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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_927_Библиотеки_им_академика_М_И_Перельмана.pdf
R U
S
ODUCTION
INTR
Solitary rectal ulcer syndrome (SRUS) is a chronic benign disorder
of the rectum and pelvic oor that produces ulcerated and polypoid
areas in the rectal wall. Although some patients have a single rectal
ulcer, the term is misleading because the ulcers sometimes are multiple and extensive, and at times no ulcers are present but the rectal
wall has a polypoid appearance (colitis cystic profunda). e condition predominantly aects young adults with equal gender incidence.
SRUS causes signicant symptoms associated with disordered defecation, and it can be diagnosed via a biopsy according to its specic histologic features. Its annual incidence is estimated to be 1 in
100,000 population. In this chapter, current thoughts about the cause,
presentation, and treatment of SRUS will be discussed.
C
AUSE
A
lthough poorly understood, the cause of SRUS is thought to be disordered rectal evacuation associated with straining. Complete satisfactory rectal evacuation requires the coordinated and integrated
normal function of the rectum, anus, and pelvic oor, including the
reex arcs and the voluntary responses to rectal lling that control
them. Failure of this complex mechanism may result in a spectrum
of problems ranging from minor mucus seepage to incontinence and
obstructed defecation. A degree of rectal prolapse or intussusception and outlet obstruction attributed either to the redundant rectal
wall, paradoxical contraction of puborectalis, or both is common to
patients diagnosed with SRUS. It is likely that the individual presentation of each aected patient is determined by the degree of prolapse,
the redundancy of tissue, and the strength of straining as patients
seek to defecate and satisfy the urge they are feeling.
P
ATHOPHYSIOLOGY
A p
aradoxical contraction of the puborectalis upon straining is not
unique to SRUS; it also is a common cause of outlet obstruction
to defecation in patients who do not have SRUS. However, it is the
combination of rectal prolapse and paradoxical contraction of the
puborectalis that seems to generate the ulceration seen in persons
with SRUS. Persistent and prolonged straining pushes the prolapsing
rectum against a closed pelvic oor and results in mucosal ischemia,
trauma, and ulceration through compressive and shear forces. When
the puborectalis muscle relaxes normally, a prolapsing rectal wall or
mucosa may impact against the top of the anal canal, blocking evacuation. is type of trauma, which is less severe than that causing the
ulcerated type of SRUS, is likely to produce the polypoid appearance
that is sometimes seen. Patients experience a sense of rectal fullness
as a result of retained stool and the presence of redundant prolapsing rectum. More straining may exacerbate the prolapse, which then
S
Da
vid Bartolo
orsens the feeling of incomplete emptying, thus producing further
w
straining in a vicious cycle.
CLINIC
e clinical presentation of SRUS is nonspecic, and the dierential
diagnosis includes a spectrum of disorders. Frequent unproductive
straining is almost universal because of a constant desire to defecate
and feelings of incomplete evacuation. Bleeding and passage of mucus
occur in almost all cases. e bleeding sometimes leads to anemia and
on rare occasions is massive. Diculty initiating defecation is common. Most patients report tenesmus, and 20% of patients have a deepseated pelvic ache. About 50% of patients have some degree of fecal
incontinence. ere is an association with the abdominal symptoms
of irritable bowel syndrome and a high prevalence of psychoneurosis.
e rectal prolapse associated with SRUS takes time to develop,
and patients oen have a long history of unsatisfactory evacuation,
chronic straining, and pelvic fullness.
Apart from an occasional patient with mildly abnormal perineal descent, few external physical signs are present. Digital rectal
examination may reveal anterior rectal wall nodularity, friability, and
erythema. Upon performing a sigmoidoscopy, excess rectal mucus
is frequently noted with localized mucosal edema and reddening.
Ulceration is usually seen on the lead point of the prolapsing bowel.
Ulcers or polypoid changes are anterior in more than 90% of cases
and are usually around 7 to 10 cm from the anal verge.
Some debate exists regarding the relationship between SRUS
and colitis cystica profunda syndrome (CCP). e syndromes share
common clinical presentations, underlying pathogenesis, and some
endoscopic features, although in persons with CCP the endoanal
ultrasound will show multiple submucosal cysts and intervening
echorefringent brosis. Endoscopically, both SRUS and CCP can be
mistaken for a neoplasm. A biopsy is the key to making the diagnosis.
