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PubMed1982

Treatment and prognosis of rectal prolapse in cystic fibrosis.

Rectal prolapse occurred in 112 (18.5%) of 605 cystic fibrosis patients. In 48 patients prolapse preceded diagnosis of cystic fibrosis, but physicians (pediatricians, pediatric and general surgeons, and proctologists) rarely appreciated its importance as a symptom of this disease. Prolapses frequently cease with institution of pancreatic enzyme replacement therapy following diagnosis of cystic fibrosis. However, even when the disease remains undiagnosed, the symptom is often transient and frequently resolves at 3-5 yr of age. Prolapse occurring initially after cystic fibrosis is diagnosed rarely responds to manipulation of diet or enzyme doses. Many patients develop a method of reduction which involves voluntary abdominal, perineal, and gluteal muscles and does not require manual pressure on the prolapsed segment. Most patients do not need specific treatment for the prolapse. Surgery is rarely necessary. A sweat test should be obtained on any child who has had even a single episode of rectal prolapse.

Adolescent↗
PubMed2003

Management of rectal prolapse: the role of laparoscopic approaches.

Rectal prolapse is a lifestyle-altering disability which has been treated with over 100 surgical options. The specific goals of surgical management of full thickness rectal prolapse are to minimize the operative risk in this typically elderly population, eradicate the external prolapse of the rectum, improve continence, improve bowel function, and reduce the risk of recurrence. The theoretical advantages of a laparoscopic approach are to couple reductions in surgical morbidity and good post-operative outcome. Studies which compare the same laparoscopic and open surgical approach for rectal prolapse have demonstrated that laparoscopy confers benefits related to postoperative pain, length of hospital stay, and return of bowel function. Virtually every type of open transabdominal surgical approach to rectal prolapse has been laparoscopically accomplished. Current laparoscopic surgical techniques include suture rectopexy, stapled rectopexy, posterior mesh rectopexy with artificial material, and resection of the sigmoid colon with colorectal anastomosis, with or without rectopexy. The growing body of literature supports the concept that laparoscopic surgical techniques can safely provide the benefits of low recurrence rates and improved functional outcome for patients with full thickness rectal prolapse.

Humans↗
PubMed2002

Initial experience with stapled anoplasty in the operative management of prolapsing hemorrhoids and mucosal rectal prolapse.

BACKGROUND: Excisional hemorrhoidectomy has remained the standard procedure in the operative management of hemorrhoids. Innovations in surgical technique have recently been introduced to try to decrease the pain associated with it. Stapled anoplasty has had promising early results in this regard. The aim of this study was to determine the ease or difficulty in introducing this new procedure, its efficacy, safety, and pain profile. DATA SOURCES: Nineteen patients underwent stapled anoplasty and were followed up from 8 weeks to 6 months postoperatively. Data were accrued through clinical evaluation and patient questionnaires. CONCLUSIONS: Seventy-two percent of patients had good to excellent results. There were no significant complications. Eighteen patients underwent surgery in an ambulatory setting and were discharged from hospital in a mean of 189 minutes. The procedure is safe and easily mastered. The staple line should be placed precisely at 3.5 to 4 cm from the dentate line to ensure greater efficacy.

Adult↗
PubMed2005

Persistent rectal prolapse in children: sclerotherapy and surgical management.

Persistent rectal prolapse is an uncommon but distressing condition in children. Significant controversy exists regarding its surgical management. The aim of this study was to identify a successful management strategy for persistent rectal prolapse in the paediatric population. Records of all children with rectal prolapse treated surgically at Birmingham Children's Hospital between 1995 and 2003 were retrospectively reviewed. Demographic data, clinical presentation, investigations, treatment modality, complications, and outcome were recorded. Inclusion criteria for the study were failure of conservative management leading to operative treatment. An exclusion criterion was cystic fibrosis. A total of 24 patients with persistent rectal prolapse were identified. Two children with cystic fibrosis were excluded from the analysis. Children below the age of 5 years, group I (n=17), were successfully managed by submucous hypertonic saline injections. Eighty-three percent (14/17) were cured by injection sclerotherapy in this group, 12/14 (71%) requiring one injection and 2/14 requiring a second injection. In the three (17.6%) children in group I in whom sclerotherapy failed, cow's milk protein (CMP) allergy was identified as the causative factor. Children older than 5, group II (n=5), either had behavioural problems (n=3) or were autistic (n=2). This group of children with adult-type, full-thickness rectal prolapse were found to be refractory to initial attempts of injection sclerotherapy. All five children were successfully managed with surgical correction. We conclude that rectal submucous hypertonic saline injections are highly effective for managing early-onset idiopathic childhood rectal prolapse. CMP allergy should be considered in young children with recurrent rectal prolapse. We recommend early definitive corrective surgery in older children with persistent rectal prolapse, as they do not respond to conservative measures or injection sclerotherapy.

