Rectal Prolapse Research Articles

Modified Altemeier Procedure as Management for Incarcerated Rectal Prolapse in a Young Healthy Male Patient: A Case Report and Literature Review

Rectal prolapse (RP) is a rare condition presenting as a partial or complete protrusion of the rectum or as mucosa through the anal canal, and it usually occurs in the elderly or females with multiple risk factors. An initial presentation of incarcerated RP is even rarer. We present a case of a previously healthy 39-year-old man who presented with an incarcerated RP that necessitated urgent perineal proctosigmoidectomy (Altemeier procedure), with diverting sigmoid colostomy, followed by a reversal of the colostomy three months later. This case highlights the importance of surgical management (the modified Altemeier procedure) for a patient with an incarcerated RP. There are no specific guidelines for management of RP; all the recommendations and latest approaches are patients-based approaches according to their presentations, risk factors, age, and gender.

Systematic literature review and meta-analysisof surgical treatment of complete rectal prolapse in male patients.

Rectal prolapse often affects women but may also affect men. This systematic review aimed to provide outcomes of surgery for complete rectal prolapse reported in studies with a predominantly male population. This PRISMA-compliant systematic literature review searched PubMed and Scopus between January 2000 and February 2024; Google Scholar was queried for studies reporting outcomes of complete rectal prolapse surgery in predominately (> 90%) male populations. Main outcome measures were recurrence, complications, operative time, and bowel function. Eight studies (452 patients; median age 45.6years) were included; 80.5% of patients underwent abdominal procedures whereas 19.5% underwent perineal procedures. The prevalenceof recurrence was 11.2% after ventral mesh rectopexy (VMR), 0.8% after posterior mesh rectopexy (PMR), 0 after resection rectopexy, and 19.3% after perineal procedures. The prevalenceof complications was 13.9% after VMR, 13.1% after PMR, 43.3% after resection rectopexy, and 17.4% after perineal procedures. The most improvement in constipation was notedafter resection rectopexy (83.3-100%) and in fecal incontinence (FI) was notedafter posterior mesh rectopexy (86.4-90%). Abdominal procedures had lower rates of recurrence (6% vs. 19.3%, RR 0.50, 95%CI 0.21-1.18, p = 0.113), similar complication rates (14.3% vs. 13.6%, RR 0.41, 95%CI 0.06-2.9, p = 0.374), and longer operative times (116 ± 47.2 vs. 74.2 ± 23.6min, p < 0.001). Treatment of rectal prolapse in male patients undergoing abdominal procedures was associated with longer operative times, lower recurrence rates, and similar complications to perineal procedures. PMR and resection rectopexy had the lowest recurrence. The most improvement in FI and constipation was noted after PMR and resection rectopexy, respectively.

Ethanol sclerotherapy in pediatric rectal prolapse: efficacy, complications, and influencing factors.

Rectal prolapse is prevalent in children and the elderly, impacting quality of life significantly. Traditional surgical interventions carry risks, especially in pediatric patients. Ethanol sclerotherapy offers a less invasive alternative, inducing fibrosis and thickening of the rectal wall. Despite its potential benefits, procedural complications are possible, emphasizing the need for careful patient selection and procedural expertise. This study aims to evaluate the safety and efficacy of sclerotherapy in treating rectal prolapse in a tertiary referral center in southern Iran. Patient records from Nemazee Hospital covering January 2014 to December 2023 were retrospectively analyzed. Pediatric patients undergoing ethanol sclerotherapy for rectal prolapse were included. Data on demographics, presentation, procedures, and outcomes were collected. Ethical approval was obtained, and specific inclusion/exclusion criteria were applied. Statistical analyses were conducted using SPSS version 26. One hundred thirtypatients were evaluated, with a mean age of 10.74 ± 5.320years. Most patients experienced constipation (56.9%). 74.2% responded well to sclerotherapy, with 12.9% needing a second injection. Complications were minimal, with bleeding being the most common (4.6%). Recurrence occurred in 18.6% of cases. Male patients showed a higher total complication rate (P = 0.010). Diarrhea-dominant patients had no recurrences post-sclerotherapy. Age significantly influenced treatment response and recurrence (P = 0.017, P = 0.035). Male predominance contradicted global pediatric rectal prolapse ratios, possibly influenced by cultural factors. Sclerotherapy remains effective, though response rates vary. Older age correlated with lower response rates and higher recurrence. Constipation-dominant prolapse was associated with increased recurrence risk. Male patients had a higher complication rate, highlighting the need for tailored management strategies.