Samples should be taken from the edge of the ulcer and ideally should
include submucosa. SRUS has the following microscopic features:
n
Er
n
ic
Fi
n
Hyperplastic glandular changes
n
C
n
P
n
Di
n
n
ese ndings, oen termed “mucosal prolapse syndrome,” are
characteristic of mucosal prolapse found anywhere in the large intestine. It is sometimes found in the sigmoid colon, where polypoid, erythematous mucosal polyps are the result of prolapse engendered by
the strong peristalsis.
AL FEATURES
oded hyperplastic mucosa
kened muscularis mucosa
bromuscularization of the lamina propria
ollagen inltration
olymorph inltrate
amond-shaped crypts are also a characteristic diagnostic
ding
111
112
n persons with SRUS, histologically, ectopic mucosal glands in
I
Solit
ary
rect
al Ulcer Syndrome
the submucosa may be confused with the invasion that is the hallmark of an adenocarcinoma; the pathologist and surgeon should
be aware of this potential for confusion. e lack of a desmoplastic
reaction around the glands is an important clue to the absence of
cancer.
GNOSIS
DIA
areful history should be obtained, including details of defecation.
A c
In particular, the evacuation pattern of the patient, with ease of initiation and completion and whether there is still a feeling of urge aerward, is a key piece of the history. A need to strain and to use manual
self-disimpaction or digitation to “push something out of the way”
add to the picture.
e dierential diagnoses of a rectal ulcer, which include rectal
neoplasia, inammatory bowel disease, lymphogranuloma venereum, syphilis, and human immunodeciency virus–associated
ulceration, need to be ruled out.
An abdominal and digital rectal examination should be performed, with evaluation of perineal descent and anal tone. e digital
examination should be performed with the patient in the le lateral
position. e patient is asked to strain or bear down. Normally, only
minimal descent of the anal canal occurs. In patients with abnormal
perineal descent, the anus may lie at the level of the ischial tuberosities at rest or may balloon down when the subject strains. Not all
patients with SRUS have perineal descent, but most patients exhibit it
to some degree. e rectum is then examined systematically, palpating around the circumference for masses. During the “bearing down”
phase of the examination, a lack of relaxation of the puborectalis can
be sensed, and prolapsing mucosa or rectal wall can sometimes be
felt to descend during the strain. Frank rectal prolapse may only be
elicited in some cases by positioning the patient on the commode and
witnessing straining.
Inspection of the anus is performed by anoscopy, and the rectal
mucosa is examined by rigid proctoscopy or sigmoidoscopy. A full
colonoscopy is advised at some stage to exclude colonic neoplasia.
During anoscopy, the patient is again asked to bear down. Prolapsing mucosa can usually be seen descending if the anoscope is slowly
withdrawn as the patient strains.
Proctoscopy most commonly will show an anterior lesion 7 to 10
cm from the verge. However, ulcers may be multiple, and mucosa
may be polypoid. Sometimes the only thing visualized is a patch of
erythema.
Whereas clinical evaluation combined with endoscopy and histology conrm the diagnosis, imaging with defecating proctography
or dynamic magnetic resonance imaging (MRI) may demonstrate
the degree of prolapse, any underlying muscular discoordination of
the pelvic oor, and the completeness of evacuation. Endoanal ultrasound may show thickening of sphincters and loss of tissue planes.
It has not yet been shown that complete correlation exists between
the obvious internal prolapse seen on MRI and the syndrome itself;
however, the presence of a traumatic mucosal lesion should conrm
the diagnosis, even in the absence of a cause being demonstrated on
proctography.
Sometimes defecating proctography and dynamic MRI of the pelvic oor have false negative results because of patient embarrassment
or the articial nature of the tests. If there is any doubt about the
diagnosis, the patient can be examined with use of deep sedation or
aer induction of general anesthesia. With use of a speculum such as
an Eisenhammer retractor, the mid rectum is grasped on the posterior wall with Babcock or similar forceps and gently pulled down. e
posterior wall is normally xed to the sacrum by the loose surrounding so tissues. In prolapse, it is mobile, and with a second pair of
forceps on the anterior rectal wall, the prolapse oen can be brought
down beyond the anus (Figs. 23-1, 23-2, and 23-3). If prolapse can be
excluded in this way, surgery should be avoided.
FIGURE 23-1
ectal mucosa showing polypoid changes in solitary rectal ulcer syndrome.
r
FIGURE 23-2
and internal pr
MANA
P
oor correlation exists between clinical features, impact on quality of life,
Complete r
An e
olapse below the ischial tuberosities.