Child, Preschool↗
PubMed1992

Rectal prolapse after oral cathartics.

Complete rectal prolapse or procidentia is an uncommon condition long recognized but of uncertain pathogenesis. We report two patients, seen a decade apart, both of whom developed complete rectal prolapse after ingestion of oral cathartics in preparation for diagnostic studies. To our knowledge, cathartic-induced complete rectal prolapse has not been reported previously in the current medical literature, despite the thousands of bowel preparations performed annually. These two cases address the implications of such an occurrence, and we discuss the pertinent management issues.

Aged↗
PubMed1995

[Fecal incontinence and rectal prolapse. Clinico-functional assessment].

Rectal Prolapse is a rare and distressing condition, with a multifactorial etiopathogenesis. Often, this pathology is associated with fecal incontinence. The recommended approach to the patient with rectal prolapse and fecal incontinence is to repair the prolapse first, then deal particularly with fecal incontinence at a second operation. A retrospective, clinical and manometric study has varying degrees of fecal incontinence. Clinically five of their operation, and a further three patients improved, in two patients the degree of fecal incontinence remained invariable. One patient was worsened after surgery. Manometrically resting and pressure (RAP) was significantly higher in continent patients than in voluntary contraction pressure (MVCP) (p < 0.05) in preoperative testing. Postoperatively, there was a significant increase in the resting anal pressure as well as in maximum voluntary contraction pressure. Patients who remained incontinent had a significantly lower RAP and MVCP than patients who improved our regained continence. In conclusion this study shows an alteration of internal and external sphincteric function in patients with rectal prolapse. The surgical treatment of this disease improves sphincteric function. Incontinent patients with RAP < 10 mmHg and MCVP < 20 mmHg, probably they would be better treated simultaneously either for rectal prolapsus and incontinence. In this kind of patients the perianal proctectomy with total sphincteroplasty could be the elective treatment.

Aged↗
PubMed1997

Long-term results of suture rectopexy in patients with fecal incontinence associated with incomplete rectal prolapse.

UNLABELLED: Suture rectopexy is the recommended therapy for complete rectal prolapse that is associated with fecal incontinence. It has been suggested that correction of an incomplete rectal prolapse is also worthwhile for patients with fecal incontinence. PURPOSE: Aims of this study were 1) to evaluate the clinical outcome of suture rectopexy in a consecutive series of patients with incomplete rectal prolapse associated with fecal incontinence, and 2) to compare these results with those obtained from patients with complete rectal prolapse. METHODS: Between 1979 and 1994, suture rectopexy was performed in 13 incontinent patients (3 males; median age, 65 (range, 45-77) years) with incomplete rectal prolapse (Group I) and in 24 incontinent patients (21 females; median age, 71 (range, 24-86) years) with complete rectal prolapse (Group II). RESULTS: After a median follow-up of 67 months, continence was restored in 5 of 13 (38 percent) patients with incomplete rectal prolapse and in 16 of 24 (67 percent) patients with complete rectal prolapse. In both groups, all male patients became continent. CONCLUSIONS: For the majority of incontinent patients with incomplete rectal prolapse, a suture rectopexy is not beneficial. The clinical outcome of this procedure is only good in incontinent patients with complete rectal prolapse. Based on these data, it is questionable whether incomplete rectal prolapse plays a causative role in fecal incontinence.

Adult↗
PubMed2002

Clinically based management of rectal prolapse.

