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Cite this article: Nonso MBAH (2017) New Surgical Technique for the Emergency Treatment of Incarcerated Rectal Prolapse without Colostomy - A Case Re-port. JSM Gen Surg Cases Images 2(3): 1033.

*Corresponding authorNonso MBAH, Department of Surgery, Chukwuemeka Odumegwu Ojukwu University Teaching Hospital (COOUTH), Amaku, Awka. Anambra State, Nigeria, Tel: +2348054872710; Email:

Submitted: 21 March 2017

Accepted: 26 July 2017

Published: 28 July 2017

Copyright© 2017 Nonso

ISSN: 2573-1564

OPEN ACCESS

Keywords•New technique•Perineal•Distal proctectomy•External plication•Single-stage•Incarcerated•Rectal prolapse

Case Report

New Surgical Technique for the Emergency Treatment of Incarcerated Rectal Prolapse without Colostomy - A Case ReportNonso MBAH*Department of Surgery, Chukwuemeka Odumegwu Ojukwu University Teaching Hospital (COOUTH), Nigeria

Abstract

A case of large incarcerated complete rectal prolapse successfully managed in a 36 year old retroviral disease negative man using a new surgical technique is reported and described. A combination of perineal distal proctectomy and external plication of the preserved viable rectosigmoid stump was employed without a protective colostomy. Patient recovered uneventfully with excellent continence of both flatus and feces. The successful treatment of this patient makes the new perineal procedure a recommendable option for the management of this otherwise challenging surgical emergency.

INTRODUCTIONIncarcerated complete rectal prolapse (ICRP) is an uncommon

surgical emergency. It’s usually the outcome of a neglected longstanding reducible prolapse. Early in the course of a rectal prolapse, the anal protrusion may be spontaneously reducible. With time, it requires manual manipulation to achieve reduction. If this condition remains unattended, it could ultimately progress to irreducibility and incarceration. This situation if untreated predisposes the rectal prolapse to ulceration, bleeding, strangulation, gangrene and eventual rupture. The emergency surgical treatment of the ICRP is perineal proctosigmoidectomy (Altemeier’s procedure) with or without a covering colostomy [1,2]. It’s an operation with a high risk for complications including fecal incontinence, anastomotic leak and disease recurrence [2,3]. A new single-stage perineal technique used for the successful emergency repair of a large ICRP without any significant complication is hereby reported and described.

CASE REPORTA 36 year old gentleman (CCK) was referred on 28th August

2016 from a private health clinic to our emergency services on account of 2 days history of irreducible, bleeding, anal protrusion associated with severe deep-seated pelvic pain. The prolapse had developed gradually and painlessly over a 5-year period. Initially spontaneously reducible, it subsequently became controlled by

manual manipulation only. However, attempts by the patient and the referring doctor at reducing the protrusion in the 2 days prior to presentation failed. He had neither passed flatus nor stool since the swelling became irreducible. The patient denied history of vomiting. He had open appendectomy several years ago otherwise there were no notable background medical and surgical history. Clinically, he was agitated and in painful distress. He was dehydrated, hypotensive (BP 80/50mmHg), tachycardic (PR 110/min) and had low-grade pyrexia (Temp. 37.8oC). His chest and abdominal examinations were unremarkable. His body mass index (BMI) was 21 (height 175cm and weight 64kg).

The perineal finding was a 10cm irreducible complete rectal prolapse with edematous pale-looking wall (Figure 1). There were few areas of superficial ulceration, bleeding from the surface and mucoid discharge. The packed cell volume (PCV) was 37%. He was retroviral screen negative. His kidney function profile showed elevated urea levels at 73.4mmol/l (normal 10 - 55) and high normal serum creatinine of 1.5mg/dl (0.7 - 1.4). Two units of blood were grouped and cross-matched. He was resuscitated vigorously with intravenous fluids, placed on nil by mouth, parenteral antibiotics, urethral catheterization and was worked up for emergency surgical repair. Intra operatively, under general anesthesia, the patient was kept in the lithotomy position. Repeated attempts at achieving manual reduction failed.

An extended lower midline laparotomy incision was

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performed in order to pack away the small bowel loops from the pelvis. A perineal circumferential full thickness excision of the everted rectal wall was performed while preserving the enclosed proximal 5 cm viable rectosigmoid stump (Figure 2a & 2b). At this time, an attempt at repositing the unresected stump back into the pelvis proved easily successful.

The prolapse was mobilized and interrupted plicating sutures inserted evenly from the distal resection margin 5mm proximal to the dentate line through the seromuscular wall of the rectosigmoid stump to include the rectal mucosa at its lowermost free margin (Figure 3). Six of these plicating 3/0 Vicryl sutures were placed equidistant to each other around the perimeter of the field of surgery and held as stay sutures until the last suture was inserted. The plicated stump was gently and easily manipulated back into the pelvis as the sutures were knotted individually to retain the reduced bowel insitu. This also approximated the distal and proximal mucosal rings (Figure 4). By so doing, the prolapse was successfully repositioned within the pelvis and the anal canal was reformed (Figure 5). The operator and assistant changed their gloves, inspected the pelvic cavity through the laparotomy wound before closing the abdomen.

An inflated size 18 Foley’s urethral catheter was left within the sigmoid colon as an improvised flatus tube. The stem of the insitu catheter was wrapped with rolled lubricated intra-anal gauze pack which abutted against the plicated rectosigmoid. Two

units of blood were transfused intra-operatively on account of blood loss.

