[Intussusception and Rectal Prolapse: A Common Cause for Defecation Disorders].

INTRODUCTION: A rectal prolapse is mainly a disease of the elderly population, occurring more frequently among women. The medical practitioner has an important role in the recognition and initiation of therapy for rectal prolapse. Appropriate therapy can have an important impact on symptom reduction and healthcare resources. Surgical therapy includes perineal or transabdominal surgery, with increasing use of minimally invasive techniques such as mesh rectopexy. This operation is indicated and feasible regardless of age. The management of the rectal prolapse in specialized pelvic floor centres with interdisciplinary expertise for diagnosis and therapy is recommended.

Incarcerated Prolapsed Sigmoid Intussusception Presenting as Rectal Prolapse Without a Lead Point.

This case series presents two patients with symptoms consistent with acute rectal prolapse. The prolapses were subsequently found to be sigmoid intussusception that had prolapsed through the anus without rectal prolapse and without any intraluminal pathology or lead point. Both were recognised on examination and underwent colonic resection rather than proctectomy.

Rectosigmoid intussusception due to large submucosal lipoma mimicking rectal prolapse.

Rectosigmoid intussusception is a rare cause of bowel obstruction, accounting for only approximately 1%-2% of all bowel obstruction cases. While intussusception in adults typically occurs intra-abdominally and presents with signs and symptoms of intestinal obstruction, in rare cases, it can mimic a rectal prolapse if the intussusceptum protrudes through the anal canal. We herein report a case where an octogenarian woman presented with rectosigmoid intussusception through the anal canal, due to a sigmoid colon submucosal lipoma, who eventually required an open Hartmann's procedure. Patients with rectal prolapse symptoms should be carefully examined to rule out intussuscepting masses as a differential, as it would necessitate earlier surgical intervention.

Pelvic floor training improves faecal incontinence and obstructed defaecation despite the presence of rectal intussusception.

BACKGROUND: Rectal intussusception is often observed in patients with faecal incontinence and obstructed defaecation. The aim of this study is to assess if pelvic floor training improves faecal incontinence and obstructed defaecation in patients with rectal intussusception. METHODS: Case notes of all patients referred to Bankstown Hospital Pelvic Floor Clinic between 2013 and 2018 for the management of faecal incontinence and obstructed defaecation and rectal intussusception were retrospectively reviewed using a prospectively maintained database. St Mark's faecal incontinence and Cleveland clinic constipation scores were obtained from patients before and after they underwent pelvic floor training. RESULTS: One hundred and thirty-one patients underwent pelvic floor training at Bankstown Hospital Pelvic Floor Clinic between 2013 and 2018. Sixty-one patients had rectal intussusception (22 low-grade and 39 high-grade). Median St Marks score improved following pelvic floor training from 8 to 1 (P < 0.001). Median Cleveland Clinic constipation score improved from 8 to 5 (P < 0.001). In patients with low grade rectal intussusception, pelvic floor training improved median St Mark's score from 3 to 0 (P = 0.003), whereas Cleveland Clinic constipation score improved from 9 to 7 (P < 0.001). In patients with high-grade rectal intussusception, pelvic floor training improved median St Mark's score from 9 to 2 (P < 0.001), whereas median Cleveland Clinic constipation score improved from 8 to 4 (P < 0.001). CONCLUSION: Pelvic floor training without biofeedback therapy improves faecal incontinence and obstructed defaecation. Improvement in symptoms is unrelated to rectal intussusception observed on proctography or at examination under anaesthesia in these patients.

Cap-assisted endoscopic sclerotherapy is effective for rectal mucosal prolapse associated outlet obstructive constipation.

