Advanced Therapy in Gastroenterology and Liver Disease - part 7 pptx

Fecal Incontinence: Evaluation and Treatment / 515 recently reported excellent results; at a median of 2 years, 73% of previously incapacitated patients achieved full con- tinence; symptoms markedly improved for the others. Unlike the neosphincter procedures, SNS has been associ- ated with minimal morbidity. This fact suggests that indi- cations for the procedure might reasonably be broadened, at least on an investigational basis, in the future. R adio frequency Energy Delivery S ub mucosal radiofre- quency energy delivery to the anal canal (also known as the Secca procedure) is a thermal technique currently under investigation in a multicenter trial. The procedure consists of anal insertion of a heat-controlled probe. The probe then deploys electrodes that pierce the mucosa and heat the muscularis, resulting in collagen contraction. However, the exact mechanism of action using this technique is unknown. Early results have shown modest improvement in incontinence severity. Anal Canal Bulking and Obstructing Agents In contrast to stool bulking agents, anal canal bulking agents are made of implanted natural or synthetic materials, such as colla- g en, silicone, or carbon coated beads, that are injected into the intersphincteric space to bolster function of the inter- nal anal sphincter. We do not perform this procedure, although good outcomes in very small series have been reported. Obstructing agents, such as pliable rubber bal- loons, are placed in the anus; they can be removed by the patient for controlled defecation (Norton and Kamm, 2001; Mortensen and Humphreys, 1991). Such an inter- vention might be useful for patients who are at very poor risk for surgery. Stoma For patients with refractory incontinence, a properly placed and well-constructed stoma offers restoration of bowel control (if not true continence) with minimal associated morbidity. Although the presence of a st o ma admittedly distorts an individual’s body image, this disadvantage is usually outweighed by the patient’s enhanced ability to function normally (or nearly so) in social, work, and sexual situations without fear of loss of bowel control. Summary Fecal incontinence is a prevalent and frustrating problem that has a profound impact on physical and psychological well-being. Appropriate care relies on systematic evalua- tion and application of a tailored treatment plan. Figure 88-3 presents a systematic algorithm for care of patients with persistent fecal incontinence.Although we champion the me thodical approach, we frequently encourage a com- bined treatment plan, such as medical optimization, biofeedback, and sphincteroplasty, depending on the needs and ab ilities of individual patients. Broad adaptation of a standardized pre- and postintervention evaluation system will enhance the individual patient’s experience and our und erstanding of treatment effectiveness. FIGURE 88-2 Radiograph of an implanted sacral nerve stimulator device. Courtesy of Robert D. Madoff, MD. Fecal Incontinence: Evaluation and Treatment / 517 P arker SC, Morris AM, Thorson AJ. New developments in anal surgery: incontinence. Seminars in Colon & Rectal Surgery 2003;14:82–92. Parker SC, Spencer MP, Madoff RD, et al. Artificial bowel s phincter: long-term experience at a single institution. Dis C olon Rectum 2003;46:722–9. Rockwood TH, Church JM, Fleshman JW, et al. Fecal Incontinence Quality of Life Scale: quality of life instrument for patients with fecal incontinence. Dis Colon Rectum 2 000;43:9–16; discussion 16–7. S helton AA, Madoff RD. Defining anal incontinence: establishing a uniform continence scale. Seminars in Colon & Rectal Surgery 1997;8:54–60. Whitehead WE, Norton NJ,Wald A. Introduction. Advancing the t reatment of fecal and urinary incontinence through research. G astroenterology. 2004;126(1 Suppl 1):S1–2. Wong WD, Congilosi SM, Spencer MP, et al. The safety and efficacy of the artificial bowel sphincter for fecal incontinence: results from a multicenter cohort study. Dis Colon Rectum 2 002;45:1139–53. 518 CHAPTER 89 RECTAL PROLAPSE,RECTAL INTUSSUSCEPTION, AND SOLITARY RECTAL ULCER SYNDROME ANDERS MELLGREN,MD,PHD, JOHAN POLLACK,MD,AND INKERI SCHULTZ,MD,PHD Brodén and Snellman (1968) used defecography and could demonstrate that rectal prolapse starts as an inter- nal rectal intussusception. They demonstrated that rectal prolapse starts as anorectal intussusception 6 to 8 cm up in the rectum and as the patient strains, the intussuscep- tion progresses and extends down through the rectum and out through the anus. The underlying mechanism for the rectum to prolapse remains unclear.A mobile rectum, a weak pelvic floor, and excessive straining at stool, all predispose for development of rectal prolapse. Lack of rectal support is of etiological importance, but rectal prolapse also develops in young men and in nulliparous women with normal pelvic floor and anal sphincter function. Symptoms Rectal prolapse is a full-thickness, circumferential intus- susception of the entire rectal wall through the anal canal and anus. The prolapsing bowel itself, mucosanguineous discharge, bleeding, constipation and/or incontinence, and a f e eling of incomplete evacuation, are the most frequent complaints . The incidence of preoperative incontinence and constipation has only been reported prospectively in a few studies and definitions vary. Allen-Mersh and col- leagues (1990) studied 57 patients with rectal prolapse prospectively and found fecal incontinence symptoms in 49% and constipation symptoms in 30% of the patients. Madden and colleagues (1992) reported some degree of anal incontinence in 17 of 23 patients (74%) and consti- pation