years) and 126 (116 women) in LCS group (mean age, 50.7 years; range, 41-75 years). The mean surgeons' perception score, was 15.36 (SD, 3.93) in the CAS group and 12.26 (SD, 4.22) in the LCS group (P < .0001; 2-sample t test). At 3-month follow-up, urge to defecate was observed in 18 (14.6%) CAS group patients and in 13 (10.7%) LCS group patients (P = .34; Fisher's exact test). These values drastically decrease at 6 months until no urge to defecate in all patients at 12 months was observed. At 12-month follow-up, a successful outcome was achieved in 100 (78.1%) CAS group patients and in 105 (83.3%) LCS group patients (P = .34; Fisher's exact test). No significant differences between groups were observed in the hospital stay and rates of early or late complications occurring after STARR.STARR with Transtar associated with prior decomposition of prolapse, using linear staplers, seems to be less difficult than that without decomposition. Both procedures appear to be safe and effective in the treatment of obstructed defecation syndrome resulting in similar success rates and complications.
- Critical analysis of fecal incontinence scores. [Journal Article]
- Pediatr Surg Int 2016 Aug; 32(8):737-41.
Objectively evaluating the lack of bowel control (fecal incontinence) continues to be a challenge. Many have attempted to measure the severity of fecal incontinence and to evaluate its impact on the quality of life by developing standardized scoring systems. Some of these systems have been validated but none have achieved widespread use and all have limitations in evaluating pediatric patients.A review of the literature was performed looking for validated scoring systems of fecal incontinence that are currently used for either adult or pediatric patients. The identified scoring systems were then critically analyzed and their applicability for managing fecally incontinent children considered.Thirteen of the most frequently used fecal incontinence scoring systems were selected (6 for adults and 7 for children). Quality of life questionnaires were excluded not only because of their length and complexity, but mostly because they do not accurately reflect a measurement of bowel control. Our analysis revealed that all pediatric scoring systems require some degree of interpretation as they included at least one subjective parameter. These unverifiable subjective parameters were: "sensation of rectal fullness", "sphincter squeeze", and "anal shape". Equally problematic, the pediatric systems frequently focused on factors unrelated to fecal continence such as "frequency of bowel movements", "rectal prolapse", "abdominal pain", "blood in the stool", "leakage of urine", "diarrhea", and "constipation". The most objective system found from our review is the Krickenbeck system, which focuses upon two objective factors. Those two factors are the absence of voluntary bowel movements and the presence of soiling in the underwear. The major weakness of the Krickenbeck system is that it does not allow for reassessment after medical or surgical interventions. In this paper, we propose a modification of the Krickenbeck system that allows for such an assessment to be applied to those patients who are able to achieve voluntary bowel movements with the aid of laxatives or constipating agents.Most scoring systems are flawed because they invite bias and interpretation due to their subjective nature, while systems focused on measuring quality of life do not address the fundamental issue of bowel control. The Krickenbeck score seems to be the most applicable and objective method of evaluating bowel control in pediatric patients that may be more useful when modified to assess patients after medical intervention.
- Single port laparoscopic mesh rectopexy. [Journal Article]
- Prz Gastroenterol 2016; 11(2):123-6.
Traditionally, laparoscopic mesh rectopexy is performed with four ports, in an attempt to improve cosmetic results. Following laparoscopic mesh rectopexy there is a new operative technique called single-port laparoscopic mesh rectopexy.To evaluate the single-port laparoscopic mesh rectopexy technique in control of rectal prolapse and the cosmesis and body image issues of this technique.The study was conducted in El Fayoum University Hospital between July 2013 and November 2014 in elective surgery for symptomatic rectal prolapse with single-port laparoscopic mesh rectopexy on 10 patients.The study included 10 patients: 3 (30%) males and 7 (70%) females. Their ages ranged between 19 years and 60 years (mean: 40.3 ±6 years), and they all underwent laparoscopic mesh rectopexy. There were no conversions to open technique, nor injuries to the rectum or bowel, and there were no mortalities. Mean operative time was 120 min (range: 90-150 min), and mean hospital stay was 2 days (range: 1-3 days). Preoperatively, incontinence was seen in 5 (50%) patients and constipation in 4 (40%). Postoperatively, improvement in these symptoms was seen in 3 (60%) patients for incontinence and in 3 (75%) for constipation. Follow-up was done for 6 months and no recurrence was found with better cosmetic appearance for all patients.Single-port laparoscopic mesh rectopexy is a safe procedure with good results as regards operative time, improvement in bowel function, morbidity, cost, and recurrence, and with better cosmetic appearance.
