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SURGICAL THERAPY
When the previous management options are unsuccessful, surgery
should be considered. These patients have a high morbidity and
mortality rate with mortality in the range of 30% to 60%. Surgery
may include the placement of a cecostomy tube or subtotal colectomy
and stoma formation. High mortality rates are associated with those
patients with ischemic disease or perforation.
SUMMARY
ACPO presents with signs and symptoms of mechanical colonic
obstruction without evidence of structural lesions. It is a motility
disorder that occurs primarily in hospitalized patients with comorbid
medical illness or recent surgery or trauma. Diagnosis is made by
performance of cross-sectional imaging. There is a high rate of complications from ischemia and perforation. Close monitoring should be
done with serial imaging, bowel rest, intravenous fluids, and frequent
imaging studies. If colonic distention persists or progresses, pharmacologic treatment with neostigmine should be considered followed
by endoscopic colonic decompression with guided intraluminal tube
placement. Further treatment may necessitate percutaneous cecostomy by experienced experts followed by either laparoscopic or open
surgery. Surgery for refractory ACPO carries a high mortality rate.
S u g g e S t e d R e a d i n g S
De Giorgio R, Knowles CH. Acute colonic pseudo-obstruction. Br J Surg.
2009;96:229–239.
Frankel A, Gillespie C, Lu C-T, etal. Subcutaneous neostigmine appears safe
and effective for acute colonic pseudo-obstruction (Ogilvie’s syndrome).
ANZ J Surg. 2019;89:700–705.
Naveed M, Jamil LH, Fujii LL, et al. American society for Gastrointestinal
Endoscopy guideline on the role of endoscopy in the management of
acute colonic pseudo-obstruction and colonic volvulus. Gastrointest
Endosc. 2020;91:228–234.
Rex DK. Colonoscopy and acute colonic pseudo-obstruction. Gastrointest
Endosc Clin N Am. 1997;7:499–508.
Vanek VW, Al-Salti M. Acute pseudo-obstruction of the colon (Ogilvie’s
syndrome): an analysis of 400 cases. Dis Colon Rectum. 1986;29:203–210.
Vogel JD, Feingold DL, Stewart DB, et al. Clinical practice guidelines
for colonic volvulus and acute colonic pseudo-obstruction. Dis Colon
Rectum. 2016;59:589–600.
Management of
ColonicVolvulus
Jose G. Guillem, MD, and Jonathan M. Stem, MD
INTRODUCTION
Colonic volvulus, or a twisting of the colon on its tethered mesenteric axis, is a rare condition that accounts for less than 5% of bowel
obstructions in the United States. In other regions of the world,
colonic volvulus is more prevalent, accounting for up to 50% of intestinal obstructions. It most commonly occurs in the sigmoid colon,
followed by the cecum. The transverse colon and splenic flexure are
additional rare sites of occurrence.
SIGMOID VOLVULUS
Sigmoid volvulus is the most common form of colonic volvulus
accounting for 50% to 90% of all cases. It is associated with significant morbidity and mortality, with mortality rates approaching 10%.
There is a 2:1 male predominance as well as an association with
increasing age. Patients typically present in the seventh decade of
life or beyond. In addition to advancing age, many factors including
diet, race, diabetes, pregnancy, and constipation/dysmotility increase
one’s risk for sigmoid volvulus. Institutionalized patients as well as
those with psychiatric and neurologic disorders are at a greater risk
secondary to gastrointestinal dysmotility resulting from behavioral
and pharmacologic factors.
Presentation is analogous to that of any large bowel obstruction:
obstipation, abdominal distention, pain, and cramping. Early in
the patient’s course, there is often a lack of systemic manifestations.
Tachycardia, hypotension, and oliguria occur with progressive disease. In more advanced cases, characterized by ischemia and perforation, patients may present with peritonitis and sepsis. Diagnosis
relies upon radiographic findings such as a “bent inner tube” or
“omega loop,” which are noted on plain films in 60% to 75% of patients
(Fig. 1). If plain films are nondiagnostic, computed tomography (CT)
will provide additional diagnostic information by demonstrating a
mesenteric whirl and paucity of rectal gas (see Fig. 1). CT provides a
near 100% accuracy in the diagnosis of sigmoid volvulus.
Once the diagnosis of sigmoid volvulus has been made, initial
treatment may be operative or nonoperative depending upon the
stability and examination of the patient. Initial management strategies aim to relieve the large bowel obstruction with either reduction
of the volvulus or resection of the affected colon. Further definitive
treatment is directed at the prevention of recurrence.
The initial decision point in the management of the patient with
sigmoid volvulus is dictated by hemodynamic stability and physical
findings. Patients who are stable, with no evidence of colonic ischemia,
including fever or peritonitis, should proceed with an attempt at endoscopic detorsion. This can be accomplished by the use of a rigid proctoscope or a flexible endoscope. Rigid proctoscopy should be performed
only in the setting of a lack of access to standard flexible endoscopy,
as it carries a higher risk of perforation and does not afford the ability
to visually inspect colonic mucosa. Upon insertion of the endoscope,
a classic “pinwheel” appearance is noted at the point of torsion of the
colonic mucosa (Fig. 2). With gentle pressure and insufflation, the
scope should be passed through the torsed segment. The remaining
colon should be endoscopically decompressed, ultimately allowing for
detorsion of the colon. Rates of successful endoscopic detorsion are
variable, ranging from 55% to 94%. After detorsion, we prefer to leave a
soft red-rubber catheter in the colon to allow for continued decompression and prevention of a short-term recurrence of the volvulus.
After successful detorsion of the sigmoid volvulus, the focus
moves to prevention of recurrence, which can occur in up to 85% to
90% of cases. Measures aimed to prevent recurrence of sigmoid volvuli historically consisted of two main strategies: colonic fixation and
resection. There have been numerous methods of colonic fixation
described; however, these are typically not recommended as many
carry a significant risk of recurrence. In spite of this, there may be a
role for their use in highly selected cases.