in 11 (48%) of their patients. In another prospec- tive study, Huber and colleagues (1995) included 42 patients, 5 of whom had internal rectal intussusception. They found fecal incontinence in 54% and some degree of constipation in 44% of the patients. T he underlying mechanism for incontinence symptoms in approximately 50% of patients with rectal prolapse is not fully understood. Porter used needle electromyography and not ed excessive reflex inhibition in prolapse patients. Recently, it has been demonstrated that patients with rec- tal prolapse have a thickened internal anal sphincter at Rectal Prolapse The word prolapse comes from the Latin term ”prolapsus” and means “falling down.” Rectal prolapse was described in 1500 BC in the Ebers papyrus, and Mr. Frederick Salmon, the founder of the famous St. Marks Hospital in London, wrote his classic article “Practical observations on prolapsus of the rectum” in 1831. Rectal prolapse is a benign disorder that is frequently associated with disturbed bowel function. Rectal prolapse can be treated surgically by many different techniques and results regarding recurrence rate and mortality are gener- ally good. Unfortunately, anal incontinence and/or consti- pation sometimes continue to bother the patients after otherwise successful correction of the prolapse. Epidemiology Rectal prolapse is most commonly found in elderly and the peak incidence is found after the fifth decade. Being female is one of the highest risk factors for development of rectal prolapse and women represent approximately 90% of the patient population. Rectal prolapse in elderly women is fre- quently accompanied with poor sphincter function and fecal incontinence. In the rather few younger women with rectal prolapse, continence function is frequently preserved. A background history of lifelong straining is common in these patients. Rectal prolapse is sometimes associated with underlying psychiatric illness. Etiology There are two theories regarding development of rectal prolapse. Moschowitz proposed in 1912 that rectal pro- lapse is a sliding hernia that protrudes through a defect in the pelvic floor. He found that patients with rectal prolapse ha ve a deep cul-de-sac, which he believed resulted from herniation of the small intestine into the anterior wall of the rectum. He suggested that the herniation pushed the rectum down, resulting in rectal prolapse. This idea is sup- ported by the finding of a deep cul-de-sac in many pro- lapse patients. Rectal Prolapse, Rectal Intussusception, and Solitary Rectal Ulcer Syndrome / 519 endo-anal ultrasound (Marshall et al, 2002). Several mech- anisms have been proposed to explain prolapse-associated incontinence. These include direct sphincter trauma caused by repeated stretching by the intussuscepting rectum or t hat the intussuscepting rectum leads to chronic stimula- tion of the rectoanal inhibitory reflex. Constipation, defined either as abnormally few stools per week or increased straining at stool may be explained by the pres- ence of the intussuscepting bowel in the rectum, colonic dysmotility or inappropriate puborectalis contraction. Preoperative Evaluation Verification of the rectal prolapse and differentiating it from hemorrhoids and/or mucosal prolapse is usually the first step in the examination of patients with a history sugges- tive of rectal prolapse. Rectal prolapse is identified as a cir- cular, full-thickness prolapse extending outside the anal verge when the patient strains. Occasionally the patient is unable to reproduce their prolapse at clinical examination in the left lateral position. Examination in the sitting posi- tion on a commode or diagnosis using defecography may then be quite helpful (Mellgren et al, 1994). The patient history should include preoperative con- stipation and incontinence symptoms, bowel frequency, obstetric history, and other associated pelvic floor disor- ders, such as co-existing urinary incontinence or genital prolapse. Patients with rectal prolapse are at an increased risk for other concomitant pelvic floor abnormalities. The clinical examination includes inspection of the per- ineum. Digital examination will assess the resting and squeeze tones of the anal sphincters. Proctoscopy or endoscopy will frequently reveal an area of mild erythema within the lower rectum. Sometimes a solitary rectal ulcer w il l be found in the mid-rectum. This may sometimes be difficult to distinguish from a polyp or tumor, and biop- sies may therefore be needed. Evaluation of the remain- ing colon is encouraged, to exclude any coexisting colorectal pathology, particularly cancer. Solitary rectal ulcer syndrome (SRUS) is discussed later in this chapter. Colon transit studies, anorectal manometry, pudendal latencies and endo-anal ultrasound may also be used in the examination of prolapse patients, but they are usually not essential for the preoperative assessment. Surgical Therapy Rectal prolapse in children is generally treated conserva- tively, whereas surgical repair is suggested for adults. In 1912, Moschcowitz presented his theory that rectal pro- lapse is a sliding he rnia and he suggested obliteration of the deep cul-de-sac of Douglas as treatment, but this method had a high recurrence rate. Today both abdominal and perineal approaches are used. Abdominal approaches include different types of rectal suspension and fixation and they usually have low recurrence rates (Table 89-1). Perineal approaches have higher recurrence rates and they are usually reserved for elderly patients or patients with concomitant health p roblems. Abdominal Rectal Prolapse Repair Most authors advocate complete posterior mobilization of the rectum to the coccyx, and some recommend