- Long-term outcome of perineal rectosigmoidectomy for rectal prolapse. [JOURNAL ARTICLE]
- Int J Surg 2016 Jun 23.:78-82.
Rectal prolapse is a disabling condition that often affects older patients with multiple comorbidities making complex surgeries impossible to perform.A retrospective review of patients who underwent perineal rectosigmoidectomy (Altemeier procedure) for rectal prolapse from January 1999 to March 2015 was performed in a Reference Hospital, being evaluated complications and surgery recurrence.Thirty-six Altemeier procedures were performed in 33 patients during the study. Twenty-five (76.8%) were women and the mean age was 67 (range 31-91) years. The mean duration of rectal prolapse symptoms was 7.8 years; other complaints were: pain, bleeding, mucus discharge, constipation and fecal incontinence. The mean operative time was 134.8 min and the blood loss was little. The mean postoperative length of hospital stay was 3.9 days. There was no mortality. Early postoperative complications occurred in 3 (9.1%).an acute pulmonary edema, an urinary infection and a surgical site infection with partial anastomotic leak. This patient developed anastomotic stenosis requiring dilatation. The recurrence rate was 26.7% (8 patients), with a mean follow-up of 50 months, and three of them were treated with repeat Altemeier repair. Many patients complain of some degree of fecal incontinence, but all reported improvement in their quality of life after surgery.The Altemeier procedure showed low morbidity but it was associated with significant recurrence rate. The same procedure can be repeated in case of recurrence with satisfactory results.
- A transanal procedure using TST STARR Plus for the treatment of Obstructed Defecation Syndrome: 'A mid-term study'. [JOURNAL ARTICLE]
- Int J Surg 2016 Jun 23.:58-64.
The aim of this study was to assess the safety, efficacy and outcomes of TST STARR (Stapled Transanal Rectal Resection) plus to treat Obstructed Defecation Syndrome (ODS) at mid-term follow-up.From April 2013 to September 2014, 50 cases (7 male patients) with ODS caused by rectocele and/or internal rectal prolapse were treated with the new TST STARR Plus. Clinical data from the 18 month mid-term follow up, including efficacy and constipations were recorded.The average duration of surgery was 21 ± 4 min (range 12-35 min). The average postoperative hospital stay was 5 days (range 4-8 days). The pathological findings showed that the specimens contained full-thickness rectal tissue in all patients. The mean volume of resected specimen was 12.3 cm(3). Postoperative complications included five cases with transient faecal urgency that dissipated after 3 months; one patient suffered anastomotic bleeding on the sixth day after surgery, with successful haemostasis achieved through conservative therapy. The Wexner constipation score improved in patients affected by ODS from 13.96 ± 2.37 preoperatively to 7.00 ± 3.90, 7.28 ± 3.91, 8.10 ± 4.05 and 8.44 ± 4.08 at 3,6,12 and 18 months postoperatively, respectively, with all p < 0.05. Overall outcome was reported as ''excellent'' in 42% of patients, ''good'' in 36% of patients, ''adequate'' in 12% of patients, and ''poor'' in 10% of patients after 18 months of follow-up.The TST STARR Plus is a simple, safe, and effective option for selected patients with ODS. Long-term prospective clinical studies are needed to validate the advantages of this emerging, novel procedure.
- Benign intestinal glandular lesions in the vagina: a possible correlation with implantation. [Journal Article]
- Diagn Pathol 2016; 11(1):52.
Enteric-type glandular lesions are extremely rare in the vagina. Their histological origin remains a matter of speculation at present.We review two rectal mucosal prolapse-like polyps and one intestinal-type adenosis in the vagina.Case 1, a 64-year-old woman, presented with a vaginal polypoid lesion with a size of 4 × 3 × 3 cm. Case 2, an 8-year-old girl, had a 1.5 × 1.5 × 0.8-cm pedunculated polyp in the vaginal navicular fossa and a clinically suspected rectovaginal fistula. Case 1 and 3 had an obsolete severe perineal laceration. On histopathological examination, cases 1 and 2 resembled rectal mucosal prolapse or inflammatory cloacogenic polyp (rectal mucosal prolapse-like polyp). Case 3 had an incidental intestinal-type adenosis in the removed vaginal wall. Immunohistochemistry confirmed the intestinal differentiation in all 3 lesions by showing diffuse CDX2-positive, CK20-positive, and scattered chromogranin A-positive neuroendocrinal cells in the lower compartment of the crypt.In summary, we report herein three unusual cases of benign intestinal-type glandular lesions in the vagina including two rectal mucosal prolapse-like polyps and one case of intestinal-type adenosis, and discuss possibilities for their histogenetic basis.