A New Combined Urogynecology and Colorectal Surgery Pelvic Floor Clinic-1 Year On.

This study is aimed at characterizing patients seen at a new combined pelvic floor clinic (CPFC) established at a tertiary women's hospital in Singapore. Study goals include identifying patterns of symptom clusters and reviewing management strategies compared with international care standards, improving understanding of complex female pelvic floor dysfunction, and guiding future development of clinical and ancillary support. This is a single-center, retrospective cohort study of medical case record review for all patients seen at the CPFC between 1 September 2020 and 31 August 2021. All patients seen at CPFC during this study period were included for analysis. Data were deidentified and aggregated, with analysis performed for descriptive and summary statistics. Institutional Review Board approval was obtained with waiver of informed consent. Sixty-six referrals were made to the CPFC, with 57 patients seen in 11 clinic sessions across the 12-month period. The most common reasons for referral were fecal or flatus incontinence (30, 52.6%), severe constipation or defecatory dysfunction (21.1%), and rectal prolapse (17.5%). Most patients (78.9%) had multiple symptoms. Our patient demographic profile aligns with known risk factors for pelvic floor dysfunction, presenting with gastrointestinal symptoms-similar to PFCs worldwide. The new workflow and services were well positioned to address patients' needs, including those left previously untreated, or received uncoordinated care. Conservative approaches were first employed, like with other global PFCs. The combined multidisciplinary model of care resulted in good outcomes for patients managed both conservatively and surgically. Future studies to analyze patient satisfaction are planned.

The PPP - Perineal Body Preserving PSARP (Posterior Sagittal Anorectoplasty) for anorectal malformation with rectovestibular fistula in females - report of early outcomes.

Introduction The perineal body preserving PSARP (posterior sagittal anorectoplasty) (PPP) is a novel modification of the original PSARP for female patients with rectovestibular fistulas designed to eliminate the risk of perineal body dehiscence. This study aims to examine the outcomes following PPP. Methods A retrospective, single institution study was performed examining female patients with rectovestibular fistula who underwent PPP between 1/2020-12/2023. Exposure was done through the intended anoplasty only, there was no perineal body or posterior sagittal incision utilized. No routine post-operative dilations were performed. Post-operative outcomes, day of discharge, time to first feeding, and early stooling patterns were assessed. Results Fifteen patients underwent a PPP at a median age of six months (range 2 days-19 months) and median follow up of eleven months (range 1-36). Three (20%) patients underwent repair within the first three months of life. Five (33%) had diverting ostomies prior to referral to our team. There was no incidence of dehiscence or rectal prolapse. Two (13%) patients developed an anal stricture which required revision. Fourteen (93%) patients resumed normal feeds on post operative day one. Eleven (73%) were discharged on post operative day one. All patients were stooling spontaneously at their most recent clinical encounter with eleven (73%) utilizing laxatives. Conclusions The PPP eliminates the risk of perineal body dehiscence and has a quick return to regular diet and home. There is a 13% stricture rate which could relate to a difference in the distal rectal mobilization compared to the traditional PSARP.

Mesh-associated complications in minimally invasive ventral mesh rectopexy: a systematic review.

Ventral mesh rectopexy (laparoscopic and robotic) is a common and well established treatment of rectal prolapse. Although described as safe and effective, complications, especially mesh-associated ones are often mentioned. Additionally, there is no consensus regarding the mesh type and fixation method as well as the materials used for this purpose. The aim of this systematic review was to identify the total amount of complications and of those the mesh-associated ones. Pubmed, Web of Science and Cochrane Central Register were screened for complications in general and in detail regarding the mesh(es) and a systematic review was performed. Following qualitative evaluation, 40 studies were identified for further investigation. Across 6269 patients, complications were found in 9.2% (622 patients). Mesh-related complications were described in 1.4% (88 patients) of which 64.8% were erosions, 11.4% fistulas and 13.6% mesh releases. The complication rate according to the different materials were low with 1% in biological and synthetic meshes and 1.8% in not further described or mixed mesh type. Non-absorbable material to fixate the mesh was most frequently used to fixate the mesh. Laparoscopic ventral mesh rectopexy is a safe operation with a low-complication rate, regardless of mesh type.