partial anterior mobilization as well. The extent of lateral mobi- lization has been debated and there is little data reported in the literature. It has been found in patients undergoing posterior mesh rectopexy for prolapse that division of lat- eral ligaments may contribute to the development of onset constipation. A marked increase of constipation has been found in patients who had undergone Wells rectopexy with division of lateral ligaments, when they were compared TABLE 89-1. Recurrence Rates After Treatment of Rectal Prolapse Number Mean Follow- Recurrence of Patients Up (years) (%) Abdominal Procedures Ripstein Holmström 1986 82 6.9 5 Roberts 1988 130 3.4 10 Tjandra 1993 129 4.2 8 Winde 1993 35 4.2 0 Posterior rectopexy with mesh Mann 1988 51 4.8 0 Yoshioka 1989 135 32 McCue 1991 53 3.1 2 Suture rectopexy Ejerblad 1988 — 6.8 4 Blatchfor d 1989 51 2.3 2 Graf 1996 135 5.3 9 Resection r ectopexy Madof f 1992 5.4 6 Huber 1997 51 4.5 0 Anterior resection Schlinkert 1985 53 7 9 Perineal Pr ocedur es Perineal recto-sigmoidectomy 51 — — Altemeier 1971 135 ? 3 W illiams 1992 53 1 10 Delorme Uhlig 1979 51 — 7 Monson 1986 135 — 7 Senapati 1994 53 2 22 Oliver 1994 — 3.9 13 Tsunoda 2003 31 3.3 13 Watkins 2003 52 5 6 520 / Advanced Therapy in Gastroenterology and Liver Disease with patients who had undergone Ripstein’s operation with the lateral ligaments preserved. Preservation of the lateral ligaments may therefore be recommended. R ipstein Rectopexy After mobilization, the rectum is usually suspended to the sacrum, but the optimal technique for this suspension is still debated. Ripstein (1965) described a repair based on the theory that prolapse is caused by rectal attachment to the sacrum. This repair has been used extensively in the United States. The rectopexy is performed by suturing an approxi- mately 5 cm wide piece of mesh to the sacrum. The mesh is wrapped around and sutured to the anterior wall of the rectum. The wrap should be loose enough to avoid stric- turing of the rectum. The Ripstein rectopexy has sometimes been accused of causing obstructed defecation, but early reports of post- operative constipation following this procedure were not controlled for preoperative symptoms. However, the tech- nique includes a risk for infection and fistula formation because of the circular mesh and the recurrence rate, and functional outcome does not differ from other techniques. Its popularity has therefore decreased. Wells’ Rectopexy The Ivalon sponge procedure is similar to the Ripstein pro- cedure, but the mesh is placed partially around the bowel instead of circumferentially. This technique was popular- ized because of concerns over sling obstruction with a cir- cumferential mesh. The technique was described by Wells in 1959. Wells based his procedure on the use of a polyvinyl alcohol sponge (Ivalon) with its tendency to create a reactive fibrotic response. It is, however, unclear whether this reac- tive response is needed, as techniques such as suture rec- topexy seem to offer the same low recurrence rates as the Wells’ procedure. Suture Rectopexy Direct suture rectopexy was first advocated by Cutait in 1959. The suture rectopexy is used as a temporary sus- pension of the rectum while adhesions form between the rectum and the presacral fascia. This technique has gained renewed interest after the introduction of laparoscopic surgery (see below). After mobilization, the rectum is sus- p ended to the sacrum with 2 to 4 sutures that are anchored in the mesorectum and the presacral fascia. Suture rectopexy seems to offer similar recurrence and complication rates as techniques involving mesh. Suture rectopexy is therefore an attractive alternative and it may also be used together with simultaneous sigmoid resection (see below) because no foreign material is used. Resection Rectopexy Another topic of debate is whether the redundant sigmoid colon should or should not be resected at suture rectopexy. W hen Frykman and Goldberg (1969) described resection rectopexy, the original rationale of the resection was to sus- pend the left colon from the splenic flexure to prevent recurrence. It is apparent today that this is not needed when the low recurrence rates in most series evaluating abdominal pro- lapse repair. On the other hand, the use of resection may decrease the risk for postoperative constipation symptoms. A higher rate of new or persisting constipation has been reported in three additional trials in patients treated with sling rectopexy alone versus those treated with suture rec- topexy and sigmoid resection. Sometimes patients are not relieved of preexisting con- stipation despite a sigmoid resection at the time of rec- topexy and on occasion subtotal colectomy with rectopexy may be the appropriate surgical method for carefully selected patients with severe slow transit constipation (Madoff et al, 1992). The risk for postoperative fecal incon- tinence may however be substantial, as many of these patients will have loose stools postoperatively. Anterior Resection Schlinkert and colleagues (1985) have reported the Mayo Clinic experience with anterior resection as therapy for rec- tal prolapse and found an acceptable recurrence rate (9%). They found that a low anastomosis increased morbidity without significantly decreasing recurrence when com- pared with high anterior resection. The effects of repair on patient continence were unpredictable. Laparoscopic Prolapse Repair Laparoscopic abdominal repair represents a new develop- ment in rectal prolapse surgery. Laparoscopy offers improved patient comfort, better cosmetic result, and decreased lengths of hospital stay and disability (Solomon and Eyers, 1996; Kellokumpu et al, 2000) and most of the