BACKGROUND: Laparoscopic repair of rectal prolapse offers the potential of lower recurrence rates for transabdominal repair coupled with the advantages of minimally invasive colorectal surgery. There have been no direct comparisons of the laparoscopic Wells procedure (LWP) and laparoscopic resection with rectopexy (LRR). This study is the first to make a direct comparison of outcomes from laparoscopic LRR and LWP repairs using a selected, symptom-based choice of operative procedure. METHODS: Consecutive patients presenting with complete rectal prolapse were evaluated by clinical history of the degree of constipation, diarrhea, or incontinence. Patients with a history of constipation or normal bowel habits with normal continence underwent LRR, whereas those with diarrhea or anal incontinence underwent LWP. The collected data included age, gender, operative time, length of hospital stay (LOS), operative blood loss, complications, and postoperative symptoms of constipation or diarrhea. Continence was scored using the Cleveland Clinic scoring system. RESULTS: Of the 24 patients, 11 underwent LRR and 13 had LWP. The patients in both groups were predominantly, female (LRR, 9/1; LWP, 10/2). The LRR patients were significantly younger (48.6 vs 63.9 years p <0.001). Both operative time and LOS were significantly longer in the RR group (operative time, 128.5 +/- 80.6 min vs 69.9 +/- 13.4 min; LOS, 3.6 +/- 3.1 days vs 2.2 +/- 1.03 days). All patients in the LRR group had constipation preoperative, and no patients were incontinent clinically. Preoperatively, 7 of the 13 patients in the LWP group had preoperative diarrhea, and 1 patient had clinical constipation. A five patients experienced clinical symptoms of fecal incontinence, manifested in different degrees. Postoperative complications occurred only in the LRR group (1 case of abdominal wall hematoma and 2 cases of prolonged ileus). During a mean follow-up period of 18.1 months, there were no recurrences; 10 of the 11 LRR patients had correction of constipation; and 4 of 5 of the incontinent LWP patients had improvement in their symptoms. Constipation developed in one LWP patient. CONCLUSIONS: Clinical assessment of preoperative bowel function and continence allows accurate selection of the appropriate laparoscopic technique for repair of rectal prolapse without the added expense of anal physiologic testing. Although LRR may be associated greater morbidity than LWP, both procedures offer good functional outcome, with short LOS and low recurrence rates.

Adult↗
PubMed1998

Rectal adaptation to distension in patients with overt rectal prolapse.

BACKGROUND: High recovery rates of continence are observed after surgical procedures for rectal prolapse. Increases in rectal compliance but no obvious rise in anal pressures have been reported. The authors' hypothesis was that decreased rectal adaptation to distension may contribute to incontinence in patients suffering from overt rectal prolapse. METHODS: This was a prospective study conducted in 20 consecutive incontinent patients suffering from overt rectal prolapse with no mucosal change (two men and 18 women; mean(s.e.m.) age 50(3) years). They were compared with 20 age- and sex-matched patients with incontinence without rectal prolapse and ten age- and sex-matched healthy volunteers observed during the same period. The subjects were submitted to phasic isobaric distension of the rectum with an electronic barostat. Anal pressures, perception scores and rectal volumes were recorded at six different preselected pressures. RESULTS: Compared with healthy subjects, maximum rectal volumes (mean(s.e.m) 98(6) versus 167(11) ml; P= 0.005), volumes related to compliance (56(5) versus 100(9) ml; P= 0.004) and tone (41(3) versus 67(4) ml; P = 0.003) were decreased significantly in the rectal prolapse group. Prolapse and incontinence groups did not differ significantly with respect to rectal adaptation for all three parameters and steps of distension considered. CONCLUSION: Patients suffering from overt rectal prolapse had markedly impaired rectal adaptation to distension which may contribute to incontinence.

Adaptation, Physiological↗
PubMed2006

Management of recurrent rectal prolapse: surgical approach influences outcome.

INTRODUCTION: Recurrent rectal prolapse is an unresolved problem and the optimal treatment is debated. This study was designed to review patterns of care and outcomes in a large cohort of patients after surgery for recurrent prolapse. METHODS: From 685 patients who underwent operative repair for full-thickness external rectal prolapse, we identified 78 patients (70 females; mean age, 66.9 years) who underwent surgery for recurrence. We reviewed the subsequent management and outcomes for these 78 patients. RESULTS: Mean interval to their first recurrence was 33 (range, 1-168) months. There were significantly more re-recurrences after reoperation using a perineal procedure (19/51) compared with an abdominal procedure (4/27) for their recurrent rectal prolapse (P = 0.03) at a mean follow-up of nine (range, 1-82) months. Patients undergoing abdominal repair of recurrence were significantly younger than those who underwent perineal repair (mean age, 58.5 vs. 71.5 years; P < 0.01); however, there was nosignificant difference between the two groups with regard to the American Society of Anesthesiologists classification (P = 0.89). Eighteen patients had surgery for a second recurrence, with perineal repairs associated with higher failure rates (50 vs. 8 percent; P = 0.07). Finally, when combining all repairs, the abdominal approach continued to have significantly lower recurrence rates (39 vs. 13 percent; P < 0.01). CONCLUSIONS: The re-recurrence rate after surgery for recurrent rectal prolapse is high, even at a relatively short follow-up interval. Our data suggest that abdominal repair of recurrent rectal prolapse should be undertaken if the patient's risk profile permits this approach.