Perineal Rectosigmoidectomy (Altemeier’s Procedure) in the Treatment of Strangulated Rectal Prolapse: A Case Series and Literature Review

Background: Rectal prolapse (RP) predominantly affects women over the age of 50 and presents as mucosal, internal, or full thickness prolapse. Strangulated rectal prolapse requires immediate medical intervention, and surgical treatment options include both abdominal and perineal approaches. We aim to present a case series of perineal rectosigmoidectomy performed urgently due to strangulation and argue that Altemeier’s procedure is the preferred method for treating strangulated rectal prolapse. Methods: Perineal rectosigmoidectomy, particularly Altemeier’s procedure, is effective for incarcerated cases. Altemeier’s procedure with diverting ileostomy was used in all three patients. Results: All patients were successfully treated, with no recurrence of prolapse and stool incontinence. Conclusions: Altemeier’s procedure is ideal for the treatment of strangulated rectal prolapse.

Feasibility of IAPWG protocol in performing high-definition three-dimensional anorectal manometry: A prospective, multicentric italian study.

The International Anorectal Physiology Working Group (IAPWG) suggests a standardized protocol to perform high-resolution anorectal manometry. The applicability and possible limitations of the IAPWG protocol in performing three-dimensional high-definition anorectal manometry (3D-ARM) have still to be extensively evaluated. The IAPWG protocol was applied in performing 3D-ARM. Anorectal manometry (ARM) and a balloon expulsion test (BET) were performed according to IAPGW protocol in 290 patients. A total of 84 males and 206 females (mean age 57.1 ± 15.7years) were enrolled in six Italian centers. The reasons for which the patients were sent to perform 3D-ARM were: constipation (53.1%), fecal incontinence (26.9%), anal pain (3.1%), postsurgical (3.8%) and presurgical evaluation (4.8%), prolapse (3.4%), anal fissure (2.8%), and other (2.1%). Due to organic and functional conditions (low rectal anterior resections, rectal prolapses, and J-pouch after colectomy), we were unable to perform a complete 3D-ARM on six patients. Overall, a complete 3D-ARM and BET following IAPWG protocol was carried out in 284 patients (97.9%). The following were recorded: rest pressure (81.9 ± 32.0mmHg) and length of the anal sphincter (37.0 ± 6.2cm), maximum anal squeeze pressure (201.6 ± 81.3mmHg), squeeze duration (22.0 ± 8.8s), maximum rectal (48.7 ± 41.0mmHg) and minimum anal pressure (73.3 ± 36.5mmHg) during push, presence/absence of a dyssynergic pattern, cough reflex and rectal sensations (first constant sensation 48.4 ± 29.5mL, desire to defecate 83.7 ± 52.1mL, and maximum tolerated volume 149.5 ± 72.6mL), and presence/absence of rectoanal inhibitory reflex. Mean 3D-ARM registration time was 14 min 7 s ± 3 min 12 s. This is the first multicentric study that evaluates the applicability of the IAPWG protocol in 3D-ARM performed in different manometric laboratories (both gastroenterological and surgical). The IAPWG protocol was easy to perform and was not time consuming. A diagnosis according to the London Classification was easily obtained in most patients in which 3D-ARM was carried out. No clear limitations to the applicability of the IAPWG protocol were detected.

Advancing the predictive accuracy of PNTML in rectal prolapse: An ongoing quest

Fecal incontinence is a common symptom among patients with rectal prolapse. Pudendal nerve terminal motor latency (PNTML) testing can serve as a reference indicator for predicting the outcomes of rectal prolapse surgery, thereby assisting surgeons in formulating more appropriate surgical plans. The direct correlation between preoperative PNTML testing results and postoperative fecal incontinence in patients with rectal prolapse remains a contentious issue, necessitating further clarification. Thus, we analyze the existing publications from both clinical and statistical perspectives to comprehensively evaluate the accuracy of preoperative PNTML testing in rectal prolapse and provide some feasible statistical solutions.

The Role of Dicrocoelium dendriticum Egg Antigen in Colitis: A Molecular, Pathological and Serological Study in an Experimental Model of C57BL/6 Mice.

Inflammatory bowel disease (IBD) is a chronic and recurrent disease of the gastrointestinal tract that enhances the chance of developing colorectal cancer. Since standard treatments such as Mesalazine have limited effectiveness and are often accompanied by numerous side effects, the use of immune modulators derived from worms has been proposed as a new immunotherapy method for inflammatory diseases such as ulcerative colitis. The aim of this study is to investigate the protective effects of D. dendriticum egg antigen on DSS-induced colitis in C57BL/6 mice. D. dendriticum egg antigen was extracted and DSS (3.5%) was used to induce colitis in mice. Treatment and prophylaxis included intraperitoneal injections of D. dendriticum egg antigen. Histopathological indicators and the disease activity index (DAI), including weight loss, rectal bleeding, stool consistency, and rectal prolapse, were used to assess the severity of colitis. Real-time PCR measured the expression of transforming growth factor-β (TGF-β) and interleukin-17 (IL-17), while ELISA determined the concentration of these cytokines. Treatment with D. dendriticum egg antigen significantly improved the clinical symptoms and decreased the severity of DSS-induced colitis. Furthermore, D. dendriticum egg antigen increased the expression of TGF-β mRNA and reduced the expression of IL-17 mRNA, leading to a positive adjustment in the regulation of proteins and reduction of inflammatory proteins. As a result, the macroscopic, microscopic inflammation and activity index (DAI) of DSS-induced decreased. D. dendriticum egg antigen provides a promising new way to modulate the immune system and improve ulcerative colitis.

