Strangulated recurrent rectal prolapse after a Delorme intervention, a case report

A modified perineal approach for the management of strangulated rectal prolapse: A case report

INTRODUCTION

Conditions associated with increased intraabdominal pressure may lead to rectal prolapse. Like any pathological herniation, rectal prolapse can strangulate if incarcerated. When a patient presents with signs and symptoms of strangulation, emergent surgical intervention is warranted. This report strives to strengthen existing evidence for the use of an Altemeier-type perineal approach as a viable choice for the management of strangulated rectal prolapse in healthy individuals.

PRESENTATION OF CASE

A healthy 70-year-old female presents with worsening rectal pain and an irreducible strangulated rectal prolapse. She is brought to the operating suite for an emergent exploration under anesthesia followed by an Altemeier-type procedure without diverting colostomy. The postoperative course is uneventful, and the patient is discharged on postoperative day three. Upon follow up, the patient reports having normal bowel function, and there is no evidence of recurrence.

DISCUSSION

Rectal prolapse is traditionally managed through either a perineal or transabdominal approach depending on the patient's clinical disposition. Incarcerated prolapse is a precursor to strangulation, and recent case reports have demonstrated the efficacy of the Altemeier procedure (perineal rectosigmoidectomy) to treat strangulated prolapse. Our initial exploration under anesthesia revealed a small section of ischemic rectal mucosa that was proximal to the rectosigmoid junction. As a result, we decided to remain within perineal parameters and perform the resection in an Altemeier-type fashion based on the boundary of ischemia.

CONCLUSION

An Altemeier approach was a reasonable option for emergent surgical management of strangulated rectal prolapse in an otherwise relatively healthy individual. This case has been reported in line with the SCARE criteria (Agha et al. [1]).

Anorectal emergencies: WSES-AAST guidelines

Anorectal emergencies comprise a wide variety of diseases that share common symptoms, i.e., anorectal pain or bleeding and might require immediate management. While most of the underlying conditions do not need inpatient management, some of them could be life-threatening and need prompt recognition and treatment. It is well known that an incorrect diagnosis is frequent for anorectal diseases and that a delayed diagnosis is related to an impaired outcome. This paper aims to improve the knowledge and the awareness on this specific topic and to provide a useful tool for every physician dealing with anorectal emergencies.The present guidelines have been developed according to the GRADE methodology. To create these guidelines, a panel of experts was designed and charged by the boards of the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) to perform a systematic review of the available literature and to provide evidence-based statements with immediate practical application. All the statements were presented and discussed during the WSES-AAST-WJES Consensus Conference on Anorectal Emergencies, and for each statement, a consensus among the WSES-AAST panel of experts was reached. We structured our work into seven main topics to cover the entire management of patients with anorectal emergencies and to provide an up-to-date, easy-to-use tool that can help physicians and surgeons during the decision-making process.