Circular stapling procedure for mucosal prolapse of the rectum associated with outlet obstruction

Procedure for Prolapsed Hemorrhoids for Treatment of Rectal Mucosa Prolapse following Anorectoplasty for Imperforate Anus

Surgical management of imperforate anus and rectal mucosal prolapse has evolved significantly over the last two decades. The procedure for prolapsed hemorrhoids (PPH) is now widely used primarily for rectal mucosal prolapse and internal hemorrhoids. We describe the use of PPH in the management of symptomatic rectal mucosal prolapse in a 39-year-old man with a history of a high imperforate anus and pelvic floor reconstruction. At 4-year follow up, the prolapse has not recurred and the preoperative symptoms have resolved. To the best of our knowledge, this is the first report on the use of a PPH in the management of rectal mucosal prolapse in a patient with these characteristics.

Treatment of rectal mucosal prolapse with radiofrequency coagulation and plication--a new surgical technique

BACKGROUND

This study was designed to assess the outcome of using a new technique of mucosal ablation using a radiofrequency device followed by its plication for rectal mucosal prolapse and to compare the results with those under the conventional ligature and excision procedure.

MATERIALS AND METHODS

The procedure of radiofrequency ablation and mucosal plication (RAMP) is described. A Ellman radiofrequency generator was used for the procedure. Out of the 46 patients with rectal mucosal prolapse, 24 patients were randomized to undergo ligature and excision procedure (LEP) and 22 were operated with RAMP. The operating time, amount of pain (VAS scale)[Primary end points], postoperative analgesic requirement, time to return to work, wound healing period and postoperative complications were documented.

RESULTS

Radiofrequency ablation and mucosal plication procedure on an average resulted in shorter operation time (9 vs. 32 minutes, p < 0.0001), shorter hospitalization (16 vs. 42 hours, p < 0.0001) significantly lesser postoperative pain, fewer cumulative requests for analgesia by the patients (21 vs. 54 tablets, p < 0.0001), earlier return to work (7 vs. 18 days, p < 0.0001) and faster wound healing time (14 vs. 35 days, p < 0.0001). The complication rate was 9 % with RAMP group and 29 % with LEP group.

CONCLUSION

The procedure of radiofrequency ablation and plication of mucosa shows promising results in patients with rectal mucosal prolapse. Being safe, effective, and a swift technique, it can be proposed as an improved alternative to conventional surgical procedure.

Randomized controlled study: radiofrequency coagulation and plication versus ligation and excision technique for rectal mucosal prolapse

BACKGROUND

A novel technique of radiofrequency ablation and plication of the rectal mucosa (RAMP) as a treatment for rectal mucosal prolapse is reported. The results of this technique are compared with the conventional ligature and excision procedure (LEP).

METHODS

Radiofrequency ablation was performed using an Ellman radiofrequency generator. Patients with rectal mucosal prolapse were randomized to undergo either LEP or RAMP. The intra- and postoperative outcomes and complications were recorded.

RESULTS

RAMP on average resulted in reduced operation time, shorter hospitalization, and significantly less postoperative pain. Return to work was earlier and wound healing times were shorter than that of patients in the control group. The complication rates also were significantly shorter (9% in the RAMP group and 29% in the conventional LEP group).

CONCLUSION

The procedure of radiofrequency ablation and plication of rectal mucosa is safe, effective, and swift. It can be proposed as an effective alternative to conventional surgical procedures.

Complications and recurrence after excision of rectal internal mucosal prolapse for obstructed defaecation

BACKGROUND

Rectal internal mucosal prolapse (RIMP) may cause obstructed defaecation and encouraging short-term results have been reported after its transanal excision. The objective of this retrospective study was to assess both clinical and functional outcome after this procedure alone for patients presenting with evacuatory difficulty.