GEMENT
ectal prolapse with extensive ulceration of the
vacuation proctogram showing perineal descent
and endoscopic ndings, and the goals of treatment may vary between
patients. Aer conrmation of the diagnosis, exclusion of neoplasia,
and investigation for associated underlying disorders, treatment may be
directed at relief of symptoms, management of prolapse, and improvement
in pelvic oor coordination. Some persons simply require reassurance and
a full explanation of the pathophysiology. ereaer, they may be able to
manage their symptoms by simply avoiding straining when it is clear that
stool will not easily emerge.
Nonoperative Management
I
nitial treatment with stool-bulking agents and advice regarding def-
ecation may improve symptoms in persons without severe prolapse.
FIGURE 23-3
gross perineal descent.
P
atients should ingest 30 to 40 g of ber per day and should stay well
A magnetic r
esonance imaging proctogram showing
hydrated. Prolonged unproductive straining should be avoided, and
toilet times should be limited. ese measures can improve symptoms in more than 70% of patients.
Pelvic oor retraining with biofeedback may yield excellent
results in persons with internal prolapse and ulceration that does
not respond completely to dietary interventions. Rectal irrigation is
an option that provides symptomatic relief for some persons. Such
irrigation may simply be performed with the use of a 50-mL enema
bottle, or full colonic lavage may be performed with a few liters of
water and a rectal infusion system.
Surger
O
y
perating on patients with this complex condition, the cause of
which is almost certainly multifactorial, is dicult. e combination
of varying degrees of perineal descent together with varying degrees
of rectal prolapse and varying patterns of abnormal defecation with
both outlet obstruction and slow-transit constipation explain why one
surgical or medical therapeutic option may not suit all patients. Successful treatment must address all aspects of the patient’s condition.
Local procedures are appropriate for distal mucosal prolapse, and
local mucosal excision or Delorme-type procedures have been used
with encouraging results. Success is more likely when there is no fullthickness rectal prolapse and in cases of polypoid rather than ulcerated lesions.
Patients with full-thickness rectal prolapse or large internal prolapse are unlikely to benet from conservative measures and should
be considered for early surgery.
Rectopexy in this setting improves symptoms in up to 60% of
cases, especially when full-thickness rectal prolapse is shown preoperatively. Rectopexy oers a variety of options: posterior rectopexy,
ventral rectopexy, and resection rectopexy. e great advantage of
ventral rectopexy is that the colon is not resected, thus avoiding the
complexities of anterior resection syndrome. A minimalist approach
to rectal dissection avoids interfering with the nerve supply of the
rectum. Posterior and lateral dissection denervates the rectum,
which may explain why constipation is so common aer a simple
rectopexy, especially in younger patients. Resection with rectopexy is
RECTAL AND PARARECTAL REGION
t
heoretically addressed at resecting the denervated colon, but consti-
113
pation does not necessarily get better. Indeed, in some patients new
constipation develops as part of the anterior resection syndrome,
although most patients recover well with good functional outcomes.
Rectopexy carried out for symptoms in the absence of physical
changes of solitary ulceration is ineective and therefore contraindicated. Although proctectomy with coloanal anastomosis is a logical
treatment, it has proved unsuccessful. is procedure has been associated with recurrent ulceration in the colonic segment and renewed
symptoms.
In the most severe cases, fecal diversion or proctectomy may be
considered once other treatment options have been exhausted.
CONCLUSIONS
RUS is rare. It can be misdiagnosed as malignancy or inammatory
S
bowel disease or vice versa, and it oen occurs in somewhat challenging patients. Sometimes patients have been inappropriately treated
for several years, including treatment with medications such as steroids and immune-suppressive drugs. It is essential to conrm the
diagnosis endoscopically and histologically, as well as to document
the underlying problems in pelvic oor physiology, to undertake the
correct management for each patient.
SRUS is a complex condition that can be dicult to diagnose and
complex to treat. Tertiary referral should be considered given the
uncertainty of outcomes. orough counseling and education of the
patient is important, and surgery should be approached with considerable caution. Currently, ventral rectopexy appears to be the treatment of choice in patients with prolapse, but as with this complex
condition, long-term outcomes need to be awaited.
u
S
B
El Muhtaseb MS, Bartolo DC, Zayiae D, Salem T. Colonic transit before and
Ho YH, Ho JMS, Parry BR, etal. Solitary rectal ulcer syndrome: the clinical
Jarrett ME, Emmanuel AV, Vaizey CJ, Kamm MA. Behavioural therapy
Kang YS, Kamm MA, Engel AF, Talbot IC. Pathology of the rectal wall
Morio O, Meurette G, Desfourneaux V, et al. Anorectal physiology in
Nicholls J. Rectal prolapse and the solitary rectal ulcer syndrome. In: Kamm MA,
Orrom WJ, Bartolo DC, Miller R, etal. Rectopexy is an ineective treatment
Rao SS, Ozturk R, De Ocampo S, Stessman M. Pathophysiology and role of
Warren BF, Dankwa EK, Davies JD. Diamond-shaped crypts and mucosal
S t
g g e
ove A, Bellini M, Battaglia E, et al. Consensus statement AIGO/SICCR
diagnosis and treatment of chronic constipation and obstructed defeca-
tion (part II: treatment). World J Gastroenterol. 2012;18:4994–5013.
aer resection rectopexy for full-thickness rectal prolapse. Tech Coloproctol.
