Management of Acute Incarcerated Rectal Prolapse Paravasthu S. Ramanujam, M.D., Karukurichi S. Venkatesh, M.D. From the Department of Surgery, Walter O. Boswell Memorial Hospital, Sun City, Arizona, a n d Desert Samaritan Hospital, Mesa, Arizona Perineal excision was used to treat eight elderly patients with acute incarcerated prolapse: four showed signs of strangulation with areas of gangrene, six made an uneventful recovery without colostomy, and two developed anastomotic leak, needing diverting colostomy with a complete recovery. There were no mortalities. There were no recurrences of rectal prolapse. [Key words: Incarceration; Perineal excision; Rectal prolapse; Strangulation] Ramanujam PS, Venkatesh KS. Management of acute incarcerated rectal prolapse. Dis Colon Rectum 1992; 35:1154-1156.
sode of rectal prolapse. All were w o m e n over the age of 75 years with a long-standing history of constipation. All were nursing h o m e residents at the time of incarcerated prolapse. None of these eight patients c o m p l a i n e d of anal i n c o n t i n e n c e prior to the incarceration. The presenting symptoms in these patients were feelings of intense rectal pressure, fullness, rectal pain, and blood-stained mucus drainage. These patients also e x p e r i e n c e d lower abdominal pain and nausea. There was no evidence of a neoplastic ectal prolapse represents full-thickness protruprocess precipitating the prolapse. Various meth. sion of the rectum through the anal sphincter ods were used to r e d u c e the incarcerated rectal mechanism. Complete rectal prolapse is an uncomprolapse and included placing ice packs and inm o n disorder. Elderly females are more susceptijecting a mixture of dilute e p i n e p h r i n e and hyaluble to developing this disabling condition. Rarely, ronidase solution prior to attempted reduction. A the prolapsed portion of the rectum can acutely final attempt was always made at reduction after b e c o m e incarcerated or even strangulated. anesthesia was given, w h e n the tissues were reOver a nine-year period (1982-1990), 70 elderly laxed. These m e t h o d s w e r e unsuccessful. The papatients were treated for c o m p l e t e rectal prolapse tients were managed with intravenous hydration in two large retirement communities in the metand broad-spectrum antibiotics prior to surgery. ropolitan Phoenix area. Eight patients p r e s e n t e d Because mechanical bowel preparation was not with acute incarcerated rectal prolapse (irreducipossible, the distal colonic segment was irrigated ble). In four patients, the prolapsed rectum was with Betadine | (Purdue Frederick Co., Norwalk, strangulated with areas of gangrene. The present CT) solution, using a large Foley (Bard Urological study describes the perineal approach for manageCo., Covington, GA) catheter, after anesthesia was ment of acutely incarcerated (irreducible) rectal instituted. A perineal excision was p e r f o r m e d unprolapse. der regional anesthesia, in the lithotomy position. A circular incision was made proximal to the MATERIALS A N D M E T H O D S dentate line in the viable portion of the rectal Seventy elderly patients with rectal prolapse mucosa. The incision was d e e p e n e d through the were treated b e t w e e n January 1982 and D e c e m b e r full thickness of the rectal wall. The m e s e n t e r i c i990. Of these 70 patients, eight had incarcerated vessels were carefully ligated. The prolapsed inrectal prolapse. Four of these patients p r e s e n t e d carcerated rectum was amputated up to the viable with obvious strangulation with areas of gangrene portion. The full thickness of the proximal colon (Figs. 1 and 2). Unlike patients with chronic recurwas sutured full thickness to the distal rectum, in rent rectal prolapse, these eight patients experia circumferential manner, using a one-layer teche n c e d incarceration during the first and only epinique. Posterior levator repair was p e r f o r m e d w h e n feasible. The patients were kept on bowel rest until bowel functions returned. These patients were Read at the meeting of The American Society of Colon and carefully e x a m i n e d for peritoneal signs frequently Rectal Surgeons, St. Louis, Missouri, April 29 to May 4, 1990. to check for anastomotic leaks in the immediate Address reprint requests to Dr. Ramanujam: 10615 West Thunderbird Boulevard, Suite #C400, Sun City, Arizona 85351. postoperative period. 1154
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Figure 1. Gangrenous rectal prolapse. The line of demarcation between viable and nonviable tissue is clearly seen.
Figure 2. Another patient with gangrenous rectal prolapse.