PATIENTS AND METHODS

Forty patients (30 females, mean age 54 years), all suffering from obstructed defaecation, underwent RIMP excision at our unit during the last 11 years. RIMP was of first degree in three patients, of second degree in 21, and of third degree in 16 with 28/40 cases (70%) having associated anorectal pathology. The operation was carried out by hand suture (submucosal excision, Sarles endorectal excision, or the Delorme mucosectomy) in 26 patients, by circular stapled prolapsectomy in nine patients, or by combined manual and stapled techniques in five cases. Proctoscopy was carried out after 2 months for all patients, with anorectal manometry in 30 patients. Patients were independently assessed by state-trait anxiety scales for attendant anxiety and depression.

RESULTS

Eighteen patients (45%) had significant postoperative complications with a surgical reintervention rate of 32.5%. Overall, 21 patients (52%) reported recurrent constipation and of these 14 (65%) had recurrent RIMP; six patients were treated successfully by rubber-band ligation alone. Two patients (5%) experienced new onset faecal incontinence. The recurrence rate of RIMP was unaffected by the type of operation, being 53% after manual techniques and 48% after combined procedures. There was no difference between postoperative manometric values in patients presenting with recurrent RIMP or constipation compared with those without RIMP or constipation on follow-up. Forty-eight percent of the patients with both recurrent constipation plus RIMP had manometric evidence of non-relaxing puborectalis syndrome compared with 26% with RIMP but without constipation (P<0.05). Ten of the 14 patients (71%) with anxiety and/or depression complained of recurrent constipation after surgery compared with nine of the 26 patients (24%) with normal psychological profiles (P<0.01). Patients with a preoperative rectocele were more likely to suffer from recurrent constipation than those without rectocele (eight out of 15, 53.3% vs. seven out of 25, 28%; P<0.05).

CONCLUSIONS

Primary excision of RIMP does not seem an effective treatment for obstructed defecation with predictive factors for an adverse outcome in terms of recurrence (RIMP and constipation) including the presence of preoperative non-relaxing puborectalis syndrome and a demonstrated anxiety or depression psychological profile. The technique of prolapsectomy does not seem to affect outcome.

Stapled transanal rectal resection (STARR): a new option in the treatment of obstructive defecation syndrome

BACKGROUND

Rectocele and distal intussusception are organic causes of outlet obstruction. A new surgical option called the stapled transanal rectal resection (STARR) is described within a prospective study.

PATIENTS AND METHODS

Fourteen patients with symptomatic rectocele (four females), rectocele with coexistent intussusception (eight females), and intussusception (two males) underwent STARR procedure. The symptoms were measured by means of a defecation score (0-20 points).

RESULTS

Complications included local bleeding postoperatively in two cases, and temporary ischuria in four cases. The subjective sense of pain was low; from day 1 postoperatively five patients did not need any analgetics. Only one female patient had prolonged pelvic pain, without any organic reason. All patients showed improvement in rectal evacuation. The mean score of defecation (0-20 points) decreased from 13+/-3 to 4+/-3 after 1 month (p<0.05) and remained low. The overall follow-up was 19+/-9 months. Only one male patient with intussusception had defecation disorder again 6 months after surgery. Three patients had temporary urge incontinence.

CONCLUSION

STARR is an effective therapy for obstructive defecation disorder due to a symptomatic rectocele and/or a distal intussusception.

Defecación obstructiva. Métodos diagnósticos y tratamiento

Obstructive defecation is observed in approximately half of all patients with functional constipation. Functional constipation has been related to alterations in intestinal motility (slow transit constipation) and to pelvic floor disorders leading to obstructive defecation associated with anatomical alterations of the pelvic floor (rectocele, posterior perineal hernia, enterocele and sigmoidocele, internal rectal intussusception, occult mucosal prolapse, solitary rectal ulcer and descending perineum syndrome), or obstructive defecation without anatomical alterations (pelvic floor dyssynergy or anismus). The diagnostic methods used (history and physical examination, colonic transit time, balloon expulsion test, proctography, anorectal manometry and electromyography) are reviewed. Conservative medical treatment and the indications for surgical treatment and its results are also discussed.