The current gold standard approach for the prevention of recurrent sigmoid volvulus is sigmoid colon resection with primary
anastomosis. Because morality rates are as high as one in three with
recurrent volvulus, it is recommended that elective resection be
230 MANAGEMENT OF COLONICVOLVULUS
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BA
FIG. 1 (A) Plain film abdominal radiograph demonstrating the classic “bent inner tube” sign of sigmoid volvulus directed towards the right upper quadrant.
(B) Coronal CT image displaying a mesenteric whirl characteristic of sigmoid volvulus. (From Federle M, Lau, J. Sigmoid Volvulus. In: Imaging in Abdominal
Surgery. Elsevier; 2018, 282.)
FIG. 2 Classic pinwheel appearance of colonic mucosa visualized during
endoscopic decompression of sigmoid volvulus. (From Tang S-J, Wu R.
Endoscopic decompression, detorsion, and reduction of sigmoid volvulus. Video J
Encyclopedia GI Endos. 2014;2:22.)
performed during the index hospitalization. Both open and minimally
invasive laparoscopic or robotic techniques are acceptable. When
performing an open resection, a lower midline laparotomy or Pfannenstiel incision will typically suffice. Resection with end colostomy
and Hartmann’s pouch, as well as primary anastomosis with diverting
loop ileostomy, are additional acceptable options that may be used
when severe colonic edema is encountered. In all cases of sigmoid
resection, a nononcologic resection is performed, ligating the sigmoid
mesentery close to the bowel. Recurrence after sigmoidectomy for volvulus is extremely rare. One specific setting in which recurrence rates
remain high after sigmoidectomy, however, is in patients presenting
with megacolon. Recurrence rates after sigmoidectomy in megacolon
are greater than 80%. In this circumstance, consideration may be given
to subtotal colectomy. One caveat is that the patient’s ability to tolerate
such an operation must be thoroughly considered.
In contrast to clinically stable patients, those presenting with signs
of ischemia, perforation, sepsis, or evidence of shock should proceed
with emergent surgical intervention as should those that fail attempted
endoscopic detorsion. After initial resuscitation and administration
of broad-spectrum antibiotics, a midline laparotomy should be performed with resection of the ischemic or perforated segment of bowel.
Compromised bowel should not undergo detorsion before resection.
In the setting of perforation, copious irrigation of the abdomen with
saline is performed. After resection of the specimen, two options may
be considered at the time of initial operation: primary anastomosis
versus end colostomy with a Hartmann’s pouch. The decision to
restore gastrointestinal continuity is dependent upon intraoperative
findings and patient-specific factors. Proximal bowel dilatation, fecal
contamination, and the presence of ongoing hemodynamic abnormalities must be weighed when deciding upon restoration of continuity.
Additional patient factors such as nutritional, functional, and frailty
status must be taken into account. Surgical resection in the emergent
setting is associated with higher rates of mortality. This should be
addressed with patients and family at the time of initial presentation.
CECAL VOLVULUS
The second most frequent type of colonic volvulus is the cecal volvulus, which accounts for 10% to 40% of colonic volvulus cases. In
general there are two types of volvuli that can occur in the cecum.
The most common is characterized by an axial twisting of the cecum
and accounts for up to 90% of cases. In this type, the cecum rotates
around its long axis forming a clockwise twist, leaving the cecum in
the right lower quadrant. The less common type is not a true volvulus but rather a folding of the cecum upon itself directed toward the
hepatic flexure, known as a bascule. Overall this accounts for only
10% of reported cases.
Although a mobile cecum predisposes one to volvulus, factors
and conditions often noted in patients presenting with cecal volvulus include chronic constipation, psychiatric illness, high fiber
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FIG. 3 (A) Plain film abdominal radiograph demonstrating the classic “coffee bean” sign of cecal volvulus, with the axis directed toward the left upper
quadrant. (B) Coronal CT image revealing distended, upside-down, backward cecum with the ileocecal valve pointed lateral. (From Federle M, Lau J. Cecal
Volvulus. In: Imaging in Abdominal Surger y. Elsevier; 2018, 283.)
231
diet, chronic laxative use, pregnancy, and prior abdominal surgeries.
Cecal volvulus has a slight female predominance of 1.4:1.
The presentation of cecal volvulus is variable and nonspecific.
Patients may present in a chronic or acute manner. Symptoms may be
mild and intermittent including dull, crampy abdominal pain and constipation. Other common signs and symptoms are obstipation, severe
pain, and nausea/vomiting. Radiographic workup is essential in all suspected volvulus patients. In very few cases, plain film abdominal x-rays
will be diagnostic. Plain film radiographs diagnostic of cecal volvulus
will reveal a large, dilated loop of colon with a classic “coffee bean” sign
pointing to the left upper quadrant (Fig. 3). Most often there will be an
associated paucity of rectal gas. CT scan provides the added benefit of
assessing bowel for ischemia or signs of impending ischemia. Intestinal
thickening, hypoenhancement of the bowel wall, pneumatosis, and
abdominal free fluid should prompt more urgent operative intervention.
Similar to sigmoid volvulus, patients presenting with signs of cecal
ischemia, perforation, or shock should immediately undergo aggressive fluid resuscitation, administration of broad-spectrum antibiotics,
and proceed to the operating room for emergent intervention. Surgical
intervention in the emergent setting consists of an ileocolic resection
or right hemicolectomy, ensuring resection of the compromised segment. Primary anastomosis at the time of the initial operation will be
dependent on many patient-specific factors including hemodynamics,
comorbidities, fecal contamination, and local inflammatory changes.
For patients who present without signs of acute shock or perforation,
surgical intervention, although not emergent, remains urgent in nature.
