Approach to Pt. With Something Coming out of AnusDR. HASSAN MAHMUDPGR TEACHING SURGERY UNITA.B.S.T.H

History

Usama 15 year Male Student Kotla Gujrat Opd 15-03-16

Presenting Complaint

Something coming out of anus- 4years Bleeding PR on & off- 4years

HOPI

Pt. was alright 4 years back when he noticed something coming out of anus. It was initially small but gradually increased in size. It is including whole circumference of anus. It always comes out during defecation or straining. It is associated with bleeding per rectum. It is of bright red color & comes after defecation. There is no associated bruises on skin or Hx of gum bleed. No Hx of constipation, diarrhea, jaundice. He has Hx of sodomy.

Cont.

No past medical or surgical Hx No family Hx No personal Hx No drug Hx

Impression

Rectal Prolapse Large rectal polyp Hemorrhoids

Examination

A young healthy boy, well oriented, lying comfortably on bed

Vitals: Pulse: 82/min Temp: 98 degree F B.P: 110/70 mmHg R.R: 24/min

Examination

A pinkish mass coming out of anus during straining, covering anus circumferentially, soft in consistency, non tender, no bleeding spots, having concentric rings and grooves around its wall, reduced manually.

Cont.

GIT: Normal CVS: Normal CNS: Normal Resp: Normal Genitourinary: Normal

Investigations: Baselines

USG Abdomen

Rectal ProlapseDR. HASSAN MAHMUDPGR TEACHING SURGERY UNITA.B.S.T.H

Outline

Introduction Types Etiology Pathophysiology Clinical Features Evaluation Examination Investigations Non surgical Management Surgical Management Complication

Introduction

Rectal Prolapse is circumferential descent of rectum (bowel) through the anal canal.

Common in infants, children & elderly

Common in females (6:1)

Types

Partial or Rectal mucosal prolapse:• Protusion of the rectoanal mucosa & submucosa

Complete prolapse or Procidentia• Include mucosa, submucosa & muscles

Internal prolapse or intussusception:•Occult rectoanal intussusception• Prolapse does not protude from the anus•Not always pathologic/symptomatic• Occurs in 50% of defograms

Mucosal vs Full Rectal Prolapse

Mucosal vs Full Rectal Prolapse

Difference Between Rectal Prolapse and Hemorrhoids

Rectal Prolapse Hemorroids

Tissue Folds Circumferential Radial

Abnormality on Palpation

Double Rectal Wall Hemorrhoidal Plexus

Resting and Squeeze Pressures

Decreased Normal

Difference Between Rectal Prolapse and Hemorrhoids

Etiology Extreme of age Children: first three years (male=female)

● Cystic fibrosis, malnutrition, diarrhea, severe cough, parasites

Constipation (component of colonic dysmotility)Weakening/malfunctioning of pelvic floor/sphinctersAnismus – spastic pelvic floorPudendal neuropathy (obstetric injuries, aging)Sphincter dysfunction (trauma, aging)Decreased sacral curvatureMultipara femaleDiarrhea, cough, malnutritionDecreased ischiorectal fossa fatMental illness (depression, autism)

Pathophysiology Rectum passes through opening in pelvic floor funnel

Intussusception occurs much like what happened with hiatal hernia

• Lateral & rectosigmoid attachments relax

• Mesorectum lengthens

• Anal sphincters stretch

• Rectal prolapse

Pathophysiology

Associated pelvic anatomic abnormalities

● Deep anterior cul de sac

● Redundant sigmoid colon

● Patulous anal sphincter

● Loss of posterior rectal fixation

Clinical Features Mucus Discharge

Rectal Bleeding

Soilage

Feeling of incomplete evacuation

Diarrhea, constipation, Fecal Incontinence

Itching

Clinical Features

Constipation is associated with prolapse in 30%-70% of pts

Chronic straining, sensation of anorectal blockage, need of digital evacation

60% have coexisting incontinence ● Stretching of anal sphincters ● Impaired rectal compliance

20-35% have associated urinary incontinence

Evaluation

Ask patient to produce the prolapse

If not obvious

● straining in sitting position (toilet)

● phosphate enema or glycerine suppositories (children) to induce strain

Look for associate vaginal prolapse (15-30%)

Examination

Concentric rings and grooves

Perianal skin excoriation and maceration

Chronic prolapse● Inflamed, edematous and irregular surface ● Biopsies to rule out neoplasia

Digital examination● Sphincter pressures

Investigations Colonoscopy or barium enema

● Exclude tumor● Biopsy of ulcers and mass lesions

Defecography • Megarectum, incontinence, nonrelaxing puborectalis, abnormal perineal descent, rectocele, mucosal prolapse