Anal sphincter function in rectal intussusception and high and low "take-off" external rectal prolapse-A prospective observational study.

Rectal intussusception (RI) and external rectal prolapse (ERP) are associated with anal sphincter dysfunction. The aim of this study was to examine sphincter function with anal acoustic reflectometry (AAR) in RI and two distinct phenotypes of ERP termed high and low "take-off". A prospective study of patients with RI and ERP attending a tertiary pelvic floor unit. Clinical data, AAR, and conventional anal manometry were analysed according to the Oxford prolapse grade. A total of 108 (102 [94%] female, median age 62 years [range: 26-95]) patients were recruited into three groups according to prolapse grade: Oxford grades I and II (intrarectal RI, n = 34), Oxford grades III and IV (intra-anal RI, n = 35) and Oxford grade V (ERP, n = 39). As the grade of prolapse increased, resting AAR measurements of opening pressure, opening elastance, closing pressure, and closing elastance decreased (p < 0.001). Maximum resting pressure with manometry was reduced in ERP and intra-anal RI compared to intrarectal RI (p < 0.001). However, incremental squeeze function was not different between the three groups with either AAR or manometry (p > 0.05). There were no differences in AAR or manometry variables between grade IV RI (n = 18) and high take-off ERP (n = 20) (p > 0.05). By contrast, opening pressure (p = 0.010), closing pressure (p = 0.019) and elastance (p = 0.022) were reduced in low take-off ERP (n = 19). Increasing rectal prolapse grade is associated with reduced anal sphincter function at rest indicating internal anal sphincter dysfunction. Physiological differences exist between high and low take-off ERP with sphincter function in the former similar to that seen in grade IV RI.

7308 A Case of Thyroid Hormone Resistance Associated With a Novel Mutation in the THRA Gene

Abstract Disclosure: J.A. Siddiqui: None. M. Barbosa: None. V. Fettig: None. C.J. Romero: None. Introduction: Thyroid hormone resistance (THR) is a syndrome leading to decreased response of target organs to thyroid hormone. Normal thyroid hormone action is mediated by thyroid hormone nuclear receptors and is essential for normal development and metabolism. Two isoforms are encoded by the thyroid hormone receptor α and β genes (THRA and THRB). Mutations in THRB are commonly reported with limited cases of THRA mutations. We report a 15-month-old and her mother with a pathogenic variant in the THRα receptor leading to thyroid hormone resistance. CASE: A 15-month-old ex-39-week gestation female was born small for gestational age (birth weight: 2450 grams,3rd %ile and birth length: 17 inches,1st %ile). The newborn screen was normal. She presented with macroglossia, low tone and global developmental delay. She had severe constipation complicated by rectal prolapse that required surgical correction. There are multiple relatives (mother, maternal half-brother and maternal grandparents) with neurodevelopmental issues. The mother’s previous genetic evaluation was non-diagnostic. Mother reports a thyroid condition but without treatment. The patient was initially referred to genetics and whole exome sequencing revealed a heterozygous c.1205 T&amp;gt;C p. (L402P) variant in the THRα gene, which was maternally inherited and reported as a variant of uncertain significance. On physical exam, Heart rate was 112 bpm; height &amp;lt;1%ile (Z-score -3.22 SD), weight 3%ile (Z-score -1.89 SD). Patient has a wide anterior fontanelle (4x3 cm), macroglossia and delayed teeth eruption. Other exam findings: non-palpable thyroid and postaxial polydactyly on the 5th digit of the right toe. Thyroid hormone testing: normal TSH 1.829 uIU/mL, low total T4 4.4 mcg/dL, low Free T4 of 0.58 ng/dL and high free T3 of 4.24 pg/mL. Levothyroxine treatment was initiated(25 mcg daily). After 1 month treatment, TSH level was 0.23 uIU/mL, total T4 was 6.1 mcg/dL and low reverse T3 of 5.8 ng/dL. DISCUSSION: Thyroid hormone resistance due to THRα mutations are rare and under-recognized. The main clinical phenotype includes growth retardation, delayed development, decreased muscle tone, delayed tooth eruption and constipation. Unlike patients with THRβ mutations, the hypothalamus-pituitary-thyroid axis in patients with THRα mutations is minimally affected with a normal TSH level. Total T3 levels are elevated with slightly low total T4 and free T4:T3 ratio is low. Treatment with levothyroxine leads to suppressions of TSH levels, therefore confirming intact central T3 feedback loop. Reports, however, show minor clinical improvements with treatment; therefore further research is needed in these patients to explore more effective therapeutic options. We present a case of a novel congenital THRA mutation leading to a clinical phenotype consistent with THR. She continues care in our clinic with hopes to further study her mutation. Presentation: 6/2/2024