Unlike sigmoid volvulus, endoscopic reduction is not recommend
because attempts are unlikely to be successful (approximately 30%
success rate) and may lead to perforation. Initial operative management
consists of assessment of bowel viability. This should be done via laparotomy. Minimally invasive techniques are hindered by the gross distension of the cecum and proximal small bowel. Upon laparotomy and
inspection of the abdomen, necrosis of the cecum is a common finding
necessitating resection with consideration of primary anastomosis. If no
necrosis is detected, a right hemicolectomy or ileocolic resection with a
side-to-side stapled anastomosis is typically performed.
In the absence of necrosis, nonresection techniques such as
detorsion with or without cecostomy and cecopexy have been
described in the literature. These techniques are not recommended, however, due to their high recurrence rates as well as high
morbidity and mortality. Both cecostomy and cecopexy are reserved
for patients who are poor resection candidates due to their underlying comorbid conditions or physiologic status. It is important to
assess the quality of the bowel wall when considering these strategies. The fragile or edematous tissue typically associated with cecal
volvulus is a poor candidate for holding suture. This can ultimately
lead to complications such as leak and failure of apposition to the
abdominal wall or retroperitoneum.
Rare Types of Volvulus
Sigmoid and cecal volvuli account for the majority of colonic volvulus
with other types of volvuli occurring in rare instances. Transverse colon
and splenic flexure volvuli account for 2% to 5% of all colonic volvulus cases. Typically, these occur in a younger patient population with
an increased incidence in women. Similar to other forms of volvulus,
predisposition to transverse colon and splenic flexure volvuli is due to
conditions that elongate the colon and its mesentery. These include high
fiber diet, chronic constipation, and colonic obstruction. Additionally,
the loss of the traditional attachments of the colon due to abdominal
surgery is associated with increased rates of splenic flexure volvulus.
Patients will present in a similar manner to other types of volvulus, with either acute symptoms of large bowel obstruction or more
chronic and intermittent symptoms. Diagnosis is rarely made by
using plain films alone. Splenic flexure volvulus is characterized by
a “coffee bean” sign in the left upper quadrant on abdominal x-ray.
Conversely, volvulus of the transverse colon can be characterized
by an “inverted coffee bean” sign. Additionally, two distended loops
of colon and a paucity of rectal gas may be visualized. CT imaging
provides improved diagnostic capability and will reveal a mesenteric
whirl. Oftentimes, laparotomy is required to determine the location
of the whirl and volvulus. Due to the rarity of the condition, diagnosis is delayed in many instances, leading to high mortality rates.
Treatment of these rare types of volvulus is similar to that of
cecal volvulus. Endoscopic decompression should not be attempted
because recurrence rates are high. The initial step in treatment is
laparotomy with assessment of bowel viability. Noncompromised
bowel may be detorsed before resection. The extent of the resection
depends upon the location of the volvulus. Options for resection
consist of extended right hemicolectomy or a segmental resection.
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Determination of primary anastomosis versus end colostomy will
depend upon patient-specific factors and operative findings.
One other form of volvulus is ileosigmoid knotting, which is
exceedingly rare in Western society. This occurs when a loop of
ileum becomes entangled with the sigmoid colon leading to obstruction. There are three major types of ileosigmoid knotting. Type 1,
accounting for approximately 50% to 60% of cases, occurs when a
portion of ileum encircles the sigmoid colon. Type 2 accounts for
approximately 20% of cases and is characterized by wrapping of the
sigmoid colon around a loop of ileum. In both type 1 and type 2,
wrapping can occur in a clockwise or counterclockwise fashion. Type
3, a rare entity, consists of the ileocecal segment wrapping around the
sigmoid colon. The remaining cases are of indeterminate anatomy.
Most commonly, ileosigmoid knotting occurs in males (approximately 80%) in the late third or fourth decade of life. The true
incidence is unknown, and the majority of case reports are from
Asia, Africa, and the Middle East. Clinical presentation consists of
abdominal pain and tenderness with associated symptoms of small
bowel obstruction such as distention, nausea, and emesis.
Diagnosis can be challenging as radiographic imaging will reveal
dilated loops of small bowel accompanied by a distended sigmoid
loop. Abdominal plain films alone are rarely diagnostic. In addition
to bowel dilatation, CT imaging will reveal whirling of the ileal and
sigmoid mesentery with associated medial deviation of the cecum and
left colon. Ileosigmoid knotting may be confused for sigmoid volvulus
on imaging prompting attempted endoscopic decompression. In these
cases, endoscopic decompression will fail due to the wrapping of the
mesentery, further raising the suspicion for ileosigmoid knotting.
After initial resuscitation, emergent laparotomy is indicated
because clinical deterioration is often rapid due to the quick progression of knotted bowel segments to ischemia. In fact, upon operative
exploration, gangrenous bowel is discovered in more than 70% of
cases. Operative management will vary depending on the nature of the
ileosigmoid knot as well as the stability and condition of the patient. As
the majority of cases present with gangrene, resection is typically performed. In many cases, multiple resections are necessary. In the event
that a viable sigmoid colon is encountered, resection is recommended
to prevent further recurrence. The decision to perform primary anastomosis versus enteric diversion will depend upon many factors.
SUMMARY
Colonic volvulus is a rare entity in the United States, accounting for
<5% of all intestinal obstructions. In spite of this, a high index of
suspicion must be present as prompt surgical evaluation is a necessity.
Clinical presentation is quite variable, ranging from chronic mild
symptomatology to acute obstruction and shock. Only in the case
of sigmoid volvulus is initial endoscopic decompression appropriate.
Definitive treatment consists of operative intervention. Although
techniques without resection are described in rare specific circumstances, colonic resection is considered the gold standard to alleviate
obstruction and prevent future recurrence. Operative decision making
regarding performance of primary anastomosis must be decided on an
individualized basis and is impacted by many patient-specific factors
as well as surgeon experience and comfort.