RESULTS Over a period of nine years, eight elderly women underwent perineal excision for incarcerated rectal prolapse. Four patients showed evidence of strangulation with areas of gangrene. Two patients developed signs of pelvic peritonitis secondary to anastomotic leak in the immediate postoperative period. Both underwent diverting colostomies and pelvic drainage with complete recovery. Peritoneal fecal contamination was minimal in these patients. There were no deaths. The average hospital stay was two weeks. The
six patients without diverting colostomies had acceptable anal continence. The follow-up period ranged from 18 to 84 months. There were no carcinomas. Two patients who required diverting colostomy subsequently developed severe anastomotic stenosis; hence the colostomies were not reversed. DISCUSSION Complete rectal prolapse is usually encountered in elderly patients with significant associated medical problems. >6 Rarely the prolapsed portion of
1156
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the rectum can b e c o m e incarcerated or even strangulated.6, 7 The exact incidence of incarceration of rectal prolapse is unknown. Goligher 7 describes a case of gangrenous rectal prolapse managed by perineal rectosigmoidoscopy. It is also interesting to note that the very first case treated by Mickulicz 8 in 1889 was an irreducible rectal prolapse managed by perineal excision. Unlike chronic recurrent rectal prolapse, acute incarcerated rectal prolapse is seen in patients during the first and only episode in this group. However, incarcerations also occur in recurrent rectal prolapse. The exact mechanism of incarceration of rectal prolapse in these patients during the first episode is u n c l e a r . No neoplastic mass can be identified as precipitating the cause. However, it is possible to assume that the sphincter m e c h a n i s m and pararectal tissues have not u n d e r g o n e the chronic laxity and stretching that are seen with recurrent rectal prolapse. The relatively tight sphincter mechanism and pararectal tissues probably prevent the acute incarcerated rectal prolapse from spontaneous reduction. The surgical treatment options are very limited in patients with acute incarcerated rectal prolapse. Goligher v states, "Irreducibility with gangrene remains o n e of the few indications for r e c t o s i g m o i d o s c o p y (perineal) at the present day." Abdominal approach with resection of the involved segment will necessitate a c o l o s t o m y and impose a greater risk in these already high-risk patients. Careful frequent follow-up examinations in these patients in the immediate postoperative period cannot be overemphasized. In this small series of patients, perineal excision was successful in preventing formation of a stoma in 75 percent. The two patients who d e v e l o p e d anastomotic leaks made uneventful postoperative recoveries. The anastomotic leak rate following perineal r e c t o s i g m o i d e c t o m y is e x t r e m e l y low. In 1971, Altemeier e t a L 9 r e p o r t e d 19 years' e x p e r i e n c e with perineal r e c t o s i g m o i d e c t o m y without any r e p o r t e d anastomotic leaks. Gopal e t al. 4 treated 18 elderly patients with perineal excision with n o anastomotic leaks. Wassef e t al. 1~ p e r f o r m e d a similar p r o c e d u r e in 33 patients with no postoperative leaks. In this small series of eight patients, two d e v e l o p e d anas-
Dis Colon Rectum, December 1992
tomotic leaks after emergency rectosigmoidectomy. The anastomotic leak rate was higher in this select subgroup of patients with incarcerated rectal prolapse. It is safe to assume that the anastomotic leaks were due to vascular compromise. CONCLUSIONS From this study, it appears that perineal excision of incarcerated rectal prolapse is an effective modality to treat this rare and difficult clinical problem. Colostomy can be p r e v e n t e d in a majority of these patients. Morbidity can be kept to an acceptable level by careful follow-up in the immediate postoperative period for signs of anastomotic leak.
REFERENCES 1. Prasad ML, Pearl RK, Abcarian H, Orsay CP, Nelson LR. Perineal proctectomy, posterior rectopex~r and postanal levator repair for the treatment of rectal prolapse. Dis Colon Rectum 1986;29:547-52. 2. Altemeier WA~ Guiseffi J, Hoxworth P. Treatment of extensive prolapse of the rectum in aged or debilitated patients. Arch Surg 1952;65:72-80. 3. Ramanujam PS, Venkatesh KS. Perineal excision of rectal prolapse with posterior levator and repair in elderly high-risk patients. Dis Colon Rectum 1988; 31:704-6. 4. Gopal KA, Amshel AL, Shonberg IL, Eftaiha M. Rectal procidentia in elderly and debilitated patients: experience with the Altemeier procedure. Dis Colon Rectum 1984;27:376-81. 5. Watts JD, Rothenberger DA, Buls JG, Goldberg SM, Nivatvongs S. The management of procidentia: thirty years experience. Dis Colon Rectum 1985;28: 96-102. 6. Wassef R, Rothenberger DA, Goldberg SM. Rectal prolapse. Curr Probl Surg 1986;23:402-51. 7. Goligher JC. Surgery of the anus, rectum and colon. 5th ed. London: Bailliere Tindall, 1984:302. 8. Mickulicz J. Zur operativen behandlung dis prolapsus recti et coli invaginati. Arch Klin Chir 1889;38:74. 9. Altemeier WA, Culbertson WR, Schowengerdt C, e t al. Nineteen years' experience with one-step perineal repair of rectal prolapse. Ann Surg 1971; 173:993-1006. 10. Wassef R, Rothenberger DA, Goldberg SM. Current problems in surgery: rectal prolapse. Volume XXIII, Number 6. Chicago: Year Book Medical Publishers, 1986.