BACKGROUND AND STUDY AIMS: Outlet obstructive constipation (OOC) is a common type of chronic constipation that is usually caused by internal hemorrhoids (IH) and rectal mucosal prolapse (RMP). Cap-assisted endoscopic sclerotherapy (CAES) was demonstrated to be effective in the treatment of IH and RMP. This study explored the efficacy of CAES in treating OOC associated with IH and RMP. METHODS: Thirty-one patients (15 males and 16 females) were diagnosed with OOC after colonoscopy and anorectal manometry (AM). CAES was used to treat IH and RMP. The self-rating anxiety scale (SAS), self-rating depression scale (SDS), and Wexner constipation score (WCS) were used to assess patients at baseline and at the end of follow-up. AM tests were performed before and after CAES. RESULTS: The mean age of patients was 56.19 ± 7.969 years, and the follow-up time was 2.875 ± 3.703 months. After CAES treatment, subjective indices, including frequency of bowel movements (p < 0.05), defecation time (p < 0.05), SAS (p < 0.05), SDS (p < 0.05), and WCS (p < 0.05), were significantly improved. AM showed that the anal relaxation rate (p < 0.05), maximum squeeze pressure (p < 0.05), and rectal residual pressure (p < 0.05) were significantly improved. The ratio of Bristol stool form scale typeIII-Vincreased from 12.5 % to 56.25 % (p < 0.05). CONCLUSIONS: CAES is effective for treating OOC caused by IH and RMP. The relief of OOC symptoms could improve anxiety and depression symptoms associated with the disease.

Lipoma de recto prolapsado e incarcerado: caso clínico y análisis de la literatura / Prolapsed and incarcerated rectal lipoma: case report and literature review / Prolapso e encarceramento de lipoma do reto: caso clínico e análise da literatura

Los lipomas colónicos son tumores benignos poco frecuentes, extremadamente raros a nivel rectal. A pesar de ello, ocupan el segundo lugar en frecuencia detrás de los pólipos adenomatosos. Aunque la mayoría de los lipomas colorrectales son asintomáticos y se descubren incidentalmente, en ocasiones pueden ser sintomáticos y determinar complicaciones agudas que requieren tratamiento quirúrgico de urgencia. Estas formas de presentación pueden confundirse con las del cáncer colorrectal, constituyendo un desafío diagnóstico y terapéutico. Presentamos el caso de una paciente que consultó en emergencia por una gran masa dolorosa de aparición aguda a nivel del ano, resultando ser un lipoma rectal prolapsado a través del canal anal.

Colonic lipomas are infrequent benign tumors, extremely rare at the rectum. Nevertheless, they follow in frequency polyp adenomas. Even though most colorectal lipomas are asymptomatic and incidental, they can occasionally be symptomatic and develop acute complications that require urgent surgical treatment. This form of presentation can be confounded with colorectal cancer, therefore impairing diagnosis and treatment. We present the case of a female patient who came to the emergency room with an acute painful mass through the anus, that resulted in a prolapsed rectal lipoma.

Os lipomas colônicos são tumores benignos pouco frequentes, extremamente raros no nível retal. Apesar disso, ocupam o segundo lugar em frequência atrás dos pólipos adenomatosos. Embora a maioria dos lipomas colorretais sejam assintomáticos e descobertos incidentalmente, às vezes eles podem ser sintomáticos e levar a complicações agudas que requerem tratamento cirúrgico de emergência. Essas formas de apresentação podem ser confundidas com as do câncer colorretal, constituindo um desafio diagnóstico e terapêutico. Apresentamos o caso de um paciente que consultou na sala de emergência por uma grande massa dolorosa de início agudo ao nível do ânus, que acabou por ser um lipoma retal prolapsado pelo canal anal.

[Chinese expert consensus on the diagnosis and surgical treatment of rectal prolapse (2022 edition)].

Surgery is currently the only cure for rectal prolapse. Standardized preoperative evaluation and appropriate selection of surgical methods are crucial to the outcome of rectal prolapse surgery. With the development of a series of clinical studies in China and abroad, transabdominal surgery (such as ventral mesh fixation) and transperineal (anal) surgery (such as Altemeier surgery) have been widely recognized. Precise preoperative assessment of rectal prolapse and appropriate selection of surgical approaches has important clinical value in reducing postoperative recurrence rates and surgical-related complications. However, the current rectal prolapse assessment system needs to be improved, and the choice of surgical procedures remains controversal. To guide the diagnosis and surgical treatment of patients with rectal prolapse in China, nationwide specialists of colorectal and pelvic floor surgery have been organized by the of Chinese Medical Doctor Association Anorectal Branch, the Pelvic Floor Surgery Committee, and Clinical Guidelines Committee. Experts have conducted rounds of discussions on the core content of standardized diagnosis and surgical treatment for rectal prolapse, and jointly formulated the "Chinese expert consensus on the diagnosis and surgical treatment of rectal prolapse (2022)". We hope that this consensus will provide useful resources for the colorectal and pelvic floor surgeons, and promote the standardization of diagnosis and surgical treatment for the rectal prolapse in China.