S u g g e S t e d R e a d i n g S
Bruzzi M, Lefèvre JH, Desaint B, etal. Management of acute sigmoid volvu-
lus: short- and long-term results. Colorectal Dis. 2015;17(10):922–928.
Halabi WJ, Jafari MD, Kang CY, et al. Colonic volvulus in the United
States: trends, outcomes, and predictors of mortality. Ann Surg.
2014;259(2):293–301.
Kasten KR, Marcello PW, Roberts PL, etal. What are the results of colonic
volvulus surgery?. Dis Colon Rectum. 2015;58(5):502–507.
Naveed M, Jamil LH, Fujii-Lau LL, etal. American Society for Gastrointestinal
Endoscopy guideline on the role of endoscopy in the management of
acute colonic pseudo-obstruction and colonic volvulus. Gastrointest
Endosc. 2020;91(2):228–235.
Vogel JD, Feingold DL, Stewart DB, et al. Clinical Practice Guidelines for
Colon Volvulus and Acute Colonic Pseudo-Obstruction. Dis Colon
Rectum. 2016;59(7):589–600.
Management of
RectalProlapse
Shannon N. Radomski, MD, and Alodia Gabre-Kidan, MD,
MPH
ETIOLOGY
Rectal prolapse is defined as a prolapse of either the full or partial thickness rectal wall through the anus beyond the anal verge. Prolapse that
does not go beyond the anal verge—internal prolapse or intussusception—is managed differently and will not be discussed in this chapter.
Rectal prolapse is far more common in women than in men and
has a peak incidence in the sixth or seventh decade of life. In these
patients, rectal prolapse can coincide with prolapse or dysfunction of
other pelvic floor organs indicating an underlying etiology of pelvic
floor weakness, which in women is often from multiparity. However,
rectal prolapse can also occur in men and nulliparous women suggesting a different etiology related to constipation and/or straining
due to disordered defecation.
Although rectal prolapse relies on surgical correction as the
mainstay of treatment, it is important to recognize that the causative
factors for each patient may differ, and adjunctive treatments such
as pelvic floor physical therapy, consultation with urogynecologists,
and bowel modifications should be employed to optimize the success
of any surgical repair.
PRESENTATION
Patients with rectal prolapse can present with a number of different
symptoms. Most commonly patients describe prolapse of tissue that
spontaneously reduces or has to be manually reduced, rectal pressure
or discomfort, bleeding, mucus drainage, constipation or inability to
fully evacuate, fecal urgency, or fecal incontinence. Prolapse can be
a significant source of stress for patients, and many describe limiting their activities to be near a bathroom or planning their days to
accommodate for bowel habits.
Constipation can be both a cause of the rectal prolapse and a
result of it. Disordered defecation/pelvic floor dyssynergia leads
to increased straining, which can result in a prolapse, especially in
patients who do not have risk factors for pelvic floor weakness. Once
the prolapse becomes recurrent, it can act as a mechanical obstruction making evacuation even more difficult and lead to an increase
in the behaviors (straining, increased toilet time) that will worsen
the prolapse. This is a point of debate as many feel that it is not the
mechanical obstruction of the prolapse but the ongoing, unaddressed
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pelvic floor issues that worsen the prolapse. With chronic prolapse,
fecal incontinence can also occur from the rectal prolapse stenting
open the sphincter complex and allowing feces to leak. Over time,
however, chronic stretch of the sphincter complex by the prolapsed
segment of rectum can lead to irreversible impairment in continence.
It is important to discuss this with patients before repair in order to
appropriately set expectations. Surgical repair of the prolapse will
address the mechanical issue but may not result in a return to their
functional baseline.
EVALUATION
Any patients presenting with rectal prolapse should have a thorough
pelvic floor history and physical examination. It is important to
obtain a detailed history including onset of symptoms, bowel habits,
prior obstetrical history, prior anorectal surgery, associated pelvic
organ symptoms (urinary incontinence, frequency, prolapse, rectocele, etc.), and colonoscopy history. Physical examination for rectal
prolapse can occur in the left lateral or prone jack-knife position.
External visual examination can yield important information such as
presence of fecal smearing, mucus drainage, skin irritation or breakdown from moisture, a patulous anus, and presence of any prolapsed
tissue at rest. The patient is then asked to bear down. If the prolapse
cannot be elicited with Valsalva in the left lateral or prone jack-knife
positions, the patients should be asked to Valsalva in a seated position
on the commode. If the prolapse still cannot be elicited, photographs
of the prolapse as it occurs at home can be helpful and/or further
testing such as defecography can be pursued. Hemorrhoidal prolapse
is far more common than true rectal prolapse and patients often cannot distinguish between the two; thus it is important for the surgeon
to visualize the prolapsed tissue themselves. Full thickness rectal
prolapse appears as concentric rings/circles as the rectum telescopes
out of the anus while hemorrhoidal prolapse creates radial lines from
the center of the anus as the hemorrhoidal columns prolapse out.
Partial thickness, or mucosal, prolapse can also occur and appears
as a shorter segment of prolapsed rectum lacking the radial lines of
hemorrhoidal prolapse. The treatment of mucosal prolapse differs
from full thickness prolapse, thus distinguishing between the two is
important to guide future interventions. It is also important to document anal sphincter tone during the examination as well as presence
or absence of any associated vaginal prolapse. For patients with
multicompartmental prolapse, a combined approach with a urogynecologist is favored to address all potential issues during one surgery
as opposed to requiring the patient to undergo multiple surgeries.