2014;18(3):273–276.
entity and anorectal physiological ndings in Singapore. Aust N Z J Surg.
1995;65:93–97.
(biofeedback) for solitary rectal ulcer syndrome improves symptoms and
mucosal blood ow. Gut. 2004;53:368–370.
in solitary rectal ulcer syndrome and complete rectal prolapse. Gut.
1996;38:587–590.
solitary ulcer syndrome: a case-matched series. Dis Colon Rectum.
2005;48:1917–1922.
Lennard-Jones JE, eds. Constipation. Peterseld, Hampshire, England:
Wrightson Biomedical Publishing; 1994:289–297.
for obstructed defecation. Dis Colon Rectum. 1991;34(1):41–46.
biofeedback therapy in solitary rectal ulcer syndrome. Am J Gastroenterol.
2006;101:613–618.
elastin: helpful diagnostic features in biopsies of rectal prolapse. Histopa-
thology. 1990;17(2):129–134.
cause of solitary rectal ulceration. Gut. 1987;28:1228–1233.
e d
R
e
a d i n g
R
Pr
eetha Ali and Richard P. Billingham
DEFINITION
A r
ectocele is an abnormal protrusion of the anterior rectal wall into
the vagina (Fig. 24-1). It is found in 20% of adult women, and symptoms may develop by the fourth or h decade of life. Most rectoceles
protrude less than 2 cm into the vagina, are incidental ndings, and
require no treatment.
Rectoceles can be graded according to size. A grade I rectocele
protrudes part way into the vagina; in a grade II rectocele, the bulge
reaches the introitus, and a grade III rectocele is visible outside the
vaginal opening.
C
AUSES
e exact cause of rectoceles is unknown; however, several hypoth-
eses have been proposed. In the past, obstetric injuries and multiple
vaginal deliveries were thought to be the main precipitating factors,
but such patients have been shown to have a prevalence comparable
with nulliparous women. In a recent study, 370 symptomatic women
(e.g., women experiencing excessive straining, vaginal splinting, and
the sensation of incomplete evacuation) aged 13 to 91 years were
assessed using three-dimensional anorectal ultrasound. e prevalence of rectoceles was 65% in nulliparous women, 70% in women
with at least 1 vaginal delivery, and 71% in women who had undergone cesarean sections. No correlation was found between vaginal
deliveries and pelvic oor dysfunction.
Currently, the most commonly accepted theory for the formation of rectoceles is the pressure gradient formed between
the rectum and vagina during defecation. This is accentuated
by the increased straining caused by obstructed defecation, the
most common cause of which is paradoxical contraction of the
puborectalis muscle. Straining leads to an increased pressure gradient across the rectovaginal septum and promotes the formation
of rectoceles.
A study of 45 patients with obstructive defecation and rectocele noted that severe constipation (Cleveland Clinic Constipation Score >15) was the only factor associated with the presence of
a rectocele. In fact, persons with hypotonia of the sphincter muscles (<40 mm Hg) had a lower prevalence of rectoceles. In another
study of 487 patients evaluated by ultrasound and manometry, no
correlation was noted between the size of the rectocele and the
number of deliveries or frequency of irritable bowel syndrome
symptoms. Dysfunctional defecation, also known as “nonrelaxing
puborectalis muscle syndrome,” was noted in 60% of persons with
a rectocele compared with 24% of persons without a rectocele.
However, no specific anorectal physiologic findings were associated with rectoceles.
Rectoceles are oen associated with other pelvic disease. Rectal intussusception or prolapse, the second most common cause of
obstructed defecation, is found in roughly two thirds of patients with
114
ectoceles. Given the tendency to strain at defecation, it is not sur-
r
prising that vaginal and/or uterine prolapse, enterocele, and excessive
perineal descent are also found.