Stepped-wedge randomized controlled trial of laparoscopic ventral mesh rectopexy in adults with chronic constipation.

BACKGROUND: The effectiveness of laparoscopic ventral mesh rectopexy (LVMR) in patients with defecatory disorders secondary to internal rectal prolapse is poorly evidenced. A UK-based multicenter randomized controlled trial was designed to determine the clinical efficacy of LVMR compared to controls at medium-term follow-up. METHODS: The randomized controlled trial was conducted from March 1, 2015 TO January 31, 2019. A stepped-wedge RCT design permitted observer-masked data comparisons between patients awaiting LVMR (controls) with those who had undergone surgery. Adult participants with radiologically confirmed IRP refractory to conservative treatment were randomized to three arms with different delays before surgery. Efficacy outcome data were collected at equally stepped time points (12, 24, 36, 48, 60, and 72 weeks). Clinical efficacy of LVMR compared to controls was defined as ≥ 1.0-point reduction in Patient Assessment of Constipation-Quality of Life and/or Symptoms (PAC-QOL and/or PAC-SYM) scores at 24 weeks. Secondary outcome measures included 14-day diary data, the Generalized Anxiety Disorder scale (GAD-7), the Patient Health Questionnaire-9 (PHQ-9), St Marks incontinence score, the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12), the chronic constipation Behavioral Response to Illness Questionnaire (CC-BRQ), and the Brief Illness Perception Questionnaire (BIPQ). RESULTS: Of a calculated sample size of 114, only 28 patients (100% female) were randomized from 6 institutions (due mainly to national pause on mesh-related surgery). Nine were assigned to the T0 arm, 10 to T12, and 9 to T24. There were no substantial differences in baseline characteristics between the three arms. Compared to baseline, significant reduction (improvement) in PAC-QOL and PAC-SYM scores were observed at 24 weeks post-surgery (- 1.09 [95% CI - 1.76, - 0.41], p = 0.0019, and - 0.92 [- 1.52, - 0.32], p = 0.0029, respectively) in the 19 patients available for analysis (9 were excluded for dropout [n = 2] or missing primary outcome [n = 7]). There was a clinically significant long-term reduction in PAC-QOL scores (- 1.38 [- 2.94, 0.19], p = 0.0840 at 72 weeks). Statistically significant improvements in PAC-SYM scores persisted to 72 weeks (- 1.51 [- 2.87, - 0.16], p = 0.0289). Compared to baseline, no differences were found in secondary outcomes, except for significant improvements at 24 and 48 weeks on CC-BRQ avoidance behavior (- 14.3 [95% CI - 23.3, - 5.4], and - 0.92 [- 1.52, - 0.32], respectively), CC-BRQ safety behavior (- 13.7 [95% CI - 20.5, - 7.0], and - 13.0 [- 19.8, - 6.1], respectively), and BIPQ negative perceptions (- 16.3 [95% CI - 23.5, - 9.0], and - 10.5 [- 17.9, - 3.2], respectively). CONCLUSIONS: With the caveat of under-powering due to poor recruitment, the study presents the first randomized trial evidence of short-term benefit of LVMR for internal rectal prolapse. TRIAL REGISTRATION: ISRCTN Registry (ISRCTN11747152).

Benign anorectal disease in children: What do we know?

Benign anorectal disease refers to a diverse group of frequent anorectal complaints that cause considerable discomfort, disability, and often constitute a significant problem for the child and his or her family. Hemorrhoids, fissures, rectal prolapse, and perianal abscess and fistulas are the most common anorectal disorders in pediatric population and their appearance may be age-specific. Although they generally follow a benign course, a careful examination must be performed in order to exclude other serious and complicated underlying pathology. Their diagnosis is based on the patient's medical history, physical examination, endoscopy, and imaging. Moreover, the management of these disorders includes medical and surgical treatment options, and if they are treated promptly and properly may be limited and short lived. This review presents the currently available data in the literature on the diverse aspects of these disorders, including the definition, epidemiology, clinical presentation, pathogenesis, diagnosis, indications for surgery, and long-term outcomes.