MANAGEMENT/SURGICAL APPROACH
When considering repair of a rectal prolapse, there are several decision points that can aid in the ultimate choice of approach. First and
foremost, acutely incarcerated prolapse must be recognized because
this constitutes a surgical emergency. Similar to an incarcerated
hernia, the prolapsed bowel can become ischemic if not reduced
in a timely fashion. Temporizing measures such as applying sugar
to the mucosa of the prolapsed segment of rectum can be used in
cases where the bowel is edematous but not ischemic. If the bowel
still will not reduce after application of sugar, then urgent surgical
repair must be considered. In the setting of acute incarceration that
cannot be reduced, a perineal rectosigmoidectomy is most prudent
as it ensures that all compromised rectum is excised. Abdominal
approaches can be used if ischemia is not present and the rectum
reduces with induction of anesthesia and relaxation of the sphincter
complex. Fortunately, acute incarceration is relatively rare owing to
the stretch of the sphincter over time. As the sphincter is stretched
by chronic prolapse, the likelihood that it will be constricting and not
allow the rectum to be reduced is lowered.
Putting emergent indications aside, the majority of rectal prolapse
repairs will occur in the elective setting. The approach to repair
will need to take the degree of prolapse (full thickness vs. partial
thickness), patient factors (comorbidities, prior surgery), and associated pelvic floor pathology into account. There are six widely used
approaches to prolapse outlined in Figure 1, not taking into account
the choice of open, laparoscopic, or robotic approaches to abdominal
procedures. Thiersch wire procedures will not be discussed as they
are largely of historical interest with high rates of complications.
PARTIAL THICKNESS PROLAPSE
Mucosal Sleeve Resection
The first decision point is whether the patient is experiencing
a partial or full thickness prolapse. Partial thickness prolapse is
repaired with a perineal approach using a Delorme procedure.
This is a mucosal sleeve resection, which excises the redundant
mucosa and sutures it back to the anal transition zone just proximal to the dentate line (Fig. 2). Of note, this procedure can also
be used in short segment (<5 cm) full thickness prolapse. After
the patient is positioned, the rectum is retracted out to reproduce
the maximum amount of prolapse. A solution of saline mixed with
epinephrine is injected into the submucosal layer both to lift it off
of the underlying muscular layers but also to aid with hemostasis.
A circular incision is created just proximal to the dentate line with
electrocautery and carried down to this submucosal layer. In a
patient with full thickness prolapse, plicating sutures would then
be placed through the muscularis to accordion the rectum back to
the anal canal. These are typically placed in four quadrants to offset
the sutures to account for the mesorectum. The redundant mucosa
is then amputated, and the remaining mucosa is sutured back to the
proximal resection point.
FULL THICKNESS PROLAPSE
The options for repair of full thickness prolapse are separated into
abdominal or perineal approaches (see Fig. 1). Traditionally we
recommend a perineal approach to elderly or frail individuals as
it avoids the physiologic stress associated with a major abdominal
surgery and, in patients who are unfit for general anesthesia, can be
done under regional anesthesia. In fact, Altemeier was not the first
person to describe this technique, but his paper in 1952 described
his experience using this approach in elderly, high-risk patients
and was the beginning of the association of age and comorbidities
with a perineal approach. However, this dogma is challenged by the
evolution of better anesthetic techniques and the use of minimally
invasive surgical techniques with relatively low rates of complications
and faster recovery. Still, however, for some patients with full thickness prolapse who may be unacceptably high risk for an abdominal
approach or have had multiple prior abdominal surgeries, a perineal
approach is a good option.
Perineal Rectosigmoidectomy
Unlike a Delorme procedure, a perineal rectosigmoidectomy, or
Altemeier procedure, is a full thickness resection and coloanal
anastomosis. Once the patient is in position, the rectum is again
prolapsed out to its maximum amount and a full thickness incision is
made through the rectal wall about 1 to 2 cm proximal to the dentate
line. This is carried around circumferentially and the pelvis is typically entered anteriorly between the rectum and vagina/prostate by
dividing the peritoneal attachments to enter the pouch of Douglas.
The lateral ligaments are similarly divided using an energy device to
ensure hemostasis. The rectum and sigmoid colon are then prolapsed
out by taking posterior attachments and vessels of the mesorectum
and mesocolon until the colon cannot be prolapsed any further. The
full thickness colon wall is then divided making sure to take the
mesocolon at this level so as to not devascularize the segment that
will become part of the anastomosis. It is important to place anchoring, full thickness sutures through the colon wall as it is circumferentially divided as it can retract back into the abdomen without
234 MANAGEMENT OF RECTALPROLAPSE
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Abdominal
Approaches
Suture
Rectopexy
Mucosal Sleeve
Resection
Rectopexy
Ventral Mesh
Rectopexy
Perineal
Approaches
Perineal
Rectosigmoidectomy
FIG. 1 Approaches to rectal prolapse.
Resection
Rectopexy
+/-
Sacrocolpopexy
Perineal
Rectosigmoidectomy
+ Levatoroplasty
FIG. 2 Mucosal sleeve resection. (A) Injection of saline mixed with epinephrine to life submucosal layer. (B) Plication of muscularis and division of redun-
dant mucosa. (C) Handsewn anastomosis. (From Doane S, Yeo C. Shackelford’s Surger y of the Alimentary Tract, Vol. 2. 2019:1097–1112.)
them. At this point, if the patient had preoperative incontinence and
has a wide levator hiatus, a posterior levatorplasty can be performed
with interrupted sutures to narrow the levators. This can also be
performed anteriorly for very wide defects, but care must be taken
not to incorporate the anterior structures or make the opening too
narrow. The coloanal anastomosis can be performed in a handsewn
or stapled fashion depending on preference. For a stapled approach,
the anvil of the stapler is placed in the proximal colon and a purse
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string is sewn around the anal canal through which the stapler would
be placed. Some surgeons advocate for the creation of a small colonic
J-pouch to act as a reservoir, but a straight coloanal anastomosis with
levatorplasty is an option as well to help with incontinence as a result
of chronic stretch of the sphincter complex.
