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PubMed1993

Anterior resection for the treatment of rectal prolapse: a 20-year experience.

Between 1971 and 1991, 41 patients underwent anterior resection for the treatment of complete rectal prolapse. Anterior resection was performed after full rectal mobilization to the levator ani muscles with reanastomosis (39 hand-sewn and two stapled) carried out to peritonealized distal rectum. The 41 patients comprised 35 women and six men with an average age of 56 years (range, 7-88 years). Postoperative follow-up averaged 6 years (range, 6 months to 18 years). Three patients (7%) suffered recurrent prolapse in 2, 2.5, and 5.5 years, respectively. Mortality was 0 per cent; morbidity was 15 per cent including three incisional herniae, two small bowel obstructions, and one stroke. No pelvic sepsis, abscess, or anastomotic dehiscence occurred. Anal incontinence was a preoperative finding in 21 patients (51%) with rectal prolapse. Nineteen of these patients (90%) noted either improvement or no change in postoperative continence. Anterior resection is a familiar, frequently performed operation that does not require a foreign body or rectal suspension. We believe this to be the procedure of choice for patients with complete rectal prolapse. Anterior resection withstands long-term scrutiny both in terms of recurrence rate and associated complications.

Anastomosis, Surgical↗
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↗
PubMed1996

[Sacral rectopexy-sigmoidectomy in the treatment of rectal prolapse syndrome. Anatomical and functional results].

UNLABELLED: Various options have been suggested to improve the functional results of abdominal rectopexy for rectal prolapse and to limit the risk of post-operative constipation. OBJECTIVES: In this prospective study, we evaluated the results of posterior abdominal rectopexy-sigmoidectomy to treat rectal prolapse syndrome in terms of morbidity, anatomic correction and bowel function. Patient benefits after surgery were assessed according to their pre-operative functional status. PATIENTS AND METHODS: Twenty patients (14 females, mean age: 42 years) were treated for rectal prolapse with sutured abdominal rectopexy and sigmoidectomy. RESULTS: (a) Thirteen patients had normal post-operative course. No anastomotic leak occurred. Mean hospital stay was 9.7 days. (b) Anatomical control was obtained in all cases for a mean follow-up of 31.2 months without recurrence. (c) Functional results: bowel movements per week remained unchanged pre- and post-operatively (18.6 +/- 33 vs 18.1 +/- 17). Constipation appeared or worsened in 2 patients (10%). Anal incontinence (n = 6-30%) never worsened post-operatively and improved in 3. CONCLUSIONS: This prospective clinical study confirmed the important functional disorders occurring in rectal prolapse syndrome. Rectopexy-sigmoidectomy is a valid option with stable mid-term results. Constipation was observed in 10% with no worsening of anal incontinence.

Adolescent↗
PubMed1996

Clinical and echocardiographic features of mitral valve prolapse patients in a local population.

Mitral valve prolapse (MVP) is a commonly diagnosed condition with varied clinical presentations but local data is lacking. In our study, we reviewed 98 patients (54 males, 44 females) with echocardiographic mitral valve prolapse diagnosed between 1991 and 1993 to study the clinical profile and echocardiographic features of patients with this condition in our local population. The mean and median age at presentation/detection were 42 years and 38 years respectively. The majority of the patients were asymptomatic (59%); the rest presented with palpitations (21%), congestive heart failure (4%) and infective endocarditis (5%). On clinical examination, 64 patients had mitral regurgitation (13 patients had both mitral regurgitation murmur and a systolic click), while one or more systolic clicks were heard in another 32 patients. Six patients also had associated Marfan syndrome. 2D echo revealed isolated anterior and posterior leaflet involvement in 55 and 19 patients respectively. Another 24 patients had involvement of both leaflets. Mitral regurgitation was detected on colour Doppler study in 78 patients. Nine patients had associated tricuspid valve prolapse. Of the 98 patients, 8 patients developed flail mitral valve. Four were detected at presentation/diagnosis, while the other 4 were diagnosed incidentally on routine follow-up 2D echo. Of these 8 patients, one developed cardiac failure. The patients had been on follow-up for a mean period of 9 months. During this period, mitral regurgitation progressed in 3 patients resulting in valve surgery. Only 20 patients had arrhythmias detected on ambulatory ECG monitoring, most of them were frequent atrial and ventricular premature beats. No patient was found to have haemodynamically significant arrhythmia. In summary, most patients with MVP had anterior mitral valve leaflet prolapse and mitral regurgitation. Although most patients with MVP are asymptomatic or have minor symptoms, it is associated with significant morbidity.