procedures described above may be performed with this t e c hnique. In two recent studies (Heah et al, 2000; Zittel et al, 2000), it was reported that functional outcome after laparoscopic rectopexy was comparable with open surgery. P erin eal Rect al Prolapse Repair Perineal prolapse repair is usually reserved for elderly pat ie nts or patients with concomitant health problems, because the recurrence rate is substantially higher.The recur- rence rates in different series range from 5 to more than 50% (Williams et al, 1992; Senapati et al, 1994; Tsunoda et al, 2003; W atkins e t al, 2003; Frykman and Goldberg, 1969) and the re is a tendency that series with longer follow-up time position. The submucosa above the dentate line is injected with an epinephrine solution where after the rectal mucosa on the external side of the prolapse is dissected free from the underlying muscle. The rectal muscle is then vertically p licated in all four quadrants, usually by using eight pli- cating sutures. As these sutures are tied, the muscle is pli- cated, and the excess mucosa is then excised and the mucosa is closed with a mucosa-to-mucosa closure. Functional Outcome After Rectal Prolapse Surgery Several attempts have been made to predict postoperative outcome with physiologic testing. Preoperative manome- try results have generally not been predictive of the func- tional outcome regarding continence, though patients with very severe physiologic abnormalities may have a worse prognosis (Williams et al, 1992; Yoshioka et al, 1989). A majority of studies report that approximately 50% of incontinent patients improve after surgery. Restoration of internal anal sphincter function plays probably an impor- tant role in this process, as improved continence after surgery is often accompanied by increased resting pressures (Schultz et al, 1996). The removal of the prolapsing may also be an important reason, as the prolapse disturbs the sphincter function by repetitive sphincter dilatation. Other important factors may be postoperative improvements in anal sphincter electomyogram and improved sensation (Duthie, 1992). The frequency of postoperative constipation varies greatly between studies. Some studies report increased inci- dence (Graf et al, 1996; Aitola et al, 1999), whereas others report an unchanged (Tjandra et al, 1993), or decreased (R o berts et al, 1988; Winde et al, 1993) incidence. Possible reasons for postoperative constipation include colonic den- ervation, rectal denervation by division of the lateral liga- ments, or a redundant sigmoid that may contribute to rectosigmoid kinking. Rectal Intussusception Internal rectal intussusception is sometimes labeled “occult rectal prolapse” as the conditions are quite similar at defecography, with the only difference that rectal intus- susception does not extend beyond the anal verge. Internal intussusception is associated with several dif- ferent functional complaints. Johansson and colleagues (1985) examined 190 patients with rectal intussusception and found that 57% of patients experienced a sensation of o bstruction, 44% had fecal incontinence, 43% had painful defecations, and 27% had anal bleeding. Mucous discharge and diarrhea have also been reported. T he most common symptom associated with internal intussusception is, thus, obstructed defecation. This can be Rectal Prolapse, Rectal Intussusception, and Solitary Rectal Ulcer Syndrome / 521 have higher recurrence rates. In a recent study from our insti- tution (Kim et al, 1999), perineal rectosigmoidectomy had a recurrence rate of 16% compared with 5% after rectopexy. Functional outcomes were similar following either opera- t ion. The results suggest that perineal rectosigmoidectomy may not be the ideal operation for healthy patients due to its relatively high recurrence rate. Most authors currently favor either perineal rectosig- moidectomy or Delorme’s operation and the choice between these two types of procedures usually depends upon individual surgeon training and preference. Series comparing different perineal operations are rare. Perineal procedures are well tolerated by most patients. The postoperative course is usually benign and most patients tolerate the procedure quite well and the postop- erative stay is usually short. Perineal Rectosigmoidectomy Perineal rectosigmoidectomy was first described by Mikulicz in 1889. Renewed interest in this procedure, par- ticularly in the United States, can be attributed to W.A. Altemeier, whose 1971 report claimed only 3 recurrences in a series of 106 patients. A few series have recurrence rates comparable to those seen after abdominal repairs, but sev- eral reports have considerably higher recurrence rates. The variability in results reported by different centers stands in contrast to the marked uniformity and predictability of success seen after abdominal repairs. Perineal rectosigmoidectomy can be done under regional or regional anesthesia in the lithotomy or prone position. The rectum is externalized as far as possible, and an incision is made approximately 1 to 2 cm from the den- tate line. The incision is made full thickness through the ou t er bowel wall, entering the space between the external and internal bowel tubes of the prolapsed rectum. The rec- tal and sigmoid mesenteric vessels are divided with liga- tures or using a harmonic scalpel and the prolapsed segment of rectum is folded down as far as possible. Resection of 20 to 40 cm of rectum and sigmoid colon is not uncommon. After mobilizing the maximum length of bowel, the prolapsed segment is resected and an anasto- mosis is sutured. Addition of a levatoroplasty to the procedure might influence recurrence rates by tightening the levator hiatus and