Patients' Perception of Long-term Outcome After Laparoscopic Ventral Mesh Rectopexy; Single Tertiary Center Experience.

OBJECTIVE: To assess patients' long-term outcome and satisfaction after laparoscopic ventral mesh rectopexy (LVMR). SUMMARY OF BACKGROUND DATA: Data on the long-term outcome and satisfaction of patients undergoing LVMR are limited. METHODS: Patients who underwent LVMR between 2004 and 2017 were identified from a prospectively maintained database. We attempted to contact all patients by telephone for an interview using a standardized questionnaire to record pre-LVMR symptoms, long-term outcome, and overall satisfaction. RESULTS: Total number of patients who underwent LVMR was 848 and 99(12%) were deceased at follow-up. In the end, 544 (64%) patients were contacted successfully and 478 (56%) were able to complete the questionnaire. Median time elapsed since surgery was 7 years and mean age was 62 years. Patients' reported preoperative symptoms were obstructed defecation syndrome in 40%, fecal incontinence in 22%, combination of obstructed defecation syndrome and fecal incontinence in 21% and other conditions in 17%. Bowel symptoms were reported as improved by 69% of patients and worse by 12%. Pelvic pain was reported to be improved in 47% of the patients after LVMR but new onset of pelvic pain appeared in 15%. Sexual function was reported to be better and worse with equal frequency. Overall, 63% of the patients were satisfied with the outcome and 76% would recommend this procedure to others with similar symptoms. CONCLUSION: LVMR offers acceptable long-term outcomes and satisfaction. There is a mixed impact on pelvic pain and sexual function which requires careful consideration in counseling patients for this procedure.

SULT1A1 and SULT1A2 Associated Extensive Prolapse-Type Inflammatory Polyposis in Crohn's Colitis.

Mucosal prolapse syndrome most commonly involves the rectum and presents as solitary rectal ulcer syndrome and proctitis cystica profunda. Symptoms and endoscopic appearances are nonspecific. Histologically, mucosal prolapse is characterized by fibromuscular obliteration of the lamina propria, and displacement of crypts into submucosa and muscularis mucosae. Mucosal prolapse presenting as polyposis is rare and has only been reported involving the rectosigmoid colon. In this report, we describe a case of mucosal prolapse syndrome presenting as diffuse polyposis and colitis cystica profunda involving the hepatic, splenic flexures and descending colon in a teenage boy suffering from refractory fibrostenosing Crohn's disease. This patient was found to have possibly deleterious homozygous single nucleotide polymorphisms in both SULT1A1 and SULT1A2 genes within a unique polygenic variation of altered cell adhesion.

Trends in the Diagnosis and Management of Combined Rectal and Vaginal Pelvic Organ Prolapse.

OBJECTIVE: To examine the rates of surgical repair of comorbid rectal prolapse (RP) and pelvic organ prolapse (POP) over time in a large population-based cohort. MATERIALS AND METHODS: We queried Optum, a national administrative claims database, from 2003 to 2017. We evaluated female patients age 18 or older with a diagnosis of POP and/or RP. Sociodemographic characteristics, comorbidities, and rates of procedures were collected. RESULTS: We identified 481,051 women diagnosed with RP and/or POP. Only 2.0% of women in the cohort had comorbid POP and RP. While 29.9% of women with RP had dual prolapse, only 2.1% of women with POP had both diagnoses. Overall, 25.8% of women had one or more surgical repairs. Surgical repairs were done in 26.0% of women with POP, 15.0% of women with RP, and 48.2% of women with comorbid POP/RP, though only 19.8% of patients with dual diagnoses had both RP and POP repairs. Over the study period, the rate of multidisciplinary surgical repairs increased by 2.7-fold. CONCLUSION: The prevalence of comorbid RP and POP among women in our cohort is low (2.0%). Rates of multidisciplinary surgery have increased possibly due to the increased use of imaging, laparoscopic surgery, and awareness of the shared pathophysiology of the disease.

Laparoscopic ventral rectopexy using the transanal vacuum test for complete rectal prolapse.

