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RECTAL PROLAPSE
PRESENTER:DR RE KHALUSHI
MODERATOR:PROF LM NTLHE
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CONTENTS
Background
Anatomy
Pathophysiology
Etiology
Clinical presentation Differential diagnosis
Investigations
Non operative management
Surgical management References
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BACKGROUND
Rectal prolapse was reported as early as 400-500 BC byEgyptian and Greek civilization.
The first written report was found in the Ebers Papyrus of1500 BC
Rectal prolapse or procidentia is a protrusion of therectum beyond the anus
Complete (external) or full thickness rectal prolapse isthe protrusion of all of the rectal wall through the analcanal
Occult(internal) rectal prolapse or rectal intussusceptionsis when the rectal wall has prolapsed but does notprotrude through the anus
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HEMORRHOIDS RECTAL PROLAPSE
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BACKGROUND
Grading of prolapse
Grade 1: Occult prolapse
Grade 2: prolapse to but not through the anus
Grade 3: any protrusion though the anus
Annual incidence of 2,5 per 100000 Occurs at extreme age-in pediatrics usually diagnosed
by the age of 3 years with male and female equallyaffected. About 20% associated with cystic fibrosisdisease
In adult the peak incidence is after the 5th
and 7th
decadewith women commonly affected representing 80 to90%(male to female ratio 1:6)
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Rectal prolapse grading
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ANATOMY
Rectum is the distal 12-15 cm of the large intestinebetween the sigmoid colon and the anal canal
It start in front the 3rd sacral vertebra as continuation ofthe sigmoid colon
It passes downward following the curvature of the sacraland coccyx, it ends at tip of the coccyx by piercing thepelvic diaphragm
Divided into 3 parts:1st third is covered by peritoneum onthe anterior and lateral surface, mid third is covered byperitoneum on anterior surface, distal third devoid of
peritoneum It serves as a reservoir for fecal material
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PATHOPHYSIOLOGY
The pathophysiology of rectal prolapse is not
completely understood or agreed upon
There are two main theories:
1. Postulates that rectal prolapse is a slidinghernia through a defect in the pelvic floor
2. The rectal prolapse start as circumferential
internal intussusceptions of the rectum starting
6-8 cm to the anal verge
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Pathophysiology
Prerequisites for the development of rectalprolapse
1. The presence of an abnormal deep pouch ofDouglass
2. The lax and atonic condition of the pelvic floorand anal canal
3. Weakness of both internal and externalsphincter, often evidence by pudendal nerveneuropathy
4. The lack of normal fixation of the rectum, witha mobile mesorectum and lax lateral ligaments
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Etiology
The precise cause is not well defined, however
there are number of associated abnormalities
50% due to chronic straining and constipation
Incontinence Pregnancy-obstetric trauma
Previous surgery
Cystic fibrosis(20% of paediatric rectal prolapse)
Genital prolapse(24%)
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Etiology
Chronic obstructive airway disease
Pertussis
Pelvic floor dysfunction
Neurological disorder- cauda equina syndrome,spinal tumours,multiple sclerosis
Parasitic infection- schistosomiasis, amebiasis
Disorder of defecation
Elevated intra-abdominal pressure
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Clinical presentation
Early symptoms
Protrusion
Mucous discharge
Rectal prolapse associated with bowel movement
TenesmusLate symptoms
bleeding
Incontinence
Rectum spends most of the time prolapsed
cystocele
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Clinical presentation
Physical signs:
Protruding rectal mucosa
Thick concentric mucosal ring
Sulcus noted between anal canal and
rectum
Solitary rectal ulcer (10-25%)
Decreased anal tone
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Differential diagnosis
Hemorrhoids
Intussusceptions
Prostates disease
Anal cancer
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RECTAL PROLAPSE
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PROLAPSED HEMORRHOIDS
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THROMBOSED HEMORRHOID
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Investigations