providing a new anorectal angle that contrasts with the “straight” rectal contour typically seen in prolapse patients (Williams et al, 1992; Agachan et al, 1997). Delorme’s Operation Delorme described an alternative perineal repair and the method was popularized after the report of Uhlig and Sullivan (1979). This procedure can also be done under regional or regional anesthesia in the lithotomy or prone 522 / Advanced Therapy in Gastroenterology and Liver Disease explained by several mechanisms. The intussusception, sometimes together with a concomitant enterocele and/or rectocele, may restrict emptying or produce a sensation of rectal fullness. The intussuscepting bowel, present in the r ectum, may be experienced by the patient as fecal mater- ial that cannot be expelled. Continued straining will then increase the size of the intussusception and further worsen symptoms. The association between the internal rectal intussus- ception and the above-mentioned symptoms remains unclear. Surgical correction of the anatomical intussus- ception does not always alleviate symptoms and rectal intussusception is a frequent finding in patients with defe- cation disorders. In an evaluation of 2,816 defecography investigations, we found that 31% of the patients had a cir- cumferential rectal intussusception (Mellgren et al, 1994). Rectal intussusception has also been reported to be a fre- quent finding in defecography studies of healthy volun- teers (Shorvon et al, 1989; Goei, 1990). Diagnosis Rectal intussusception is usually diagnosed at defecography as a circumferential infolding of the rectal wall that does not pass beyond the anal verge. However, at rectal exami- nation the intussusception may be palpated or inspected with a proctoscope.A distal proctitis or a solitary ulcer may also be seen. Treatment Patients with internal rectal intussusception have often a long history of anorectal problems and they have consulted several physicians. After establishing the diagnosis, man- agement is usually conservative. Patients are informed about the condition and they are advised to avoid strain- ing at stool, as this may increase symptoms. Bulking agents may be beneficial and, sometimes, small enemas may facil- itate rectal emptying. Indications for surgical treatment vary in different stud- ies, as do the surgical results. Unfortunately most published studies are retrospective and they include relatively small numbers of patients. Fecal incontinence in patients with rectal intussusception is an indication for surgical treat- ment and most studies (Table 89-2) report improved post- o perative anal continence. Outlet obstruction is often unchanged or may even deteriorate after surgery (see Table 89-2), and patients should be counseled regarding this before surgical treatment. However the effect on outlet obstruction is unpredictable and some patients improve after rectopexy (Schultz et al, 1998). As mentioned, rectal intussusception and rectal pro- lapse are quite similar at defecography, with the only dif- ference being that rectal intussusception does not extend beyond the anal verge. Sometimes the risk for developing rectal prolapse is used as a surgical indication in patients with rectal intussusception. This risk seemed however to be quite limited, when we followed rectal intussusception patients over time (Mellgren et al, 1997). SRUS SRUS is a proctologic disease characterized by erythema and/or one or several ulcerations of the rectal wall. It is a benign condition with a characteristic histologic picture, and patients usually have associated disordered defecation. The ulcer is usually located anteriorly in the rectum, and instead of an ulcer, the lesion may also be polypoid. The histologic characteristics of the lesion were first described by Madigan and Morson in 1969 and they include a thickened muscularis mucosa, a lamina propria expanded by fibroblasts, and smooth muscle cells arranged to point towards the lumen. Colitis cystica profunda is a form of the SRUS, with dilated displaced glands filled with mucus and lined with normal colonic epithelium in the submucosa. Frequently the lesion at SRUS can be difficult to distinguish from adenomateus polyps or tumors, and biopsies are therefore essential to verify the diagnosis. T he et iology of SRUS remains obscure and patients fre- quently have concomitant pelvic floor disorders. There is an asso ciation between SRUS, rectal prolapse, internal rectal intussusception, paradoxical sphincter reaction (PSR), and ou tle t o bst r uction. The symptoms are similar and the con- dit io ns so metimes coexist, but the relationship between these disorders is not fully understood, as all can exist alone. T ABLE 89-2. Treatment Results of Rectal Intussusception Technique Number of Patients Mean Follow Up (years) Incontinence Constipation Ihre 1975 Ripstein 36 2 to 13 Improved Worse Johansson 1985 Ripstein 63 — Improved Worse Lazorthes 1986 Post. Recopexy 14 > 0.5 Improved Improved Berman 1990 Delorme 21 > 3 — Improved McCue 1990 Wells 12 2.2 Improved Worse Christiansen 1992 Wells + Orr 9 + 15 1 to 8 Improved 45% Improved van Tets 1995 Post. Rectopexy 21 6 — Improved Briel 1997 Sutur e r ectopexy 13 5.6 38% improved — A llen-Mersh TG, Turner MJ, Mann CV. Effect of abdominal Ivalon rectopexy on bowel habit and rectal wall. Dis Colon Rectum 1990;33:550–3. B innie NR, Papachrysostomou M, Clare N, Smith AN. Solitary rectal ulcer: the place of biofeedback and surgery in the treatment of the syndrome. World J Surg 1992;16:836–40. Brodén B, Snellman B. Procidentia of the rectum studied with cineradiography: a contribution to the discussion of causative mechanism. Dis Colon Rectum 1968;11:330–47. C utait D. Sacro-promontory fixation