SYMPT
e most common symptoms are the feeling of incomplete evacua-
tion and the sensation of a vaginal or perineal bulge. e associated
obstructed defecation causes prolonged straining at stool and a sensation of blockage upon defecation. Many women with symptomatic
rectoceles nd that manual splinting via pressure on the perineum or
inside the vagina helps facilitate defecation. Some women also report
dyspareunia, anorectal/vaginal pain, urologic symptoms, and occasionally fecal soiling.
OMS
DIAGNOSIS
e first step in diagnosis is to obtain a thorough history. Ques-
Th
tions regarding bowel function (e.g., constipation, continence),
childbirth, dyspareunia, urologic symptoms, and additional
maneuvers performed to assist in defecation (as previously
mentioned) are all relevant. The Cleveland Clinic Constipation
Score or the Knowles-Eccersley-Scott Symptom questionnaire
can be administered as part of the baseline evaluation and can
be helpful when performed after interventions to assess symptom
improvement.
Upon digital rectal examination, a nger is gently pressed against
the anterior rectal wall. A rectocele is felt as a weakness that allows
the nger to pass through the normal position of the rectovaginal
septum into the vagina, just above the sphincter mechanism. With a
grade III rectocele, the examining nger will be seen in the introitus.
Video defecography (VDG) using oral and rectal contrast material has proved to be the most helpful diagnostic test by providing an
assessment of rectocele size and the ability to empty with normal defecation; it also documents other disease such as paradoxical puborectalis contraction, rectal prolapse, intussusception, and sigmoidocele/
enterocele. A rectocele is considered clinically signicant if it measures greater than 3 cm on VDG or has retention of barium or stool
aer evacuation of the rectum.
Magnetic resonance imaging provides good visualization, and if
it is performed as a dynamic study, it can correlate the rectocele with
pelvic oor movements. Images caught during defecation can identify abnormal bladder, vaginal, or rectal descent. However, magnetic
resonance imaging scans are generally performed with the patient
supine, which is a nonphysiologic position for assessing defecation;
these scans are also more expensive and oen miss the diagnosis
of enteroceles. e newer modality of three-dimensional anorectal
ultrasound correlates closely with VDG and may help delineate the
pelvic oor. Anorectal manometry, measurements of pudendal nerve
RECTAL AND PARARECTAL REGION
115
Uterus
Bladder
Vagina
Rectocele
Rectum
Anus
A
B
FIGURE 24-1
Atlas and Text of Clinical Medicine. Philadelphia: Saunders; 2009.)
erminal motor latency, and endoanal ultrasound are important for
t
assessing anal neuromuscular function and associated sphincter
defects. In general, VDG is the most helpful and accurate test in evaluating overall pelvic oor function.
MANA
e first step in management is to assess the results of the diag-
Th
nostic studies and make a judgment about the relative contribution of each identified abnormality to the patient’s symptoms.
In general, if rectal prolapse, enterocele, or other surgically correctable conditions are thought to be major contributors to the
patient’s symptoms, these conditions should be addressed first,
and then the contribution of the rectocele to any remaining symptoms should be reassessed.
If the rectocele alone is believed to be the major cause of the
patient’s symptoms, an important rst step is to address any underlying defecation disorder, such as a nonrelaxing puborectalis muscle,
prior to surgery. Although ber supplements and laxatives are oen
prescribed to optimize stool consistency and frequency, they are
rarely eective in treating the defecation disorder itself. A course of
biofeedback or pelvic physiotherapy should be prescribed to retrain
the pelvic oor muscles to work synergistically. With the proper specialized therapist and a cooperative patient, good success can result
from this modality of therapy.
Indications for surgical treatment of a rectocele include a size
of 3 cm or larger, signicant barium trapping on defecography, the
requirement for vaginal or perineal splinting, or failure of biofeedback therapy to relieve the patient’s symptoms.
Anatom
y of a rectocele.
GEMENT
(Fr
om Ferri FF. Ferri’s Color
SURGIC
R
ectoceles may be repaired transanally, transvaginally, or through
the perineum, depending on patient factors and preferences. If
additional disease is present in the rectum or vagina that would
benefit from surgical correction, then this dictates the choice of
approach.
AL TREATMENT
Transanal Repairs
A t
ransanal repair is the best option for treating rectoceles that have
an isolated rectovaginal septal defect above the sphincters and those
causing stool-related symptoms.
Most repairs can be performed on an outpatient basis. Patients
are placed in a prone jackknife position, and a vertical incision is
made in the rectal mucosa anteriorly starting just above the dentate
line, extending proximally to the apex of the palpable septal defect.