Adult↗
PubMed1996

Surgical treatment of prolapse of the rectum--evaluation of distant results.

In the years 1972-1995 41 patients suffering from prolapse of the rectum were operated according to the Moore method. The method is based on the observations which suggest that the cause of prolapse is intestinal intussusception which can be prevented by translocating the anus under the pubic joint. The observation time is from 1 to 23 years. Two patients were reoperated; one-as a result of a recurrence of rectal prolapse and one due to a post-operative adhesive ileus. One patient died as result of peritonitis following an overlooked microperforation in the rectal wall. In the case of the remaining patients, the treatment was fully successful. Regular defecation cycle as well as incontination of stool and flatus returned and the anal sphincters almost fully regained their tension in comparison to the pre-operative state. Early and distant results of surgery of prolapse of the rectum are satisfactory.

Adult↗
PubMed1997

Perineal repair of rectal prolapse.

Perineal approaches to the repair of rectal prolapse are frequently used in elderly or high-risk patients. These repairs have lower operative mortality and morbidity than intra-abdominal repairs but in general have higher recurrence rates. This study reviews our recent results with perineal prolapse repairs, briefly summarizes the literature, and discusses the available perineal operations. Eight patients (mean age 75 years) underwent surgical prolapse repair over an 18-month period. Treatment was by Altemeier's procedure (perineal rectosigmoidectomy) in 6 patients and Delorme's procedure in 2 patients. There were no operative mortalities, and an anastomotic dehiscence in 1 patient was managed nonoperatively. All patients with preoperative constipation improved and no patient reported worsening of continence. Surgical approaches from the perineum may be used in elderly and poor risk patients to treat rectal prolapse with low mortality and morbidity. These techniques have not adversely affected fecal continence and have improved symptoms of constipation with an acceptable rate of recurrence.

Aged↗
PubMed1997

Surgical treatment for prolapse of the anterior mitral leaflet.

BACKGROUND AND AIMS OF THE STUDY: Mitral valvuloplasty (MVP) for the prolapse of the anterior mitral leaflet (AML) is more difficult than that for the posterior mitral leaflet. The introduction of artificial chordae (November, 1986) and the concomitant maze operation (November, 1992) were surgical 'turning points' in our 17 years' experience. METHODS: In total, 163 surgical cases of AML prolapse based on the above turning points, and carried out between 1979 and 1996, were reviewed. These included 110 MVP and 53 mitral valve replacements. MVP was performed in only 46% (29/63) of patients before October 1986 (Group I); in 72% (42/58) of patients between November 1986 and October 1992 (Group II); and in 93% (39/42) of patients after November 1992 (Group III). RESULTS: Reoperation was required in nine patients. The reoperation-free rate after MVP was 79% at 17 years in all cases, 82% at 17 years in Group I, 86% at 10 years in Group II and 97% at four years in Group III. Besides reoperation cases, grade 3/4 mitral regurgitation (MR), assessed by color Doppler echocardiography, was detected in seven patients. The event-free (reoperation, MR, thromboembolism) rate was 69% at 17 years in all cases, 78% at 17 years in Group I, 71% at 10 years in Group II and 92% at 4 years in Group III. A concomitant maze operation was performed in 19 of 20 current patients with atrial fibrillation. The percentage of sinus rhythm after operation in Group I, II and III was 53%, 60% and 84%, respectively. CONCLUSIONS: During 17 years' experience, mortality and morbidity after MVP for AML prolapse were satisfactory. With the use of artificial chordae, we have been able to perform MVP in more than 90% of current patients with AML prolapse. Further, a concomitant maze procedure could provide a higher incidence of postoperative sinus rhythm.

Actuarial Analysis↗
PubMed1998

[Isolated prolapse of the posterior leaflet of the mitral valve. Results of reconstructive surgery].