Abdominal Approaches
There are two main abdominal procedures for rectal prolapse: rectopexy or resection rectopexy. These can be accomplished via open,
laparoscopic, or robotic approaches, and in a resection rectopexy
the surgeon would perform a sigmoid colectomy in conjunction
with their chosen rectopexy technique. Centered around this decision point is the debate as to whether resection rectopexy offers an
advantage over rectopexy alone. Advocates of resection rectopexy
argue that a redundant sigmoid colon contributes to constipation,
which then leads to the prolapse. Advocates of a rectopexy alone
argue that segmental resection is not an adequate operation for
constipation and adding a resection increases the potential for complications, especially in frail patients. This was studied as one arm of
the PROlapse Surgery PErineal or Rectopexy (PROSPER) trial that
is still, to date, the largest randomized trial comparing approaches to
rectal prolapse. In this study, there was no significant difference in
recurrence between patients undergoing a resection rectopexy versus
suture rectopexy alone, although the main limitation was inadequate
sample size to power all comparisons.
The next decision point is in the technique used for the rectopexy.
The most common technique is a suture rectopexy, but ventral mesh
rectopexy is gaining in popularity for a number of reasons that will
be discussed.
Suture Rectopexy
The goal of suture rectopexy is to fully mobilize the rectum down
to the levator muscles and restore its anatomic position by suturing
it to the sacral promontory to allow further scarring and fibrosis to
occur to fix the rectum back in place. Whether this is accomplished
in an open, laparoscopic, or robotic approach depends on surgeon
experience. The rectum is fully mobilized by incising the peritoneum
at the sacral promontory, and this dissection is carried down to the
levator muscles posteriorly. It is important to note that the surgeon
should not divide lateral stalks of the rectum close to the rectal
wall but rather leave peritoneal “wings” to suture back to the sacral
promontory. Care must be taken to avoid injury to the hypogastric
nerves when performing this posterior dissection. Once the rectum
is fully mobilized, the lateral stalks are placed on tension to bring the
rectum back to its anatomic position and suture it to the sacral promontory on both sides with nonabsorbable suture or tacks if using a
minimally invasive approach. The sutures should be placed lateral
to the hypogastric nerves and medial to the ureter and, once they
are tied down, should not narrow the rectum or place it at a sharp
angle, which will make evacuation difficult postoperatively. Potential
areas for concern postoperatively include increased constipation due
to division of lateral stalks and compromise of nervous innervation
running within them as well as potential for sexual dysfunction in
men due to the extensive posterior mobilization with increased risk
of nerve damage. Many surgeons advocate for a perineal approach to
full thickness prolapse in men to avoid these areas of potential nerve
damage altogether.
Ventral Mesh Rectopexy
There have been many approaches to rectal prolapse that involve
the use of mesh either as a material to fix the rectum to or as a
sling/wrap to return the rectum to its usual position in the pelvis. A
ventral mesh rectopexy avoids the posterior dissection and division
of the lateral stalks that are worrisome in a suture rectopexy and
relies on an anterior fixation. Similar to a suture rectopexy, the peritoneum is incised over the sacral promontory taking care to avoid
the hypogastric nerves and iliac bifurcation. This is only performed
on one side of the rectum, typically the right side. This dissection
is carried down laterally and into the rectovaginal septum with a
complete dissection anteriorly to the pelvic floor (Fig. 3). A strip
of mesh is cut and placed into the space between the rectum and
FIG. 3 Robotic ventral mesh rectopexy. (A) Mesh being
secured in rectovaginal space. (B) Pulling mesh to sacral
C
promontory. (C) Suturing into sacral promontory. (Courtesy
D. Lisle.)
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vagina and sutured to the anterolateral rectal wall on either side
of the rectum also incorporating a small amount of pelvic floor
musculature into sutures. The mesh is then stretched to the sacral
promontory and tacked or sutured to the right side of the promontory after it has been adequately cleared. The peritoneum that has
been incised laterally is usually then sutured back to itself to cover
the mesh if possible.
Advantages to ventral mesh rectopexy include lack of a posterior mobilization and potential autonomic nerve injury, as well as
the ability to address multicompartmental prolapse in a combined
approach with our female pelvic medicine and reconstructive surgery (FPMRS) colleagues. Potential complications include mesh
erosion and/or infection, which has motivated some surgeons to
use biologic mesh instead of synthetic mesh. Regardless, rates of
erosion even with synthetic mesh are quite low and reported to be
anywhere between 2% to 4%. There have not been many studies to
determine if there is a difference between recurrence rates using
biologic versus synthetic mesh, but in a recent meta-analysis by
Lobb et al. of suture rectopexy versus ventral mesh rectopexy, there
was no statistically significant difference in recurrence between the
two groups.
Recurrent Prolapse
The complication that is an inherent risk of any rectal prolapse repair is
recurrence. Data in the literature vary widely depending on the degree
of prolapse present preoperatively, the approach, and patient factors.
The widely accepted dogma that perineal approaches lead to higher
rates of recurrence has been challenged with the results of the PROSPER trial showing that there was no statistically significant difference in
recurrence between perineal and abdominal approaches. However, this
trial also showed recurrence rates between 13% and 31%. This is much
higher than the averages reported in the literature, which are typically
below 10% to 15% and are likely a reflection of specialization of surgeons
and a multidisciplinary approach to pelvic floor dysfunction.
The most important factor to consider in the approach to a
recurrent rectal prolapse is the type of repair the patient underwent
previously. Every effort should be made to obtain previous operative
records. The biggest mistake that can be made is to inadvertently leave
behind a segment of devascularized colon. This can only happen in
patients who had a previous resection via a resection rectopexy or
perineal rectosigmoidectomy. In these patients, the safest approach is
a rectopexy as it does not involve any further resection and potential
for vascular compromise. In patients who had a previous perineal
rectosigmoidectomy, a repeat perineal rectosigmoidectomy can be
performed provided that their previous anastomosis is fully resected.