Complete history and physical examination
Screening tool- endoscopy or barium enema isrecommended for adult
Evaluating the rectal prolapse
1. Rigid proctosigmoidoscopy2. Cinedefecography-asses pelvic floor
movement
3. Anorectal manometer-pressure generated bysphincter
4. Electromyography-check denervation andcolon transit
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NON OPERATIVE MANAGEMENT
Sedation, field block with local
unaesthetic
prolapsed rectum can be reduced with
gentle pressure Sprinkling the prolapse with either salt or
sugar
Other modalities-stool softener, enema
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SURGICAL MANAGEMENT
More than 100 procedures were
described for rectal prolapsed
Aim for the treatment:
1. Control the prolapse
2. Restore continence
3. Prevent constipation
Divided in to Abdominal and Pelvicprocedures
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Abdominal procedures
1.Suture Rectopexy-
First described by Cutait in 1959
involves mobilization and upward fixation of the rectum
No mortality, recurrence rate 0-3%(majority) withexception of one series with recurrence of 27%
Clinical outcome- symptoms were better overall in male2.Prosthetic or Mesh Rectopexy
Involves insertion of material like fascia lata,nonabsorbable syntheticmesh,polypropylenemarlex,polyvinyl alcohol,polytef
Two types mesh rectopexy: posterior mesh rectopexyand anterior sling Rectopexy
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Abdominal procedures
Posterior Mesh Rectopexy
After rectal mobilization prosthetic materialis inserted between rectum and sacral
,sutured in to the rectum and suture intothe periosteum of sacral promontory
Mortality rate 0-3%,Recurrence rate 3%,significant pelvis sepsis as major(2-16%)
contributor to post operative complications Clinical outcome-improve continence
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Abdominal procedures
Ripstein Procedure (anterior sling Rectopexy)
First described by Repstein in 1952
After complete mobilization of the rectum,anterior sling of fascia lata or synthetic material
is placed in front of the rectum and sutured tothe sacral promontory
Mortality 0-2,8%,recurrence rate 0-13%
Clinical outcome-yield conflicting result as it
improves continence and causes obstructeddefecation
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Abdominal procedures
3.Resection
Recto sigmoid resection
Mortality 0-6,7%,recurrence rate0-5%
Clinical outcome- there was overall
reduction with constipation, continence
improved and causing less outlet
obstruction
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Abdominal procedures
4.Laparoscopic Rectopexy
The procedure involves either suture or
posterior mesh rectopexy with or without
resection Mortality 0-3%,reccurence rate 0-8% in 8
and 30 months follow up
Clinical outcome depends on the type ofprocedure done
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Perineal procedure
1.Delorme operation
First described Delorme in 1900
Stripping of the prolapsed rectum and
suture plication of the remnant baremuscle, the mucosa is then approximated
to seal the anastomosis
Mortality 0-4%, recurrence rate 4-38%
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continue
2.Perineal Rectosigmoidectomy
First described by Mickulicz in1889
Full thickness excision of the rectum and if
possible portion of sigmoid colon Mortality 0-5%,recurrence rate 0-16%
3.Stapled trans-anal rectal Resection (STARR)
Few published studies
Reported to be safe and effective technique foroutlet obstruction
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REFFERENCES
1. Lechaux D, Trecbuchet G, etal. Laparoscopic rectopexy for fullthickness rectal prolapse.Surg Endosc(2005)19:514-518
2. Madiba T.E, Baig M.K,Wexner S.D.surgical management of rectalprolapse. Archive Surgery(2005)140:63-73
3. Gourgiotis S,Baratsis S.Rectal Prolapse. Int J ColorectalDis(2007)22:231-243
4.Otto S.D,Ritz J.P, Grone J, etal. Abdominal Resection Rectopexywith an Absorbable Polyglactin Mesh:prospective evaluation ofmorphological and functional changes with consecutiveimprovement of patients symptoms. World J Surg(2010)34:2710-2716
5. Kodner IJ, Fry RD, Fleshman JW. Rectal prolapse and other pelvicfloor abnormalities.Ann Surg 1992;24:157190
6.Cirocco WC,Brown AC.Anterior resection for the treatment of rectalprolapse:20 years experience.Am Surg.(1993)59:265-269
7. Snell R.S. Clinical Anatomy by regions.8th edition.335-380
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