Clinical outcome of the Gant-Miwa-Thiersch procedure for colonic mucosal prolapse after intersphincteric resection-a single-center report from Japan

Introduction

Dysfunctions such as mucosal prolapse occur after intersphincteric resection (ISR) to treat lower rectal cancer, even when it is possible to preserve the anus.

Method

We analyzed the data of 12 patients with rectal or colonic prolapse who underwent the Gant-Miwa-Thiersch procedure between March 2017 and May 2021.

Result

There were no severe postoperative complications or recurrences.

Case presentation

A 75-year-old Japanese man initially underwent ISR and had mucosal prolapse nine months after his initial operation. We performed the Gant-Miwa-Thiersch procedure for colonic mucosal prolapse after ISR.

Surgical procedure

Our procedure is a perineal plication method of prolapsed colonic mucosa with nylon wiring (The Gant-Miwa procedure), using a 1-nylon wire encircled three times to straighten the anal canal, with a cord inserted above the internal sphincter muscle (Thiersch procedure).

Discussion

Mucosal plication is performed via the Gant-Mowa or Delorme procedure to reduce the risk of recurrence. However, mucosal plication can be performed many times. Our Thiersch procedure involves encircling and straightening the anal canal with a 1-nylon wire to fix the new internal anal sphincter. In conclusion, the Gant-Miwa-Thiersch procedure for rectal and colonic mucosal prolapse, especially after ISR, is a viable treatment option.

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Our procedure is The Gant-Miwa procedure, using a 1-nylon wire encircled three times (Thiersch procedure).

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Mucosal plication is performed via the Gant-Mowa or Delorme procedure to reduce the risk of recurrence.

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The Gant-Miwa-Thiersch procedure for rectal and colonic mucosal prolapse, especially after ISR, is a viable treatment option.

Delorme surgery for colonic mucosal prolapse after intersphincteric resection

PURPOSE

Mucosal prolapse at the site of anastomosis is a long-term complication unique to ISR. It reduces the QOL of patients due to a worsened anal function and local symptoms around the anus. We herein sought to assess the surgical outcomes after Delorme surgery for these patients.

METHODS

ISR was performed in 720 patients with low rectal cancer between January 2001 and March 2019 at the National Cancer Center Hospital East. Among these patients, the 33 (4.5%) who underwent initial Delorme surgery for postoperative colonic mucosal prolapse were identified from the medical records and then were analyzed retrospectively. We estimated the anal function using Wexner's incontinence score and assessed whether local anal symptoms due to the prolapse improved postoperatively.

RESULTS

Stoma closure was performed before Delorme surgery in 15 (45.5%) patients, and we compared the preoperative and postoperative anal function in these patients. The average Wexner's incontinence score changed from 15.1 before to 12.9 after Delorme surgery. Local symptoms around the anus improved in all 33 (100%) patients. Recurrence of colonic mucosal prolapse occurred in 5 patients (15%), and Delorme surgery was reperformed in these cases.

CONCLUSION

Delorme surgery for colonic mucosal prolapse following ISR has clinical benefits for both improving anal local symptoms and slightly improving the anal function.

Duodenal intussusception secondary to ampullary adenoma: A case report

BACKGROUND

Because the duodenum is fixed onto the retroperitoneum, duodenal intussusception is usually impossible except in cases of malrotational abnormality. Although cases of duodenal intussusception without malrotational abnormalities have been reported, it is unclear whether they constitute true intussusception or simple mucosal prolapse.

CASE SUMMARY

A 66-year-old woman presented with whole-body edema and malaise. Blood analysis indicated severe anemia and cholestasis. Endoscopic examination revealed a pedunculate polyp on the second part of the duodenum that migrated distally with mucosal elongation. Computed tomography showed duodenal intussusception. A tumor as the lead point and retroperitoneal structure, including the head of the pancreas and fat, invaginated beyond the duodenojejunal flexure. She was diagnosed with ampullary adenoma caused repeated intussusception that reduced spontaneously and underwent pancreaticoduodenectomy. Laparotomy showed tumor prolapse beyond the duodenojejunal flexure without intussusception. There was no evidence of malrotational abnormality. She was discharged with no complications.

CONCLUSION

We report true duodenal intussusception without malrotational abnormality. This phenomenon was also associated with mucosal prolapse.

Solitary rectal ulcer syndrome complicating sessile serrated adenoma/polyps: A case report and review of literature

Solitary rectal ulcer syndrome (SRUS) is a rare benign condition, which can mimic many other diseases because of their similarities in clinical, endoscopic and histological features. Sessile serrated adenoma/polyp (SSA/p) is a premalignant lesion in the colon and rectum. The misdiagnosis of SSA/p in SRUS patients has been noted, but the case of SRUS arising secondarily to SSA/p has been rarely reported. We herein report the case of a 59-year-old man who presented with an ulcerative nodular lesion in the rectum, accompanied by the symptoms of blood and mucus in the feces, diarrhea and constipation. Magnetic resonance imagining revealed thickening of the rectal mucosa-submucosa. Histologically, the lesion was characterized by the hyperplastic lamina propria and diffusely serrated crypts. Further immunohistochemical staining showed the loss of HES1 and MLH1 expression in the epithelial cells in the serrated area. The patient with SRUS had histological changes of SSA/p, suggesting a potential of tumor transformation in certain cases. SRUS uncommonly accompanied by serrated lesions should at least be considered by pathologists and clinicians.

Anorectal complications after robotic intersphincteric resection for low rectal cancer

BACKGROUND

Robotic intersphincteric resection (ISR) has been introduced for sphincter-preservation in the treatment of low rectal cancer. However, many patients experience anorectal symptoms and defecatory dysfunction after ISR. This study aims to evaluate the anorectal complications that develop after ISR.

METHODS

The medical records of 108 patients who underwent robotic ISR at Taipei Medical University Hospital, Taipei, Taiwan between December 2011 and June 2016 were retrospectively reviewed. Photographic records of perineal conditions were documented at the following time intervals after surgery: 1 day, 2 weeks, 1, 2, 3 and 6 months. Clinical outcomes and treatment results were analysed.

RESULTS

Eighty-five patients (78.7%) developed edematous hemorrhoids after surgery. These subsided at a median of 56 days after operation (range 23-89 days). Forty-six patients (42.6%) were found to have anal stenosis requiring anal dilatation. Sixteen patients (14.8%) had neorectal mucosal prolapse, which was noted to occur at an average of 98 days after surgery (range 41-162 days). Multivariate analysis showed that the occurrence of edematous hemorrhoids was associated with operating time (P = 0.043), and male gender was a significant risk factor for anal stenosis (P = 0.007).

CONCLUSIONS

This is the first study reporting on the clinical outcomes of anorectal status after robotic ISR. Further studies are needed to assess the long-term effects of these anorectal complications.