Abdomen↗
PubMed1978

Repair of rectal prolapse: experience with the Ripstein sling.

Forty-eight patients with rectal prolapse were seen at Ochsner Clinic from 1955 to 1977. The charts of these patients were reviewed to assess the results of treatment and to evaluate a suggested association between rectal prolapse and solitary rectal ulcer syndrome. Since 1970 the Ripstein sling procedure has been used exclusively to treat those patients with rectal prolapse who are able to undergo a transabdominal procedure. We compared the results of this procedure with the ones formerly used: perineal (Altemeer), sigmoidectomy, and Thiersch procedures. Although the earlier operations for rectal prolapse were associated with either a high recurrence or a high complication rate, the Ripstein has both a low recurrence and a low morbidity rate: two patients had recurrence and two had the sling applied too tightly. The Ripstein procedure was shown to be an effective, safe procedure for repair of rectal prolapse, and the result was considered satisfactory by 20 of the 21 patients questioned. Regarding the association of rectal ulcer and rectal prolapse, we found that, although the symptoms of the solitary rectal ulcer syndrome and rectal prolapse are similar, they appear to represent a different response to the same stimulus, and the syndrome is relatively unabated by repair.

Adolescent↗
PubMed2002

Incidence of occult rectal prolapse in patients with clinical rectoceles and defecatory dysfunction.

OBJECTIVE: The purpose of this study was to determine the incidence of occult rectal prolapse (rectal intussusception) by defecating proctography in patients with clinical rectoceles and defecatory dysfunction. STUDY DESIGN: Patients who were seen from September 2000 through August 2001 with defecatory dysfunction and clinical rectoceles underwent single contrast defecating proctography. Radiologists who specialized in gastrointestinal fluoroscopy interpreted the results, which were retrieved from a computerized database. Study Design: Sixty patients who met the inclusion criteria were evaluated. Twenty patients (33%) had intussusception; 58 patients (97%) had rectocele; 1 patient (1.7%) had sigmoidocele, and 6 patients (10%) had anismus (paradoxic contraction of the puborectalis). RESULTS: All but 1 case of intussusception was associated with a rectocele radiographically. Anismus was associated with rectoceles radiographically, except in 1 patient for whom it was the sole finding. CONCLUSION: The data suggest a 33% incidence of occult rectal prolapse in patients with clinical rectoceles and defecatory dysfunction. This is highly clinically significant because one third of patients who are examined for defecatory dysfunction and rectocele may require sigmoid resection rectopexy along with other reconstructive procedures to restore pelvic floor function and prevent symptomatic recurrence.

Constipation↗
PubMed1995

Solitary rectal ulcer and complete rectal prolapse: one condition or two?

We studied the physiological features of patients with complete rectal prolapse and different degrees of solitary rectal ulcer syndrome to determine whether these conditions are likely to form part of the same disorder. 52 solitary rectal ulcer patients (median age 31, 40 females), and 15 complete rectal prolapse patients (median age 31, 12 females) were studied. Solitary rectal ulcer patients were divided into 3 groups, based on the extent of accompanying rectal prolapse (no prolapse, internal prolapse, or external prolapse). Both solitary rectal ulcer patients without prolapse and with internal prolapse had significantly higher maximum anal resting (p < 0.01 for both groups) and squeeze pressure (p < 0.05 for both groups) than complete rectal prolapse patients. In contrast, solitary rectal ulcer patients having external prolapse were similar to those with complete rectal prolapse. Solitary rectal ulcer patients without rectal prolapse had significantly decreased anal and rectal electrosensitivity (p < 0.01 for both) when compared to healthy control subjects. Solitary rectal ulcer patients therefore have a spectrum of clinical and physiological features--this condition may comprise a range of different disease entities. The findings also suggest a different underlying aetiopathophysiology of solitary rectal ulcer from that of complete rectal prolapse.

Adolescent↗
PubMed2001

Surgical treatment for rectal prolapse.

BACKGROUND: The problem of full-thickness rectal prolapse is formidable, with no clear predominant treatment of choice. Several operations have been proposed to correct rectal prolapse which can be divided into transabdominal and perineal procedures. METHODS: From September 1982 to October 1999, 32 patients with rectal prolapse were treated with surgical procedures. There were 16 males and 16 females with a mean age of 58.3 years (Range 17-89). Forteen patients received rectopexy procedure, 6 patients received sigmoidectomy, 6 patients received perineal rectosigmoidectomy, 1 patient received Delorme procedure, 1 patient received Thiersch procedure and 4 patients received laparoscopic-assisted sigmoidectomy. The median follow up times were 7.5 years. RESULTS: In the rectopexy group, complication occurred in one patient (7.1%) and one patient recurred (7.1%). In the sigmoidectomy group, there were no complication but one patient recurred (10%). In the perineal rectosigmoidectomy group, there were no complication, but one patient recurred (16.7%). The total complication rate were 3.1% and total recurrence rate were 9.3%. CONCLUSIONS: Although, the best operation for rectal prolapse remains a controversial subject, we believe that laparoscopic-assisted sigmoidectomy offers a promising new option for the treatment of rectal prolapse.