To assist with submucosal dissection and aid hemostasis, the tissue
is inltrated with an epinephrine solution. Flaps of mucosa are elevated on either side of the midline, and redundant tissue is excised
(Fig. 24-2, A).
Appropriate exposure of the rectovaginal septum requires an adequate amount of dissection bilaterally to expose tissue with enough
strength to hold suture. A horizontal plication of the anterior rectal
wall is performed with running 2-0 Vicryl (Ethicon, Inc., Somerville,
N.J.) or 3-0 polydioxanone (PDS) or Maxon (Fig. 24-2, B), avoiding full-thickness bites to prevent the formation of a rectovaginal
stula. Smaller bites are taken at the proximal and distal aspects of
the incision to avoid creating a rectal shelf. A second row of imbricating sutures is then performed over this rst layer, tailoring this
to the size and shape of the septal defect (Fig. 24- 2, C). Finally, the
mucosa is reapproximated over the other sutures using a running 3-0
Vicryl suture (Fig. 24-2, D). Postoperatively, patients are given oral
pain medication and ber supplementation without diet restrictions
and are encouraged to resume normal activities. ey are seen in the
oce about 3 weeks aer surgery. Abstinence from intercourse for 4
to 6 weeks is typically recommended.
Improvement of symptoms occurs in 50% to 96% of patients as
noted in two studies with an 18- to 74-month follow-up. Recurrence
or persistence of preoperative symptoms may relate to a defective
repair but more likely is a result of an unrecognized disorder that
coincided with the rectocele, such as colonic dysmotility or a nonrelaxing puborectalis muscle.
Transvaginal Repairs
e transvaginal approach is most favored by gynecologists and
urogynecologists because it allows correction of the vaginal defect,
but it is associated with increased rates of sexual dysfunction. e
technique is preferred when rectoceles are found with other types of
vaginal disease, such as cystoceles.
e basic repair is a plication of the rectovaginal fascia performed
with the patient in the lithotomy position. e procedure is identical
to the technique of transanal repair: an incision is made in the posterior aspect of the vagina just inside the introitus and extended to
the apex of the vagina. e defect is identied by separating the vaginal mucosa from the underlying rectovaginal septum and excising
redundant mucosa to allow visualization of the rectovaginal fascia.
e fascial edges are approximated, and the excess vaginal mucosa
is excised.
Dyspareunia is reported in 5% to 33% of cases, likely as a result
of narrowing of the introitus and postoperative scarring. is repair,
however, continues to have a lower recurrence rate than transanal repairs. A success rate of 76% to 96% is noted in three studies,
although aer a short follow-up of 12 to 42 months, and in one study,
recurrence rates ranged from 5.7% to 7%.
116
Rect
ocele
Beginning
of first
suture line
A
Rectum
Rectocele
Flaps of
mucosa
Dentate line
Rectum
First
suture
line
B
Rectum
Second
suture
line
C
D
FIGURE 24-2
mucosa are elevated on either side of the midline, and redundant tissue is excised. B, First suture line beginning to imbricate tissue. C, A second,
wider suture line beginning to imbricate the first suture line. D, Closure of mucosa to imbricate the first and second suture lines.
ransperineal Repairs
T
T
ransperineal repairs have been attempted in recent years,
T
ransanal rectocele repair.
although the advantages are unclear. The patient is placed in a
prone jackknife position and a curvilinear incision is made in the
perineum. The rectovaginal septum is identified, and dissection is
A,
A vertical incision is made in the rectal mucosa anteriorly, starting just above the dentate line. Flaps of
T
ABLE 24-1:
Success Rates and Morbidity b
y Type of
Repair
Repair Type Success Rates (%) Morbidity (%)
T
ransanal 50-96 0-5
performed between the rectum and vagina to the proximal extent
of the defect. The rectovaginal fascia is identified and sutured. To
strengthen and support the rectovaginal septum, a levatorplasty
may be performed by approximating the tissues of the perineal
Transvaginal 76-96 5-33
Transperineal 63-87 0-5
body and the limbs of the puborectalis muscle in the midline.
Over a 24- to 44-month follow-up period in two studies, success
rates were noted to be 63% to 87%. Smaller studies have demonstrated a 75% improvement in evacuation and continence in
patients overall.
Augmentation of the repair has been studied with transvaginal
and transperineal approaches, using both synthetic and biologic
w
ere compared and no dierence was noted between recurrence or
postoperative function over a follow-up of 3 to 70 months. However,
the authors also emphasized the importance of patient selection for
each approach based on concomitant urogynecologic, rectal, or other
pelvic oor disorders.
mesh. To date, studies have shown no improvement in long-term
results when compared with transvaginal or transanal techniques.