sode of rectal prolapse. All were w o m e n over the age of 75 years with a long-standing history of constipation. All were nursing h o m e residents at the time of incarcerated prolapse. None of these eight patients c o m p l a i n e d of anal i n c o n t i n e n c e prior to the incarceration. The presenting symptoms in these patients were feelings of intense rectal pressure, fullness, rectal pain, and blood-stained mucus drainage. These patients also e x p e r i e n c e d lower abdominal pain and nausea. There was no evidence of a neoplastic ectal prolapse represents full-thickness protruprocess precipitating the prolapse. Various meth. sion of the rectum through the anal sphincter ods were used to r e d u c e the incarcerated rectal mechanism. Complete rectal prolapse is an uncomprolapse and included placing ice packs and inm o n disorder. Elderly females are more susceptijecting a mixture of dilute e p i n e p h r i n e and hyaluble to developing this disabling condition. Rarely, ronidase solution prior to attempted reduction. A the prolapsed portion of the rectum can acutely final attempt was always made at reduction after b e c o m e incarcerated or even strangulated. anesthesia was given, w h e n the tissues were reOver a nine-year period (1982-1990), 70 elderly laxed. These m e t h o d s w e r e unsuccessful. The papatients were treated for c o m p l e t e rectal prolapse tients were managed with intravenous hydration in two large retirement communities in the metand broad-spectrum antibiotics prior to surgery. ropolitan Phoenix area. Eight patients p r e s e n t e d Because mechanical bowel preparation was not with acute incarcerated rectal prolapse (irreducipossible, the distal colonic segment was irrigated ble). In four patients, the prolapsed rectum was with Betadine | (Purdue Frederick Co., Norwalk, strangulated with areas of gangrene. The present CT) solution, using a large Foley (Bard Urological study describes the perineal approach for manageCo., Covington, GA) catheter, after anesthesia was ment of acutely incarcerated (irreducible) rectal instituted. A perineal excision was p e r f o r m e d unprolapse. der regional anesthesia, in the lithotomy position. A circular incision was made proximal to the MATERIALS A N D M E T H O D S dentate line in the viable portion of the rectal Seventy elderly patients with rectal prolapse mucosa. The incision was d e e p e n e d through the were treated b e t w e e n January 1982 and D e c e m b e r full thickness of the rectal wall. The m e s e n t e r i c i990. Of these 70 patients, eight had incarcerated vessels were carefully ligated. The prolapsed inrectal prolapse. Four of these patients p r e s e n t e d carcerated rectum was amputated up to the viable with obvious strangulation with areas of gangrene portion. The full thickness of the proximal colon (Figs. 1 and 2). Unlike patients with chronic recurwas sutured full thickness to the distal rectum, in rent rectal prolapse, these eight patients experia circumferential manner, using a one-layer teche n c e d incarceration during the first and only epinique. Posterior levator repair was p e r f o r m e d w h e n feasible. The patients were kept on bowel rest until bowel functions returned. These patients were Read at the meeting of The American Society of Colon and carefully e x a m i n e d for peritoneal signs frequently Rectal Surgeons, St. Louis, Missouri, April 29 to May 4, 1990. to check for anastomotic leaks in the immediate Address reprint requests to Dr. Ramanujam: 10615 West Thunderbird Boulevard, Suite #C400, Sun City, Arizona 85351. postoperative period. 1154
R
Vol. 35, No. 12
ACUTE INCARCERATED RECTAL PROLAPSE
1155
Figure 1. Gangrenous rectal prolapse. The line of demarcation between viable and nonviable tissue is clearly seen.
Figure 2. Another patient with gangrenous rectal prolapse.