N Normal rectal fixation & sphincter relaxation

1 Nonrelaxed puborectalis2 Mild intussusception3 Moderate intussesception4 Severe intussesception5 ProlapseR Rectocele

Investigations

Anal manometry can help assess sphincters

● Longstanding prolapse may damage internal sphincter

EMG for patients with history of severe straining

Pudendal nerve latency studyPudendal nerve terminal motor latency (1.8-

2.2msec)

Non operative management

Treat constipation● Fiber supplements● Stool softeners

Reduce incarcerated rectal prolapse● Table sugar

Surgical Treatment

Pertial Rectal prolapse

Improve nutrition, correct constipation Submucosal injection of 10ml of 5% phenol in

almond oil, tetracycline, hypertonic saline Thiresch wiring Goodsall,s operation(excision of prolapsed

mucosa at three different places) Stapled transanal rectal resection surgery(STARR)

Surgical Treatment

Complete Rectal Prolapse

Perineal procedures● Resection, reefing, and encirclement

Abdominal procedures● Fixation, colon resection or combination of both

Choosing Type of Surgery/ Perineal

High-risk or eldery patients

Advantages● Low morbidity and pain● Low mortality

Disadvantages● Higher recurrence rate ● Risks coloanal leak

Choosing Type of Surgery/ Abdominal

Overall better results than perineal approaches

Full mobilization of the rectum, sacral fixation with or without resection

Younger patients

Choosing Type of Surgery Perineal

● Recurrence (20%) ● Constipation rate unchanged● Persistent incontinence worse rate due to removal of rectal resevoir ● Correction of associated abnormalities (rectoceole, sphincter)● No pelvic dissection – preserves sexual function

Abdominal● Recurrence low (<10%)● ↑ constipation 50% ● Higher M & M esp.

with anastomosis ● Mesh placement – stricture, migration, erosion, infection

Perineal Procedures

Perineal Proctosigmoidectomy – Altemeir

Mucosal Sleeve Resection - Delorme

Anal Encirclement - Thiersch Wire Technique Perineal suspension/fixation - Wyatt

Altemeir Procedure

Delorme Procedure

Delorme Procedure

Delorme Procedure

Thiersch Procedure

Perineal Procedures - Advocates

Pts suffer mainly from incontinence, constipation and decreased quality of life

Pts are not mainly threatened from recurrence

Surgery should be verified in priority to its effect on post op QOL rather than recurrence

Abdominal Procedures

Anterior rectopexy or Ripstein procedure ● Anterior wrapping of the rectum and fixation to

sacrum Posterior rectopexy - Wells procedure

● Synthetic mesh ● Sutures alone

Sigmoid colectomy with sutured rectopexy ● Low recurrence ● Low morbidity ● Improves constipation

Materials used for Mesh Rectopexy

Natural• Fascia Lata

Non-absorbable Synthetic• Nylon• Polypropylene• Marlex• Polyvinyl Alcohol• Polytef

Absorbable Synthetic• Polyglactin• Polyglycolic Acid

Ripstein Procedure

Ripstein Procedure

Ivalon Sponge

Laparoscopic Rectopexy

Largely replacing open abdominal procedures

Ease of performing rectopexy and colon resection simultaneously with shorter hospital stay

Morbidity and mortality no different than open controls

Recurrence rate lower but not statistically significant

Laparoscopic Rectopexy

Ideal approach

Laproscopic posterior mesh rectopexy Posterior as well as anterior mobilisation of rectum

done, mesh placed in presacral region and sutured to rectal wall and presacral fascia

Laproscopic sigmoid resection and rectopexy Done in rectal prolapse with constipation, excess

redundant sigmoid colon with kinking

Complications

Injury to hypogastric nerve causing impotence Bladder dysfunction Bleeding from sacral venous plexus Injury to rectum & colon causing fistula Constipation after rectopexy Recurrence Infection

Recurrence

Can happen after either perineal or abdominal procedure

● Overall 15% recurrence rate (range is 0-60%)

● Abdominal operations – up to 10% ● Perineal operations – up to 20%

Recurrence

2 types of recurrence ● Mucosal ● Full thickness

Early recurrence ● Occurs within first year ● Likely the result of a specific technical failure

Non-early(late) recurrence ● Generally occurs 18-24 months

postoperatively

Recurrence - Etiology

Surgical factors ● Inadequate mobilization of rectum ● Inadequate fixation of the rectum to the sacrum ● Incomplete resection of a redundant rectosigmoid

Nonsurgical factors: ● Vigorous physical activity or childbirth – disruption of

pexy ● Continued constipation with persistent straining

Pathophysiologic factors: ● Disordered defecation ● Intestinal dysmotility

Any Question???