of the rectum for complete rectal prolapse. Proc R Soc Med 1959;52:105. D elorme E. On the treatment of total prolapse of the rectum by excision of the rectal mucus membranes or recto-colic. Dis Colon Rectum 1985;28:544–53. Frykman HM, Goldberg SM. The surgical treatment of rectal procidentia. Surg Gynecol Obstet 1969;129:1225–30. Goei R. Anorectal function in patients with defecation disorders and asymptomatic subjects: evaluation with defecography. Radiology 1990;174:121–3. Heah SM, Hartley JE, Hurley J, et al. Laparoscopic suture rectopexy without resection is effective treatment for full- thickness rectal prolapse. Dis Colon Rectum 2000;43:638–43. Huber FT, Stein H, Siewert JR. Functional results after treatment of rectal prolapse with rectopexy and sigmoid resection. W J Surg 1995;19:138–43. Johansson C, Ihre T, Ahlbäck SO. Disturbances in the defecation mechanism with special reference to intussusception of the rectum (internal procidentia). Dis Colon Rectum 1985;28:920–4. Keighley MRB, Shouler PJ. Clinical and manometric features of the solitary rectal ulcer syndrome. Dis Colon Rectum 1984;27:507–12. Kellokumpu IH, Vironen J, Scheinin T. Laparoscopic repair of rectal prolapse: a prospective study evaluating surgical outcome and changes in symptoms and bowel function. Surg Endosc 2000;14:634–40. Kim DS, Tsang CB, Wong WD, et al. Complete rectal prolapse: evolution of management and results. Dis Colon Rectum 1999;42:460–6; discussion 466–9. M adden MV, Kamm MA, Nicholls RJ, et al. Abdominal rectopexy f o r complete prolapse: prospective study evaluating changes in symptoms and anorectal function. Dis Colon Rectum 1992;35:48–55. Madigan MR, Morson BC. Solitary ulcer of the rectum. Gut 1969;10:871–81. Madoff RD, Williams JG, Wong WD, et al. Long-term functional results of colon resection and rectopexy for overt rectal prolapse. Am J Gastroenterol 1992;87:101–4. M archal F, Bresler L, Brunaud L, et al. Solitary rectal ulcer syndrome: a series of 13 patients operated with a mean follow- up o f 4.5 y ear s. Int J Colorectal Dis 2001;16:228–33. M arshall M, Halligan S, Fotheringham T, et al. Predictive value of internal anal sphincter thickness for diagnosis of rectal intussusception in patients with solitary rectal ulcer syndrome. Br J Surg 2002;89:1281–5. Mellgren A, Bremmer S, Johansson C, et al. Defecography,results o f in v est ig ations in 2,816 patients. Dis Colon Rectum 1994;37:1133–41. Mellgren A, Schultz I, Johansson C, Dolk A. Internal rectal intussusception seldom develops into rectal prolapse. Dis C olo n R e ctum 1997.[In press]. Excessive straining causing trauma and ischemia of the p rolapsed mucosa is probably one of the pathogenetic fac- tors and self-digitation has also been discussed as a possi- ble causative factor (Rutter and Riddell, 1975). Symptoms SRUS affects both men and women, usually with onset before the age of 50 years. Typical symptoms include evac- uation difficulties with prolonged straining at bowel move- ments, passage of blood and mucous per rectum, tenesmus, and, sometimes, anorectal pain. Digitation for evacuation of feces is considered to be common. SRUS may, however, also be found in asymptomatic patients. Treatment Nonsurgical options are usually preferred as initial treat- ment (Vaizey et al, 1997). Retraining of bowel habits, decrease of straining efforts, and a high fiber diet, is gen- erally recommended. Biofeedback-training might be help- ful, especially if the patient has PSR (Binnie et al, 1992). Abdominal rectopexy offers long term symptom improve- ment in approximately 50% of patients (Vaizey et al, 1998). Rectal ulceration may persist after any treatment, even if symptoms improve. Surgery is frequently recommended when SRUS is accompanied by rectal intussusception or rectal prolapse. Reports on surgical outcome are, however, usually based on small series with limited follow-up time. Successful out- come has been reported after Ripstein rectopexy in 9 of 10 patients with concomitant rectal prolapse (Schweiger and Alexander-Williams, 1977), after posterior rectopexy with Marlex mesh in 5 of 6 patients with rectal prolapse (Keighley and Shouler, 1984), and after Wells’ posterior rec- topexy in 17 of 17 patients with concomitant internal rec- tal intussusception. Other reports have not found the same excellent results. Marchal and colleagues (2001) reviewed 13 patients operated on for SRUS with a mean FU of 57 months. The authors operated with various techniques and they found a high failure rate after surgery. They there- f o r e r e c ommend surgical therapy only in patients with total rectal prolapse or intractable symptoms. Editor’s Note: A complete 110-item bibliography is available at <mellgren@umn.edu>. Supplemental Reading Agachan F, Reissman P, Pfeifer J, et al. Comparison of three perineal procedures for the treatment of rectal prolapse. South Med J 1997;90:925–32. Aitola PT, Hiltunen KM, Matikainen MJ. Functional results of operative treatment of rectal prolapse over an 11-year period: emphasis on transabd o minal ap proach. Dis Colon Rectum 1999;42:655–60. Rectal Prolapse, Rectal Intussusception, and Solitary Rectal Ulcer Syndrome / 523 524 / Advanced Therapy in Gastroenterology and Liver Disease P lusa SM, Charig JA, Balaji V, Watts A. Physiological changes after Delorme’s procedure for full-thickness rectal prolapse. Br J Surg 1995;82:1475–8. Porter NH. A physiological study of the pelvic floor in rectal p rolapse. Ann R Coll Surg Engl 1962;31:379–404. R ipstein CB. Surgical care of massive rectal prolapse. Dis Colon Rectum 1965;8:34–8. Roberts PL, Schoetz DJ, Coller JA, Veidenheimer MC. Ripstein procedure. Lahey Clinic experience: 1963–1985. Arch Surg 1 988;123:554–7. Rutter