Long-term outcomes are still being studied, and no conclusions can
be made at this time.
SUMMAR
R
ectoceles are commonly found in conjunction with obstructed def-
Y
ecation and pelvic oor dysfunction. Physical examination and VDG
Comparison
ccording to the Cochrane Database analysis of surgical approaches
A
of Approaches
for pelvic oor disorders, the transvaginal repair demonstrated fewer
symptoms of recurrent prolapse compared with the transanal repair
in three separate trials (relative risk, 0.4; 95% condence interval, 0.2
to 1.0; Table 24-1). Currently no prospective, randomized controlled
trials have been performed to investigate the ideal surgical approach
for rectoceles. In one small, retrospective trial, the three approaches
remain the standard approach for diagnosis of rectoceles and can
show coexisting functional defecation disorders. If other disorders
are found, consideration should be given to treating these abnormalities rst, which may diminish or eliminate the patient’s symptoms to
the point where no rectocele repair is needed. If not, the rectocele can
be repaired, oen as an outpatient procedure. Multiple approaches
exist for the treatment of isolated rectoceles, with the choice of
technique based on the patient’s symptoms and presentation and the
preference of the surgeon.
RECTAL AND PARARECTAL REGION
117
S
u
g g e
gachan F, etal. A constipation scoring system to simplify evaluation and
A
management of constipated patients. Dis Colon Rectum. 1996;39:681–685.
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F B
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oanne Favuzza
EPIDEMIOLOGY
ectal foreign bodies are a challenging, unique, and commonly seen
R
problem. e true incidence of rectal foreign bodies varies throughout the literature because of patient underreporting. Most patients
with rectal foreign bodies are male and range from 30 to 90 years
of age. Rectal foreign bodies are most oen retained from transanal
insertion for the purpose of anal eroticism, but they can also be the
result of penetrating or blunt trauma, assault, and concealment of
drugs, and they can be iatrogenic. Objects rarely pass though the gastrointestinal tract and become lodged in the rectum. A wide variety
of foreign objects have been reported in the rectum, including vibrators, glasses, bottles, toothbrushes, light bulbs, ashlights, aerosol
canisters, cell phones, fruits, and vegetables. In this chapter the evaluation, management, and postextraction care for patients with rectal
foreign bodies will be reviewed.
EV
ALUATION
nitially, patients with a rectal foreign body should be treated simi-
I
larly to patients who have sustained rectal trauma by conrming a
patent airway and hemodynamic stability. e patient is examined for
evidence of peritonitis such as hypotension, tachycardia, fevers, and
severe abdominal pain. Abdominal radiographs with the patient in
the at and upright positions may be obtained to assess for pneumoperitoneum and to locate the object. If imaging shows that the patient
has peritonitis or free air, a laparotomy should be performed without
delay. When perforation is suspected in an otherwise stable patient,
a helical computed tomographic (CT) scan may be performed. Findings on a CT scan suggesting a rectal full-thickness injury include
rectal wall thickening, mesorectal air, pelvic uid collections, and
mesorectal fat stranding.
Patients with rectal foreign bodies are oen reluctant to visit
the emergency department because of embarrassment and fear of
humiliation. In many circumstances, they may not provide a history of foreign body insertion or trauma, but rather present to
the emergency department with reports of anal pain and bleeding. However, once the diagnosis is made, it is important to obtain
information about the object inserted in the rectum, including its
size and shape, the length of time it has been retained, and any
attempt at removing it.
Physical examination should include abdominal and digital rectal
examination to assess the location of the rectal foreign body. Foreign
bodies proximal to the rectosigmoid junction usually are not palpable on digital examination. An assessment of internal and external sphincter integrity and tone may detect internal and external
sphincter damage as a result of foreign body insertion or attempted
removal. Alternatively, the sphincter may be increased in tone as a
result of splits in the anoderm or sphincter spasm. When the foreign
body is not palpable, a rigid or exible proctosigmoidoscopy and/
118
o
r abdominal imaging should be performed. For most rectal trauma,
a CT scan is substituted for abdominal plain lms, especially when
rectal perforation is suspected.
An algorithm for evaluation of patients with a rectal foreign body
is provided in Figure 25-1.
CLASSIFIC
R
ectal foreign bodies are classied in a variety of ways.