CONCLUSION
Rectal prolapse is a debilitating disease that can be successfully
treated with a thoughtful surgical approach. Many factors including
presenting symptoms, patient comorbidities, bowel function, and
degree of prolapse must be considered as there is no single superior
approach that will be successful for every patient. However, with
the right surgical approach and technique, patients can experience a
drastic improvement in their quality of life and often even a return
to their preoperative functional baseline.
S u g g e S t e d R e a d i n g S
Altomare D, Pucciani F. Rectal Prolapse: Diagnosis and Clinical Management:
Springer; 2008.
Bordeianou L, Paquette I, Johnson E, etal. Clinical Practice Guidelines for the
Treatment of Rectal Prolapse. Dis Colon Rectum. 2017;60(11):1121–1131.
Lobb HS, Kearsey CC, Ahmed S, Rajagneshan R. Suture rectopexy ver-
sus ventral mesh rectopexy for complete full thickness rectal prolapse
and intussusception: systematic review and meta-analysis. BJS Open.
2021;5(1):zraa037.
Senapati A, Gray RG, Middleton LJ, et al. PROSPER: a randomized com-
parison of surgical treatments for rectal prolapse. Colorectal Disease.
2013;15(7):858–868.
Surgical
Managementof
Constipation
Nathalie Mantilla, MD, and Jose R. Cintron, MD
ealthy bowel habits are those considered regular, soft formed
consistency, and without the need for excessive straining.
H
However, they may vary in frequency and consistency from one
person to another and still be considered normal. Constipation is a common condition defined by fewer than three bowel
movements per week, hard stools requiring excessive straining
to pass, and/or sensation of incomplete emptying after defecation. Chronic constipation is classified as functional (primary)
or secondary. Functional constipation subtypes are based on the
etiology: slow-transit constipation (colonic dysmotility), normal
transit constipation, and/or obstructed defecation syndrome
(pelvic floor dysfunction, rectal hyposensitivity, organ prolapse,
internal intussusception). Secondary chronic constipation may be
related to medications and/or medical conditions (neurologic or
endocrine problems, irritable bowel syndrome, etc.).
Constipation affects approximately 15% of the population
worldwide and is a common cause of visits to gastroenterologists
and colorectal surgeons. Despite its benign nature, it can be quite
debilitating and can significantly impact the quality of life of those
who suffer from it.
ANATOMY AND PHYSIOLOGY
Normal defecation is a multistep physiologic process that involves
various organs. Colonic mucosa and musculature play an important role in stool formation through a proper balance between water
absorption and bowel motility. Coordination of the pelvic floor
and abdominal muscles is required in the final steps of stool elimination. Colonic peristalsis helps advance the stool bolus distally as
it thickens inside the bowel lumen. Once feces reach the rectum,
distention of the rectal wall and feedback from specialized cells in
the proximal anal canal will aid distinguishing between gas, solid
or liquid stools, and facilitates evacuation when socially acceptable. This process requires coordination between autonomic and
somatic nervous system functions.
LARGE BOWEL
Bristol Stool Chart
https://t.me/medicina_free
237
DIAGNOSIS
Clinical Assessment
A thorough evaluation is required for patients with suspected constipation, including an in-depth interview discussing associated symptoms (such as rectal bleeding, weight loss, changes in stool caliber,
etc.) medical, surgical, and family history medications, diet, toilet
habits, and so on. Characteristics of the stools should be discussed,
including consistency (Bristol stool form scale, Fig. 1), caliber,
and frequency. It is also crucial to know the onset and duration of
symptoms. Reported symptoms are useful to distinguish the type of
constipation. Infrequent hard stools refer more to cases of colonic
dysmotility, whereas patients with pelvic floor dysfunction and
obstructed defecation syndrome complain more of incomplete evacuation and straining. Abdominal pain that alleviates after defecations
may indicate irritable bowel syndrome (Box 1). Evaluation of events
occurring at the onset of symptoms may identify causes or contributing factors such as new diagnoses or medications. For example,
hypercalcemia, hypothyroidism, neurologic problems, psychosocial
issues, the use of opioids, antidepressants, anticholinergics, calcium
channel blockers, and calcium supplements are among some common conditions and medications to look for when taking the history.
Unfortunately, in many cases of constipation, no cause is identified.
A focused abdominal and pelvic physical examination is critical,
which should include external inspection followed by digital rectal
examination, including evaluation of anal tone, presence of stools,
and puborectalis muscle. In women, vaginal examination may be
necessary when rectocele is being ruled out. Rome criteria are used
to identify constipation and its subtypes but do not assess severity of
the condition (Box 2). Complementing the clinical evaluation with
validated instruments may help to distinguish the type of constipation, impact on quality of life, and the need to pursue additional
diagnostic testing. Multiple questionnaires have been made available
to assess the severity of constipation and to follow up on the response
to treatment.
Type 1
Type 2
Type 3
Type 4
Type 5
Type 6
Type 7
FIG. 1 Bristol stool form scale. (From Lewis SJ, Heaton KW. Stool Form Scale as a
Useful Guide to Intestinal Transit Time. Scand J Gastroenterol. 1997;32[9]:920–924.)
Separate hard lumps, like nuts
(hard to pass)
Sausage-shaped but lumpy
Like a sausage but with cracks
on its surface
Like a sausage or snake,
smooth and soft
Soft blobs with clear-cut edges
(passed easily)
Fluffy pieces with ragged edges,
a mushy stool
Watery, no solid pieces.
Entirely Liquid
BOX 1 Rome IV Criteria for IBS-C
Recurrent abdominal pain, on average, at least 1 day per week in
the past 3 months, associated with two or more of the following
criteria:
• Relatedtodefecation
• Associatedwithachangeinfrequencyofstool
• Associatedwithachangeinform(appearance)ofstool
• Criteriafulfilledforthelast3monthswithsymptomonsetat
least 6 months before diagnosis
• Patientreportsthatabnormalbowelmovementsareusually
constipation (such as type 1 or 2 Bristol stool form scale)
IBS-C, Irritable bowel syndrome with predominant constipation.