Out of 522 patients undergoing mitral valve reconstruction for mitral regurgitation between 1988 and June 1994, the authors studied 159 cases of isolated mitral regurgitation by prolapse of the posterior mitral leaflet. There were 98 men (62%) and 61 women (38%), with an average age of 58.4 +/- 10.4 years. The functional class and ejection fraction were 2.8 +/- 0.11 and 0.66 +/- 0.2 respectively. In 155 patients, surgery consisted in quadrangular resection of the prolapsed tissue, followed in 83 cases by sliding posterior valvuloplasty and in 72 cases by plicature of the annulus. In 4 cases, the prolapse was treated by implantation of artificial chordae tendinae. A Carpentier-Edwards ring was inserted in all cases. There were no hospital deaths. Echocardiography was performed before discharge from hospital and showed satisfactory mitral valve function in 98% of cases: slight systolic anterior motion (SAM) was observed in one case. All patients were followed up for an average of 3.67 +/- 0.10 years. At six years, survival was 93 +/- 7%; moreover, 93 +/- 7% and 97 +/- 3% of patients had no thromboembolic or haemorrhagic complications. Six patients were reoperated, three of them in the first year of follow-up. At six years, 95 +/- 5% of patients were free of reoperation and 81 +/- 11% were free of all complications. The authors conclude that the excellent medium term survival and the low rate of complications are evidence in favour of conservative surgery for treatment of mitral regurgitation due to prolapse of the posterior mitral leaflet.

Adult↗
PubMed1998

[The significance of the problem of umbilical cord prolapse during delivery].

The authors aimed at studying the significance of cord prolapse in modern obstetrics. 18836 deliveries were studied. These deliveries occurred during a 7 year period (1990-1996) and a rate of cord prolapse of 0.106% was found (1 case in 941.8 deliveries). Cord prolapse was found in 20 deliveries of which 16 were singleton pregnancies and 4 multiple. 7 of the women were nulliparous and 13 multiparous. The majority of patients were of gestational age 38-41 weeks--13 (65.0%) 4 (20.0%) were between 30-37 gestational weeks and 3 (15.0%) were 42 gestational weeks. Of the singleton pregnancies only one fetus was in a transverse lie, 8 were breech presentations and 7 vertex presentations. Delivery was accomplished by cesarean section in 2 (45.0%) cases. Of the 8 breeches 3 were delivered by CS, 4 vaginal manual delivery and one (1) by manual extraction. All multiple pregnancies were delivered vaginally normally. Of the singleton pregnancies only 2 were under 2000 g weight, Perinatal infant mortality rate in this group was 291.67% (7 of 24). Still births were 2 and they occurred intrapartially: one was a vertex presentation after refusal of CS, and the second--after breech extraction (1500 g birth weight). The authors conclude that in order to reduce the rate of cord prolapse indications for CS should be precisely revised for multiple pregnancies breech presentation.

Bulgaria↗
PubMed1998

Prolonged catheterization after vaginal prolapse surgery.

OBJECTIVE: To evaluate the domestic use of a transurethral Foley catheter after discharge from the hospital in patients with urinary retention after vaginal prolapse surgery. METHODS: We reviewed 27 patients who used a Foley catheter at home after prolapse surgery. All patients were interviewed by postal questionnaire regarding their experience of this procedure. RESULTS: Of 263 vaginal prolapse operations 27 (11%) needed a prolonged catheterization period at home. In all but two patients micturition was successfully restored after removal of the catheter at a median of 13 days after discharge. Thirty-seven percent of the patients had experienced the catheterization period as unpleasant. Seventy-nine percent experienced no longterm bladder emptying problems, the others only mild and occasionally. CONCLUSION: Domestic use of a transurethral Foley catheter is a valid alternative to intermittent or suprapubic catheterization when normal micturition is not easily restored after vaginal prolapse surgery. It is, however, experienced as relatively unpleasant by more than one third of the patients.

Adult↗
PubMed1998

Anorectal function in patients with complete rectal prolapse. Differences between continent and incontinent individuals.

AIMS: A study is made of the alterations in anorectal physiology among rectal prolapse patients, evaluating the differences between fecal continent and incontinent individuals. PATIENTS AND METHODS: Eighteen patients with complete rectal prolapse were divided into two groups: Group A (8 continent individuals) and Group B (10 incontinent women), while 22 healthy women were used as controls (Group C). Clinical exploration and perineal level measurements were performed, along with anorectal manometry, electrophysiology, and anorectal sensitivity to electrical stimuli. RESULTS: The main antecedents of the continent subjects were excess straining efforts, while the incontinent women presented excess straining and complex deliveries. Pathological perineal descent was a frequent finding in both groups, with a hypotonic anal canal at rest (p < 0.001 vs controls) and at voluntary squeezing (p < 0.001 vs controls). In turn, the incontinent patients exhibited a significantly lower anal canal pressure at rest than the continent women (p < 0.05). There were no significant differences between Groups A and C in terms of pudendal motor latency, though latency was significantly longer in Group B than in the controls (p < 0.01). Moreover, pudendal neuropathy was more common, severe and often bilateral in Group B. There were no differences in rectal sensation to distention or in terms of the volumes required to relax the internal anal sphincter. In turn, both prolapse groups exhibited diminished anal canal and rectal sensitivity to electrical stimuli. CONCLUSIONS: Patients with rectal prolapse exhibit a hypotonic anal canal at rest, regardless of whether they are continent to feces or not. Continent patients have less pudendal neuropathy and therefore less pressure alterations at voluntary sphincter squeeze than incontinent individuals.