Laparoscopic ventral rectopexy was performed in 84 patients with complete rectal prolapse from January 2016 to December 2019. In the initial 27 cases, three cases had recurrence, especially in cases of a long rectal prolapse measuring over 10 cm. In order to avoid recurrence, the transanal vacuum test was performed following the dissection of the rectovaginal septum towards the pelvic floor. The disappearance of rectal prolapse is confirmed by the intraoperative transanal vacuum test. When the posterior wall of the rectum showed the presence of prolapse according to the transanal vacuum test, then laparoscopic ventral rectopexy was converted to laparoscopic posterior rectopexy. In 94 cases in which laparoscopic ventral rectopexy was attempted, laparoscopic ventral rectopexy was completed in 57 cases, while the procedure was converted to laparoscopic posterior rectopexy in 37 cases. The recurrence rate following laparoscopic ventral rectopexy decreased from 11.1% (3/27) to 1.7% (1/57) after beginning to use the transanal vacuum test. Laparoscopic ventral rectopexy using the transanal vacuum test is therefore considered to be a useful technique to reduce postoperative recurrence.

Recurrence after Delorme's procedure in a single and multi-surgeon setting.

BACKGROUND: Delorme's procedure (DP) is a perineal repair reserved for full-thickness rectal prolapse (FTRP) in elderly/comorbid patients due to its low perioperative morbidity. Reported recurrence rates are higher than for abdominal approaches. This study reports the long-term clinical outcomes of recurrence and postoperative bowel function after DP. METHODS: A retrospective cohort study including all patients who underwent a DP for FTRP between February 2001 and March 2014 at two primary study sites: Groote Schuur Hospital (multi-surgeon) and Kingsbury Hospital (singlesurgeon). Primary outcome was the absence of recurrence of FTRP after DP. Secondary outcomes were 30-day mortality and morbidity, postoperative bowel function and length of hospital stay. RESULTS: 70 patients underwent DP: 37 were operated on by the single surgeon and 33 by multiple surgeons. The median age was 76 years (IQR 20 years). Median length of follow-up was 46 months (IQR 55 months). 16 recurrences occurred: 7 in the single-surgeon cohort and 9 in the multi-surgeon cohort (p = 0.4). Median time to recurrence was 23 months (IQR 36 months): 48 months in the single-surgeon cohort and 15 months in the multi-surgeon cohort (p = 0.6). Six patients each had minor and major complications. Three patients died postoperatively. 8 patients required reoperation. Median postoperative hospital stay was three days (IQR 2 days). There were no significant differences between the multi-surgeon and single-surgeon cohorts. CONCLUSION: Long-term follow-up demonstrates a recurrence rate of 23% after DP, with no difference between an experienced colorectal specialist and supervised trainee surgeons.

Rectal Prolapse in Children: An Update to Causes, Clinical Presentation, and Management.

BACKGROUND: Rectal prolapse is a protrusion of rectal mucosa through the anal sphincter. Although uncommon, it is seen more often in children, younger than 4 years of age. The last data analysis of rectal prolapse and its clinical characteristics in children was performed over 30 years ago. Since that time, many medical advances have occurred that may alter our workup and management of this disease in children. We performed a chart review to reassess the clinical characteristics of rectal prolapse and its management. METHODS: This was a retrospective descriptive analysis study, assessing children less than 18 years of age that were diagnosed with rectal prolapse from 1999 to 2014 at a single tertiary care center. The onset of presentation, demographics, etiology, clinical characteristics, and management were analyzed. RESULTS: A total of 158 patients were diagnosed with rectal prolapse, with mean age of onset being 3 years. Constipation was the leading cause, with straining being the most common complaint. Stool consistencies with constipation varied. Many patients diagnosed with idiopathic recurrent rectal prolapse had either a social stressor or were described as having unusual behaviors associated with prolapse. Cystic fibrosis was only diagnosed in 4 patients. Thirty-four patients (22%) required surgical correction. CONCLUSIONS: Constipation remains the main cause of rectal prolapse. Cystic fibrosis is no longer a common etiology for rectal prolapse, because of the implementation of newborn screening. Patients with social stressors or atypical behavior may be at risk for recurrent rectal prolapse.