Adolescent↗
PubMed1997

Functional problems in adult rectal prolapse and controversies in surgical treatment.

BACKGROUND: Rectal prolapse is a condition that has fascinated surgeons for a long time. To date, no single ideal surgical treatment has been identified. The aetiology of rectal prolapse remains highly controversial, but it is recognized that associated functional problems, such as incontinence and constipation, are common. The pathophysiology, and controversies surrounding continence and constipation, remain topics of debate. METHOD: All relevant papers derived from Medline and manual searching on rectal prolapse and associated functional problems were reviewed. RESULTS AND CONCLUSION: The surgical management of rectal prolapse has evolved from historical encirclement procedures to current minimally invasive ones. Successful management must include adequate attention to the associated functional problems in order to eradicate the basic abnormality.

Adult↗
PubMed1986

Clinical and manometric evaluation of anal sphincter function in patients with rectal prolapse.

We studied 27 patients with rectal prolapse (7 men and 20 women). Eight patients were continent, 8 were partially incontinent, and 11 were totally incontinent. Perineal descent and an absent anocutaneous reflex were common findings, implying damage to the external anal sphincter and the pelvic floor muscles. Both partially and totally incontinent patients had significantly lower basal and voluntary contraction pressures compared with those of control subjects, which is in accordance with previous reports on the subject. Our continent patients had normal voluntary contraction pressures, but basal pressures were lower than those of the control subjects (p less than 0.02). This suggests that there may be dysfunction of the internal anal sphincter before the development of clinical symptoms of incontinence. The internal anal sphincter reflex was present in 19 patients (70 percent). It was absent in patients with very little tone of the anal canal. It seems that absence of the internal anal sphincter reflex is not invariably connected with rectal prolapse. The results of this study indicate that rectal prolapse is often associated with dysfunction of the anal sphincters, leading to incontinence.

Adult↗
PubMed1981

Results of treatment for rectal prolapse and fecal incontinence.

Fifty-six patients were treated for rectal prolapse or incontinence. Rectal prolapse was present in 32 patients and was associated with fecal incontinence in 24 (75 per cent). Incontinence without prolapse was present in 24 patients, 12 of whom were less than 40 years old. Rectopexy was used for treatment of rectal prolapse. Surgical treatment of fecal incontinence was by postanal repair; external sphincter reconstruction and surgery was advised only if control of diarrhea and electrical therapy had been of no benefit. Rectopexy was completely successful at controlling rectal prolapse in all cases, and only four of the 20 (20 per cent) patients with incontinence and prolapse remained incontinent after rectopexy alone. Incontinence was completely controlled by postanal repair in 58 per cent of patients and by external sphincter repair alone or in combination with postanal repair in 67 per cent. Using a combination of therapies 45 of 48 patients who were initially incontinent were improved (94 per cent), and 42 of the patients have complete control of defecation (87 per cent).

Adult↗
PubMed1988

Anorectal function and defecation dynamics in patients with rectal prolapse.

Seven female patients with clinical rectal prolapse and nine healthy female control subjects were studied with anorectal manometry, external sphincter electromyography, and a saline continence test. Resting anal tone, maximum voluntary squeeze, and rectal functional capacity were significantly decreased in the rectal prolapse patients (p less than 0.02). During defecation attempts, external sphincter or pelvic floor electromyographic activity decreased in all of the control subjects, whereas six prolapse patients showed increased electromyographic activity and one had no change in activity (p less than 0.01). Continence to saline solution was also significantly impaired in prolapse patients (p less than 0.001). Postoperative studies in three patients who underwent repair revealed persistence of abnormal anorectal function and defecation dynamics. Patients with rectal prolapse have impaired resting and voluntary sphincter activity, decreased functional rectal capacity, and impaired continence. The failure of normal relaxation of the external sphincter or pelvic floor during defecation attempts, as demonstrated in the patients described herein, may contribute to the development of prolapse and denervation sphincter injury seen in such patients.

Anal Canal↗