Adolescent↗
PubMed1999

A histological and immunohistochemical study of neuropeptide containing somatic nerves in the levator ani muscle of women with genitourinary prolapse.

BACKGROUND: To evaluate the changes occurring in the somatic innervation throughout the levator ani muscle in women with genitourinary prolapse and stress urinary incontinence (SUI). METHODS: Thirty-four patients with genital prolapse entered the study and ten subjects with non-malignant pathologies acted as a control group. All patients were evaluated by urodynamic investigation and an electromyographic study of pelvic floor muscles to define the type of urinary incontinence. Biopsy samples were obtained from both groups of patients: the site of muscle biopsies were left and right part of perirectal pubococcygeus muscle. The evaluation of immunoreactivity was semiquantitative and based on staining intensity and distribution. RESULTS: In all cases, S-100 protein and NSE immunoreactivities were found in nerve fascicles running throughout the striated muscle. NPY and VIP positivities were more intense and diffuse, whereas SP immunoreactivity was quite scanty. The different patterns of NPY and VIP expression changed in relation to degree of genital prolapse and to the presence of SUI. CONCLUSIONS: Our immunohistochemical study shows the presence in the pelvic floor of neurons that are able to synthesize neuropeptides. The lower immunoreactivity score of same neuropeptides (VIP, NPY) observed among patients with third degree genital prolapse and with SUI could be related to biochemical damage of the neurons with subsequent lower production of chemical messengers.

Aged↗
PubMed2000

Female pelvic organ prolapse: a comparison of triphasic dynamic MR imaging and triphasic fluoroscopic cystocolpoproctography.

OBJECTIVE: This study compared dynamic MR imaging with fluoroscopic cystocolpoproctography for the detection and measurement of prolapse of pelvic organs. SUBJECTS AND METHODS: Ten patients underwent triphasic dynamic MR imaging and triphasic fluoroscopic cystocolpoproctography with identical amounts of contrast material to opacify the bladder, vagina, and rectum. The dynamic MR imaging procedure included cine-loop presentation. Each examination was analyzed to determine the presence and extent of prolapse of pelvic organs based on specific measurements. RESULTS: Both dynamic MR imaging and fluoroscopic cystocolpoproctography revealed 10 rectoceles (mean extents, 2.85 and 2.45 cm, respectively). Nine cystoceles were revealed by both dynamic MR imaging (mean extent, 4.05 cm) and fluoroscopy (mean extent, 4.55 cm). Seven enteroceles were revealed, one of which was initially not seen on dynamic MR imaging. Two sigmoidoceles were revealed, one of which was not seen on fluoroscopy. The mean extent of the enteroceles and sigmoidoceles on dynamic MR imaging was 3.50 cm, and the mean extent on fluoroscopy was 4.25 cm. Nine of the 10 patients were able to defecate in the supine position on the MR imaging table. Patients were divided equally in their preference for dynamic MR imaging or fluoroscopic cystocolpoproctography. CONCLUSION: Triphasic dynamic MR imaging and triphasic fluoroscopic cystocolpoproctograpy show similar detection rates for prolapse of pelvic organs. Although dynamic MR imaging underestimates the extent of cystoceles and enteroceles, it has the advantage of revealing all pelvic organs and the pelvic floor musculature in a multiplanar cine-loop presentation.

Adult↗
PubMed1975

Prolapse of the tricuspid leaflets in the systolic murmer-click syndrome.

Right ventriculography was used to assess the tricuspid valve in 61 patients with systolic murmur-click syndrome. Systolic murmurs were present in 47 cases, and 32 had clicks. Mitral valve prolapse was present in 52 patients. Late systolic prolapse of the tricuspid valve was demonstrated in 32 patients (52.4%). In 9 cases, prolapse involved the tricuspid valve alone. In the systolic murmur-click syndrome, prolapse may involve either or both of the atrioventricular valves.

Adolescent↗
PubMed1976

Prolapsing mitral valve leaflet syndrome. A spectrum that includes cleft posterior mitral valve.