KRP, Riddell RH. The solitary ulcer syndrome of the rectum. Clin Gastroenterol 1975;4:505–30. Schlinkert RT, Beart RW, Wolf BG, Pemberton JH. Anterior resection for complete rectal prolapse. Dis Colon Rectum 1985;28:409–12. Schultz I, Mellgren A, Johansson C, et al. Continence is improved after the Ripstein rectopexy.Different mechanisms in patients with rectal prolapse and rectal intussusception? Dis Colon Rectum 1996;39:300–5. Sc hultz I, Mellgren A, Nilsson BY, et al. Preoperative electrophysiologic assessment cannot predict continence after rectopexy. Dis Colon Rectum 1998;41:1392–8. Schweiger M, Alexander-Williams J. Solitary ulcer of the rectum. Its association with occult rectal prolapse. Lancet 1977;1:170–1. Senapati A, Nicholls RJ, Thomson JPS, Phillips RKS. Results of Delorme’s procedure for rectal prolapse. Dis Colon Rectum 1994;37:456–60. Shorvon PJ, McHugh S, Diamant NE, et al. Defecography in normal volunteers: results and implications. Gut 1989;30:1737–49. S olomon MJ, Eyers AA. Laparoscopic rectopexy using mesh fixation with a spiked chromium staple. Dis Colon Rectum 1996;39:279–84. Tjandra JJ, Fazio VW, Church JM, et al. Ripstein procedure is an e ffective treatment for rectal prolapse without constipation. D is Colon Rectum 1993;36:501–7. Tsunoda A, Yasuda N, Yokoyama N, et al. Delorme’s procedure for rectal prolapse: clinical and physiological analysis. Dis Colon Rectum 2003;46:1260–5. U hlig BE, Sullivan ES. The modified Delorme operation: its place in surgical treatment for massive rectal prolapse. Dis Colon Rectum 1979;22:513–21. Vaizey CJ, Roy AJ, Kamm MA. Prospective evaluation of the treatment of solitary rectal ulcer syndrome with biofeedback. Gut 1997;41:817–20. Vaizey CJ, van den Bogaerde JB, Emmanuel AV, et al. Solitary rectal ulcer syndrome. Br J Surg 1998;85:1617–23. Watkins BP, Landercasper J, Belzer GE, et al. Long-term follow- up of the modified Delorme procedure for rectal prolapse.Arch S urg 2003;138:498–502; discussion 502–3. Wells C. New operation for rectal prolapse. Proc R Soc Med 1959;52:602–3. Williams JG, Rothenberger DA, Madoff RD, Goldberg SM. Treatment of rectal prolapse in the elderly by perineal rectosigmoidectomy. Dis Colon Rectum 1992;35:830–4. Winde G, Reers B, Nottberg H, et al. Clinical and functional results of abdominal rectopexy with absorbable mesh-graft for treatment of complete rectal prolapse. Eur J Surg 1993;159:301–5. Zittel TT, Manncke K, Haug S, et al. Functional results after laparoscopic rectopexy for rectal prolapse. J Gastrointest Surg 2000;4:632–41. 525 CHAPTER 90 ILEOANAL POUCH:FREQUENT EVACUATION L.J. EGAN,MD,AND S.F. PHILLIPS,MD of the history is to determine precisely what it is about pouch function that is unsatisfactory to the patient. A typical com- plaint might be of having to “go all the time.” The physician must then determine exactly what the patient means. Is the patient having true watery diarrhea, or is the main complaint urgency or leakage? Is an inability to completely empty the pouch with consequent leakage of retained stool the real prob- lem? Careful evaluation of the patient’s complaints, in con- junction with knowledge of the likely causes of symptoms, should point to the correct diagnosis. In practice, it is advan- tageous to divide the clinical picture into those patients who are distressed soon after surgery from those who present later. Excessive or Uncontrolled Bowel Movements with Newly Formed Pouches General Approach Problems occurring soon after the operation (0 to 6 months) present more often to surgeons, but gastroenterologists need also to be aware of these issues (Table 90-1). It is helpful to Proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the most popular surgical option when colonic resection is necessary for the treatment of ulcerative colitis (UC) and familial adenomatous polyposis. However,after IPAA, patients will always defecate more frequently than do healthy people. Thus, after proctocolectomy, whether surgical continuity is restored with a terminal ileostomy or with a pouch, daily fecal volumes will be 500 to 700 mL (Metcalf and Phillips, 1986). In health, fecal volumes do not often exceed 200 mL. Moreover, the reservoir of an ileoanal pouch is smaller than that of a normal rectum. IPAA patients complaining of fre- quent bowel movements must recognize their symptoms in this context; they will never have only one or two solid stools daily! Although patients who complain of frequent defecation after IPAA may have no identifiable pathology, they can, nev- ertheless, be helped to accept a new lifestyle by being taught to understand the postoperative physiology (Dean and Dozois, 1997; Levitt and Kuan,1998).Moreover,simple antidiarrheal therapy may significantly improve their lifestyle. The majority of patients with normally functioning IPAAs should evacuate between four and eight times per day, and once or twice at night. After the initial postoperative phase, IPAA patients should not have extreme fecal urgency and should be able to distinguish between the urges of fla- tus and feces. Approximately 10 to 20% of IPAA patients experience minor leakage of stool, especially at night, when they may need to wear a pad (Meagher et al, 1998). However, they should be continent during the day. Passage of stools should be painless, should not be accompanied by the need to strain, and should feel complete. In taking the history, the features of “diarrhea”need to be defined precisely; increased fecal frequency needs to be distinguished from urgency,fecal leakage, or gross incontinence. Importance of an Adequate History The key to helping IPAA patients who complain of exces- sive bowel movements is to make an accurate diagnosis. Disorders of the