From Lacy BE, Mearin F, Chang L, et al. Bowel disorders. Gastroenterology.
2016;150(6):1393–1407.
BOX 2 Rome IV Criteria for Functional Constipation
Requires two or more of the following:
• Strainingwithmorethan25%ofdefecations
• Lumpyorhardstools(Bristolstoolformscale1or2)more
than 25% of defecations
• Sensationofincompleteevacuationmorethan25%of
defecations
• Sensationofanorectalobstruction/blockagemorethan25%of
defecations
• Manualmaneuverstofacilitatemorethan25%ofdefecations
(such as digital evacuation or support of the pelvic floor)
• Fewerthanthreespontaneousbowelmovementsperweek
Plus:
• Loosestoolsarerarelypresentwithouttheuseoflaxatives
• Insufficientcriteriaforirritablebowelsyndrome
• Criteriafulfilledforthelast3monthswithsymptomonsetat
least 6 months before diagnosis
From Lacy BE, Mearin F, Chang L, etal. Bowel disorders. Gastroenterology.
2016;150(6):1393–1407.
Following screening recommendations or the presence of
alarming symptoms, a colonoscopic evaluation should be included
to rule out intraluminal lesions, strictures, or any other underlying
conditions. Adjunct blood tests to rule out endocrine disorders
should be included when clinically indicated (thyroid and parathyroid function, diabetes, etc.).
Radiologic Testing
Sitz Marker Study (Radiopaque Marker Study)
In cases where colonic transit requires further investigation, radiopaque markers, scintigraphy, or wireless motility capsules can
be used. The sitz marker study is simple, inexpensive, and easily
available because it only requires swallowing the capsule containing
the ring-shaped markers and abdominal plain films on the day of
ingestion of radiopaque markers by the patient and on day 5 after
the ingestion. A normal test is considered if, on day 5, at least 80%
of the markers have passed. In cases when more than 20% of the
markers are still observed in the colon, the study is considered
abnormal. Slow-transit constipation is suggested in cases when
the markers are distributed throughout the colon (Fig. 2), whereas
retained markers in the rectosigmoid colon are suggestive of
obstructed defecation.
Defecography
Defecography is a dynamic test that can be performed using
fluoroscopy (cinedefecography), magnetic resonance (MRI
238 SURGICAL MANAGEMENTOF CONSTIPATION
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defecography), or ultrasound equipment (ecodefecography) and
uses radiologic contrast or ultrasound gel to opacify the rectum
and capture images during the evacuation process for further
analysis (Fig. 3). It is used to rule out associated pathologies
such as rectoceles or intussusceptions and nonrelaxing puborectalis as the cause of obstructive defecation. Each technique
offers valuable information, but they all have advantages and
limitations.
Anorectal Physiology Testing
In selected cases when pelvic floor dysfunction is suspected, anorectal physiology testing might be useful, such as anorectal manometry
(ARM) measuring resting and squeeze pressures, rectal volume
sensation, rectoanal inhibitory reflex, and balloon expulsion (Fig. 4).
Additionally, electromyography (EMG) is useful in evaluating proper
puborectalis contraction and relaxation.
MANAGEMENT
Medical Management
The first line of treatment for constipation is usually nonoperative
and includes patient education about diet modifications to increase
fiber and water intake. Fiber-rich foods and fiber supplements are
both acceptable options and are recommended before beginning
laxatives and/or enemas. Behavioral education regarding toilet habits
is a critical part of the education and treatment (straining, time spent
sitting on the toilet, etc.).
Osmotic laxatives (polyethylene glycol, magnesium hydroxide,
and lactulose) are safe options that have been demonstrated to be
very effective in most cases of constipation. Short-term use of stimulant laxatives (bisacodyl) is recommended. Newer alternatives such
as lubiprostone and linaclotide should be reserved for cases when
fiber and water intake is adequate and osmotic and stimulant laxatives have failed.
Noninvasive Techniques
Biofeedback therapy is a useful therapy in cases of constipation due
to pelvic floor dyssynergia. It has shown to improve the number of
spontaneous bowel movements by correcting pelvic muscle dysfunction, mirrored by improved quality of life.
Surgical Management
Refractory cases are those that fail to improve symptoms consistently
after appropriate medical treatment and in which surgery provides
the only option to restore quality of life. Figure 5 shows the algorithm
for management of constipation.
FIG. 2 Sitz marker study. Radiopaque marker study 5 days after ingestion
of the Sitz marker capsule. Retention of markers present throughout the
colon, suggesting colonic dysmotility. (From Kapadia M, Varma M. Evaluation
of Constipation and Treatment of Abdominal Constipation. In Steele S, etal. The
ASCRS Textbook of Colon and Rectal Surgery. Springer; 2016.)
Colonic Slow-Transit Constipation
For patients with confirmed colonic dysmotility as the cause of constipation in whom nonoperative measures have failed, total abdominal colectomy with creation of an ileorectal anastomosis (TAC-IRA)
has shown excellent results and is the procedure of choice (overall
success rates are approximately 86%). Segmental colectomies are
not recommended in these cases because failure rates are as high as
100%. Upper gastrointestinal dysmotility problems must be ruled
out before proceeding to perform a colectomy to decrease chances
of recurrent constipation. It is imperative to have a thorough conversation with the patient, setting clear expectations about outcomes
and possible complications. TAC-IRA can be performed open or
FIG. 3 Defecography. Dyskinetic puborectalis muscle syndrome. Note abnormally deep puborectalis impression (arrow) at rest (A) and at evacuation
phase (B). During the evacuation phase, there is lack of pelvic floor descent. (From Ah Young Kim. How to Interpret a Functional or Motility Test - Defecography.
J Neurogastroenterol Motil. 2011;17[4]:416-420.)
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