340 - MRI and Anorectal Manometry Characteristics Of Women with Rectal Prolapse that Presents Only During Defecation

340 - MRI and Anorectal Manometry Characteristics Of Women with Rectal Prolapse that Presents Only During Defecation

Surgical and functional outcome of laparoscopic suture rectopexy for management of pediatric rectal prolapse.

Surgical and functional outcome of laparoscopic suture rectopexy for management of pediatric rectal prolapse.

337 - Management of rectal prolapse in octogenarians: lesson learned in 13 years’ experience from a high-volume center

337 - Management of rectal prolapse in octogenarians: lesson learned in 13 years’ experience from a high-volume center

Posterior Sagittal Mesh Rectopexy versus Delorme's Procedure in The Treatment of Complete Rectal Prolapse in Adult

Posterior Sagittal Mesh Rectopexy versus Delorme's Procedure in The Treatment of Complete Rectal Prolapse in Adult

Evaluation of laparoscopic suture rectopexy for the treatment of complete rectal prolapse in children.

Evaluation of laparoscopic suture rectopexy for the treatment of complete rectal prolapse in children.

329 - Recurrent Rectal Prolapse: Re-recurrence Rate and Risk Factors

329 - Recurrent Rectal Prolapse: Re-recurrence Rate and Risk Factors

Case Report: Delorme Technique for the Treatment of Giant Non-Reducible Rectal Prolapse at the Second Level of Care

Rectal prolapse is an invagination of the rectum that causes it to protrude through the anus. Irreducible rectal prolapse is an unusual condition; in most cases, the prolapse reduces spontaneously. Non-surgical treatment alternatives have been noted, such as the use of sugar, which reduces rectal prolapse. The results have not yet been compared against surgical treatment, so they cannot yet be considered the preferred option. Given the many techniques and procedures, it should be considered that the best procedure must be chosen not only to correct the prolapse but also to restore defecatory function and to improve fecal incontinence throughout the patient's lifetime. The Delorme procedure is a transanal technique that addresses complete rectal prolapse with a low surgical risk and minimal morbidity (less damage to pelvic and hypogastric nerves compared to abdominal procedures). It is associated with a significant improvement in anal continence, low recurrence rates, short hospital stays, and patient comfort.

Anatomical and functional outcomes of rectal prolapse treatment with laparoscopic pelvic organ prolapse suspension versus laparoscopic ventral mesh rectopexy

AbstractAimVery few studies have compared laparoscopic pelvic organ prolapse suspension (POPS) and laparoscopic ventral mesh rectopexy (LVMR) in the treatment of rectal prolapse, particularly regarding the comparison of improvement rates in obstructed defecation syndrome (ODS). This study aimed to compare the anatomical and functional outcomes of these two methods over a long‐term follow‐up period.Patients and methodsThis retrospective study was conducted on 120 female patients diagnosed with rectal prolapse who underwent surgery at the Colorectal Surgery Department of Shahid Faqihi Hospital in Shiraz, Iran, between October 2015 and October 2022. The patients were categorised into two groups based on their surgical procedures: 58 underwent LVMR in the first group, and 62 underwent POPS in the second group.ResultsRecurrence of prolapse occurred in 7 (12.1%) patients in the LVMR group and 5 (8.1%) patients in the POPS group (P = .550). The mean operation time, mean length of hospital stay, Visual Analogue Scale score, early and late post‐operative complications, Cleveland Clinic Incontinence Score, ODS symptoms, and Wexner Constipation Scores did not differ significantly between the two groups.ConclusionBoth laparoscopic POPS and LVMR techniques significantly improved the anatomical and functional outcomes in the treatment of rectal prolapse and obstructed defecation. LVMR and POPS can each be considered first‐line treatment options for rectal prolapse, depending on the specific case.