pouch outlet (the anal sphincter segment), the pouch itself, or of the ileum proximal to the pouch may be the cause of an increased stool frequency. In many patients, a careful history will provide the astute clinician with a short list of diagnostic possibilities. The most important element TABLE 90-1. Approach to Patients After Ileal Pouch- Anal Anastomosis With Excessive Bowel Movements in the First 6 Months of Pouch Reanastomosis Diagnostic Cause Approaches Treatment Unr ealistic Exclude pathology by Education and expectations physical examination; reassurance ± Endoscopy, Fiber supplements, ± Pouchogram antidiarrheals Anastomotic leak Endoscopy Intestinal diversion, abscess Pouchogram drainage Pouch revision (late decisions) Defective sphincter Physical Antidiarrheals, fiber function and anal examination supplements incontinence Anal manometr y Biofeedback Anastomotic Physical examination Dilatation strictur e Endoscopy Pouchitis Pouchoscopy and biopsy Antibiotics Cuffitis Pouchoscopy and biopsy Mesalamine, steroids [...]... abolishing the underlying patho- 538 / Advanced Therapy in Gastroenterology and Liver Disease physiologic mechanism of advanced hemorrhoidal disease By promoting tissue fibrosis in various ways, the vascular cushions become fixed to the underlying muscular tissue Injection Sclerotherapy Injection sclerotherapy has been used for hemorrhoidal disease treatment for over 100 years Indicated to treat bleeding... Advanced Therapy in Gastroenterology and Liver Disease able to avoid more extensive surgery There are two chapters on perianal disease in CD (see Chapter 82, “Perianal Disease in Inflammatory Bowel Disease and Chapter 83, “Dysplasia Surveillance Program”) Anal Neoplasm Evaluation including digital rectal examination, colonoscopy, endorectal ultrasound, computed tomography, and examination of inguinal... should probably begin in the late teens or early 20s ‡Risk estimates are for all gastrointestinal malignancies, including colon 554 / Advanced Therapy in Gastroenterology and Liver Disease tomas have also been found in the large intestine of PJS patients Polyps are most frequent in the SB, but can develop anywhere in the GI tract as follows: (1) SB, 96%; (2) colon, 27% ; (3) stomach, 24%; and (4) rectum,... mucosa and submucosa excised with the PPH stapler (C) 540 / Advanced Therapy in Gastroenterology and Liver Disease uted to hemorrhoids alone without proper investigations, especially if symptoms persist following therapy Most early lesions may be treated in the office setting Advances in stapling devices offer less painful means of surgical management for advanced hemorrhoidal disease Supplemental Reading... apply increasing downward pressure during defecation Fiber supplements have been suggested to reduce bleeding and pain during defecation, however, the data are inconsistent Prescription and nonprescription topical agents are plentiful and include creams, suppositories, and ointments These products may contain astringents, analgesics, and steroidal and nonsteroidal elements that function as anti -in ammatory,... performed in the operating room under adequate anesthesia A cruciate incision is made and the edges of the skin are excised to allow adequate drainage A horseshoe abscess is drained through an incision made between the coccyx and the anus, exposing the deep postanal space An opening made in the posterior midline and the lower part of the internal sphincter is divided to eradicate the source of the infected... no specific screening recommendations exist for GI cancers, surveillance for extra-intestinal malignancies is recommended and summarized in Tables 9 5-1 and 9 5-2 In our institution, we generally perform an initial colonoscopy and continue surveillance depending on the number of polyps Hyperplastic Polyposis Although hyperplastic polyps are a common finding, especially in the distal colon and rectum, hyperplastic... screening (see Chapter 93, “Colorectal Polyp and Cancer Screening”) and another on genetic counseling (see Chapter 94, “Colonic Neoplasia: Genetic Counseling”) 5 57 558 / Advanced Therapy in Gastroenterology and Liver Disease levels at presentation, when the disease is clinically localized, often will develop CEA elevation with recurrence Liver function tests can also be useful as a preoperative indicator... further investigation should be delayed until after the initial postoperative period Treatment is surgical, and may require intestinal diversion, drainage of an abscess if present, and possibly revision of the pouch Defective Sphincteric Continence Innervation of the internal anal sphincter may be disrupted during the perineal dissection and construction of the pouch-anus anastomosis Consequently, resting... syndrome defined by clinical, endoscopic and histologic criteria that occurs in UC-IPAA patients (Mahadevan and Sandborn, 2003), and seldom, if ever, affects familial adenomatous polyposisIPAA patients Patients complain of fecal frequency, and the motions are commonly loose and watery and may contain mucous and blood Urgency and leakage, especially at night, are common In addition, depending on the . / Advanced Therapy in Gastroenterology and Liver Disease the edge of the lesion and in all four quadrants of the per- ineum. Biopsies are taken at the dentate line, anal verge, and the perineum hemorrhoids. Contributing factors include chronic straining, aging, increased intra-abdominal pressure, and absence of sinu- soidal valves. Elevated anal resting pressures and ultraslow waves are. as initial treat- ment (Vaizey et al, 19 97) . Retraining of bowel habits, decrease of straining efforts, and a high fiber diet, is gen- erally recommended. Biofeedback-training might be help- ful,