Two patients with a prolapse and cleft posterior mitral leaflet were studied. The first case had an associated ostium secundum type atrial septal defect. In both cases, the pansystolic regurgitation of contrast material during angiography corresponded to the pansystolic configuration of the murmur. In each instance, the systolic murmurs displayed a late systolic accentuation during the maximal prolapse of the mitral valve. The echocardiographic studies demonstrated only a late systolic prolapse which in both patients corresponded angiocardiographically to the maximum buckling of the pansystolic prolapse. Echocardiographic and angiocardiographic features of cleft posterior mitral valve leaflet are discussed.

Angiocardiography↗
PubMed2007

Does urodynamic investigation improve outcome in patients undergoing prolapse surgery?

AIMS: Without solid evidence, it has been advocated to perform urodynamic investigation in all patients scheduled for prolapse surgery. If urodynamic investigations were to be valuable in the diagnostic work-up, patients with normal and abnormal findings would have different treatment results. Our policy to never combine prolapse surgery and stress-incontinence surgery allowed us to study whether incontinence after surgery can be predicted from urodynamic investigation results. METHODS: A retrospective study was performed in consecutive patients undergoing vaginal prolapse surgery (anterior colporraphy and/or posterior colporraphy, and/or vaginal hysterectomy) between 2002 and 2004. All patients underwent pre-operative urodynamic investigation, including filling cystometry, urethral pressure profile measurement, and free flow cystometry. Data were collected from the files about medical history, findings at pelvic examination, findings at urodynamic investigation and presence of stress- and/or urge-incontinence after surgery. RESULTS: We studied 76 patients, of whom 5 (7%) patients reported stress-incontinence and 5 (7%) patients reported urge-incontinence after surgery. Findings at urodynamic investigation could not predict the presence of stress- or urge-incontinence after surgery. Likelihood ratios (LR) of prior presence of urge and stress-incontinence for the presence of post-operative urge- and stress-incontinence were 4.5 and 1.2, respectively. Of all findings at urodynamic investigation, only negative transmission during cough test was associated with presence of stress-incontinence (LR = 1.5). CONCLUSIONS: The prevalence of incontinence after prolapse surgery is low. None of the investigated parameters of the urodynamic investigation tests was associated with the presence of urinary incontinence after surgery.

Aged↗
PubMed1976

Life-threatening arrhythmias in the mitral valve prolapse syndrome.

This study describes seven patients with the mitral valve prolapse or click-murmur syndrome who have survived one or more episodes of life-threatening ventricular arrhythmias. These arrhythmias include cardiac arrest due to ventricular fibrillation, recurrent ventricular tachycardia causing syncope or sustained ventricular tachycardia requiring electroversion. These patients were seen over a two-year period in a single medical center. Five of the seven had repolarization abnormalities in the resting electrocardiogram. Premature ventricular contractions were present in the routine resting electrocardiograms of six of the seven patients and were frequent during treadmill testing and ambulatory electrocardiographic monitoring in all six tested. There were electrolyte abnormalities or changes in medications known to affect myocardial repolarization during the week before the episode in three of the four patients with cardiac arrest. The diagnosis of mitral valve prolapse click-murmur syndrome was made prior to the episode of life-threatening arrhythmia in only two of the seven patients. Varying forms of antiarrhythmic therapy were given to these patients during follow-up periods of five to 26 months. Although the incidence of fatal arrhythmias in the mitral prolapse syndrome is probably small, we suggest that such arrhythmias may not be extremely rare, particularly among those patients who have repolarization abnormalities in the resting electrocardiogram and frequent premature beats. Patients with unexplained ventricular arrhythmias should be screened for mitral valve prolapse.

Adult↗
PubMed1976

Mitral valve prolapse. Recent concepts and observations.

The conditions associated with prolapse of the posterior leaflet of the mitral valve are multiple. The mechanisms of mitral valve prolapse as well as the pathogenesis of pain and ectopic impulse formation are reviewed. Propranolol appears to be the drug of choice for the symptomatic treatment of patients with this syndrome since it decreases myocardial oxygen demand and wall tension thus reducing or abolishing the discrepancy between myocardial oxygen demand and supply within the mitral apparatus. It has also been reported to modify the auscultatory findings associated with this condition. The frequency of this mitral valve abnormality in patients with obstructive coronary artery disease is reviewed. It appears that prolapse of the posterior leaflet scallops in patients with significant obstructive coronary artery disease represents an intermediate stage before mitral insufficiency occurs. This group of patients with papillary muscle dysfunction includes those with prolapsed leaflets without mitral insufficiency, those with systolic murmurs and compensated heart failure and others with progressive cardiac decompensation and severe mitral regurgitation.

Animals↗