RESULTS Over a period of nine years, eight elderly women underwent perineal excision for incarcerated rectal prolapse. Four patients showed evidence of strangulation with areas of gangrene. Two patients developed signs of pelvic peritonitis secondary to anastomotic leak in the immediate postoperative period. Both underwent diverting colostomies and pelvic drainage with complete recovery. Peritoneal fecal contamination was minimal in these patients. There were no deaths. The average hospital stay was two weeks. The
six patients without diverting colostomies had acceptable anal continence. The follow-up period ranged from 18 to 84 months. There were no carcinomas. Two patients who required diverting colostomy subsequently developed severe anastomotic stenosis; hence the colostomies were not reversed. DISCUSSION Complete rectal prolapse is usually encountered in elderly patients with significant associated medical problems. >6 Rarely the prolapsed portion of
1156
RAMANUJAM AND VENKATESH
the rectum can b e c o m e incarcerated or even strangulated.6, 7 The exact incidence of incarceration of rectal prolapse is unknown. Goligher 7 describes a case of gangrenous rectal prolapse managed by perineal rectosigmoidoscopy. It is also interesting to note that the very first case treated by Mickulicz 8 in 1889 was an irreducible rectal prolapse managed by perineal excision. Unlike chronic recurrent rectal prolapse, acute incarcerated rectal prolapse is seen in patients during the first and only episode in this group. However, incarcerations also occur in recurrent rectal prolapse. The exact mechanism of incarceration of rectal prolapse in these patients during the first episode is u n c l e a r . No neoplastic mass can be identified as precipitating the cause. However, it is possible to assume that the sphincter m e c h a n i s m and pararectal tissues have not u n d e r g o n e the chronic laxity and stretching that are seen with recurrent rectal prolapse. The relatively tight sphincter mechanism and pararectal tissues probably prevent the acute incarcerated rectal prolapse from spontaneous reduction. The surgical treatment options are very limited in patients with acute incarcerated rectal prolapse. Goligher v states, "Irreducibility with gangrene remains o n e of the few indications for r e c t o s i g m o i d o s c o p y (perineal) at the present day." Abdominal approach with resection of the involved segment will necessitate a c o l o s t o m y and impose a greater risk in these already high-risk patients. Careful frequent follow-up examinations in these patients in the immediate postoperative period cannot be overemphasized. In this small series of patients, perineal excision was successful in preventing formation of a stoma in 75 percent. The two patients who d e v e l o p e d anastomotic leaks made uneventful postoperative recoveries. The anastomotic leak rate following perineal r e c t o s i g m o i d e c t o m y is e x t r e m e l y low. In 1971, Altemeier e t a L 9 r e p o r t e d 19 years' e x p e r i e n c e with perineal r e c t o s i g m o i d e c t o m y without any r e p o r t e d anastomotic leaks. Gopal e t al. 4 treated 18 elderly patients with perineal excision with n o anastomotic leaks. Wassef e t al. 1~ p e r f o r m e d a similar p r o c e d u r e in 33 patients with no postoperative leaks. In this small series of eight patients, two d e v e l o p e d anas-
Dis Colon Rectum, December 1992
tomotic leaks after emergency rectosigmoidectomy. The anastomotic leak rate was higher in this select subgroup of patients with incarcerated rectal prolapse. It is safe to assume that the anastomotic leaks were due to vascular compromise. CONCLUSIONS From this study, it appears that perineal excision of incarcerated rectal prolapse is an effective modality to treat this rare and difficult clinical problem. Colostomy can be p r e v e n t e d in a majority of these patients. Morbidity can be kept to an acceptable level by careful follow-up in the immediate postoperative period for signs of anastomotic leak.
REFERENCES 1. Prasad ML, Pearl RK, Abcarian H, Orsay CP, Nelson LR. Perineal proctectomy, posterior rectopex~r and postanal levator repair for the treatment of rectal prolapse. Dis Colon Rectum 1986;29:547-52. 2. Altemeier WA~ Guiseffi J, Hoxworth P. Treatment of extensive prolapse of the rectum in aged or debilitated patients. Arch Surg 1952;65:72-80. 3. Ramanujam PS, Venkatesh KS. Perineal excision of rectal prolapse with posterior levator and repair in elderly high-risk patients. Dis Colon Rectum 1988; 31:704-6. 4. Gopal KA, Amshel AL, Shonberg IL, Eftaiha M. Rectal procidentia in elderly and debilitated patients: experience with the Altemeier procedure. Dis Colon Rectum 1984;27:376-81. 5. Watts JD, Rothenberger DA, Buls JG, Goldberg SM, Nivatvongs S. The management of procidentia: thirty years experience. Dis Colon Rectum 1985;28: 96-102. 6. Wassef R, Rothenberger DA, Goldberg SM. Rectal prolapse. Curr Probl Surg 1986;23:402-51. 7. Goligher JC. Surgery of the anus, rectum and colon. 5th ed. London: Bailliere Tindall, 1984:302. 8. Mickulicz J. Zur operativen behandlung dis prolapsus recti et coli invaginati. Arch Klin Chir 1889;38:74. 9. Altemeier WA, Culbertson WR, Schowengerdt C, e t al. Nineteen years' experience with one-step perineal repair of rectal prolapse. Ann Surg 1971; 173:993-1006. 10. Wassef R, Rothenberger DA, Goldberg SM. Current problems in surgery: rectal prolapse. Volume XXIII, Number 6. Chicago: Year Book Medical Publishers, 1986.