The resected specimen sent for histology showed areas of ischemic necrosis without any underlying sinister pathology. During the immediate post-operative period, the patient was placed on parenteral ceftriaxone, and metronidazole. He was commenced on clear liquids from the 2nd day post op. The man passed wind though the flatus tube on 3rd day after surgery. The flatus tube was then removed with the intra-anal pack. Full oral intake was commenced and lactulose oral suspension added. Later same day, the patient had two large bowel motions without either fecal incontinence or recurrent rectal prolapse. His anal sphincteric tone was assessed and considered adequate. He was

Figure 1 Incarcerated Complete Rectal Prolapse At Presentation.

Figure 2 Healthy Rectosigmoid Stump After Distal Proctectomy.

Figure 3 Healthy Rectosigmoid Stump After Distal Proctectomy.

Figure 4 Prolapse Reduced As Plication Sutures Are Being Knotted.

Figure 5 Completed Procedure.

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discharged to the outpatient clinic the next day. He continued regular follow up visits at the surgical outpatient clinic for 6-months postop with full continence of both flatus and feces without recurrent rectal prolapse or constipation. His laparotomy and anal wounds also healed uneventfully.

DISCUSSION Incarcerated rectal prolapse is a rare and challenging surgical

emergency [1]. The curative treatment is operative2. Surgical intervention is indicated when conservative measures for temporary relief fail to return the bowel to its anatomic position or if there are obvious signs of compromised tissue viability as was the case with our patient. Jeopardizing the bowel’s viability should be avoided as gangrene significantly increases morbidity and mortality3. The aim of the operative treatment is to amputate obviously devitalized tissue, anatomically reposit the viable bowel and restore the function of the anorectal complex [4,5]. The commonest surgical operation for incarcerated complete rectal prolapse is the perineal rectosigmoidectomy (Altemeier’s) with or without a protective colostomy [2,6]. Unfortunately, the incidence of recurrence following this operation could be as high as 58% with anastomotic leak at 25% [3]. Furthermore, the restoration of continence after Altemeier procedure is unpredictable. Increased soiling, urgency and frequency of defecation are commonly reported with this technique [7]. This is irrespective of whether the anastomosis was stapled or hand-sewn. In our case, a distal proctectomy was sufficient to excise the everted and devitalized portion of the rectum alone. The healthy proximal rectum and prolapsed sigmoid limb were preserved.

Delorme in 1900 described a plication procedure from a perineal approach for the elective surgical repair of the prolapsed rectum [8]. The procedure was designed to treat reducible prolapse without the amputation of any part of the protrusion. Rather, a mucosectomy was performed prior to placement of rectal muscle plication sutures from the interior part of the bowel. Our patient had an irreducible prolapse with an oedematous ulcerated rectal mucosa which precluded him from getting a Delorme’s. On the other hand, sequel to his distal proctectomy, we plicated the seromuscular wall of the healthy rectosigmoid stump from the external part of the bowel without a mucosectomy after confirming the bowel’s reducibility. A single stitch plicated the bowel wall and approximated the distal and proximal mucosal cuffs at each of six separate sites around the field of surgery. Our technique produced the following effects:

1. The erstwhile patulous anorectum was corrected and the anal sphicteric function restored.

2. The plication of the rectosigmoid stump from the exterior served to fix this segment of the large bowel within the pelvic cavity and prevented recurrent prolapse.

3. The rectosigmoid mucosa was preserved and further enhanced the continence mechanism.

4. The absence of a separate stitch to approximate the distal and proximal mucosal cuffs other than the individually plicating sutures may have facilitated drainage of any collection from around the reduced bowel which otherwise could cause pelvic peritonitis or abscess

formation. Previous authors had reported 25% incidence of pelvic peritonitis and abscess collection after perineal surgical treatment of rectal prolapse [8].

5. The 6 plicating sutures evenly spaced around the perimeter of the wound (3 sutures in each half) were considered adequate for this procedure. Using more may be attended by bowel ischaemia, luminal occlusion or both.

We added a prophylactic laparotomy in order to displace small bowel loops out of the pelvis. The anterior peritoneal pocket is a potential space which could contain the small intestine in a large incarcerated rectal procidentia the type our patient had [2,8]. Iatrogenic injury to these structures may be inevitable during perineal proctectomy in an emergency situation unless the bowel loops are first isolated away from the operative field. Where the facilities and expertise are available, the same goal could be achieved laparoscopically [2]. In our case, no morbidities occurred from the use of the open approach.

Contrary to the experience of some workers [1-3], we did not consider a colostomy necessary during this operation. This obviated the significant complications which could attend a colostomy [1,10]. Besides, the placement of stoma does require a second hospital admission and operation for its closure.

CONCLUSIONA new single-stage perineal technique without a covering

colostomy was successfully used for the emergency treatment of a large incarcerated complete rectal prolapse in an adult male patient. This involved a distal proctectomy to remove the everted compromised part of the prolapse and six externally placed interrupted seromuscular plicating sutures to the healthy rectosigmoid stump.

A prophylactic laparotomy was added to displace small intestinal loops and avert iatrogenic bowel injury.

It remains to be seen if this surgical technique would produce a better clinical and functional outcome than the Delorme’s procedure in the elective treatment of the reducible rectal prolapse.

ACKNOWLEDGEMENT Figures 2a and 3 were jointly produced between Mr.

Okechukwu Nwafor (artist) and the author.

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Nonso MBAH (2017) New Surgical Technique for the Emergency Treatment of Incarcerated Rectal Prolapse without Colostomy - A Case Report. JSM Gen Surg Cases Images 2(3): 1033.

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