American
Rectal Organ Injury Scale
ost of the information about rectal foreign bodies is an extension
M
of information gained from the trauma literature on rectal injuries,
and the American Association for the Surgery of Trauma (AAST)
Rectal Organ Injury Scale for blunt and penetrating trauma can be
used to describe trauma from rectal foreign bodies (Table 25-1).
e degree of injury as detailed in the AAST scale dictates the
treatment necessary for rectal injuries. Full-thickness lacerations,
extension into the peritoneum, and the presence of devascularized tissue will require more extensive surgical debridement and
repair and oen will require diversion, distal washout, and presacral drainage.
Yes No
Laparotomy
Yes No
FIGURE 25-1 Alg
Computed tomography; DRE, digital rectal examination.
ATION
Association for the Surgery of Trauma
Assess for peritonitis
Upright abdominal radiograph:
check for free air
DRE-? palpable
Yes No
Attempt extraction
orithm for initial evaluation of foreign bodies. CT,
Rigid/flexible
sigmoidoscopy
or CT scan
Location of the Foreign Body
F
oreign bodies can be either low or high lying. High-lying objects are
dened as being above the rectosigmoid junction or more than 10
cm from the dentate line; low-lying objects are palpable and within
10 cm from the dentate line. Objects located above the rectosigmoid
junction or proximal rectum usually require surgery for removal,
which is performed through an abdominal approach with induction
of general anesthesia. Objects found in the mid to distal rectum are
more amenable to transanal removal.
Intraperitoneal or Extraperitoneal
e relationship of rectal injuries or foreign bodies to the peritoneal
reection determines the likelihood of intraperitoneal contamination
and peritonitis. Intraperitoneal injuries occur on the anterior and lateral surfaces of the upper two thirds of the rectum, whereas extraperitoneal injuries are posterior and in the lower one third. Intraperitoneal
rectal injuries usually require abdominal repair or resection with or
without diversion. Small extraperitoneal rectal injuries oen can be
observed. More extensive extraperitoneal injuries require transanal
repair but also may require diversion, presacral drainage, or distal
washout, depending on the degree of injury or contamination.
EXTRA
M
ost foreign bodies located low in the rectum may be removed at
the bedside through a transanal approach. Manual removal of sharp
objects should not be attempted. Adequate patient and anal sphincter
relaxation is a key component of successful transanal extraction, and
is usually achieved with conscious sedation with use of local perianal
or pudendal nerve block aids. Patients may be positioned in the le
lateral, knee-chest, or lithotomy position. e lithotomy with reverse
Trendelenburg position allows gravity to push the object distally, permitting easier digital extraction. Transanal extraction may be facilitated by manual compression of the lower abdomen to prevent rectal
foreign body displacement proximally.
When manual attempts at removal fail, a variety of innovative techniques and tools may be used to aid in extraction. Forceps have been
introduced into the rectum through an anoscope or an anal retractor
to grasp the distal edge of the foreign body. However, more proximal
foreign bodies create a vacuum in the rectum. In certain situations, a 20
to 26 French Foley catheter with a 30-mL balloon is passed beyond the
object and inated. Simultaneous manual proximal pressure and traction of the catheter releases the vacuum to permit the foreign body to
move distally. In a similar method, a exible sigmoidoscope is inserted
CTION
RECTAL AND PARARECTAL REGION
nd endoscopic balloons and polypectomy snares are advanced beyond
a
119
the object and inated or opened as the scope is removed. Both techniques release the vacuum and permit movement of the object distally
to allow manual transanal extraction. Anal dilation or lateral internal sphincterotomy also may aid in manual extraction. When direct
transanal extraction fails, a laparoscopic-assisted technique can be
attempted. A laparoscope along with a laparoscopic grasper is used to
visualize and manipulate the foreign body to be extracted transanally.
Most foreign bodies can be removed with these techniques, and a laparotomy is indicated in fewer than 10% of cases.
If the aforementioned attempts fail, the rectal foreign body will
need to be removed via an abdominal approach. If no perforation
or fecal contamination is seen, then a colotomy can be performed to
remove the object. e colotomy is then repaired primarily with no
need for diversion unless fecal contamination is noted.
An algorithm for extraction of a rectal foreign body is provided
in Figure 25-2.
MANA
ectal injury may result from the foreign body insertion, as well as
R
GEMENT
during the extraction process. Careful management of rectal injuries
is necessary to avoid postextraction complications and even sepsis.
Rectal wound management evolved from trauma literature during
World War II and Vietnam and includes diversion, injury repair,
presacral drainage, and distal rectal washout. Since that time, primary repair has become the mainstay of treatment with occasional
diversion. Primary repair may be considered without diversion for
less severe injuries, minimal contamination, and early treatment. If
any uncertainty exists about the presence and extent of injury or the
degree of contamination or if the patient has risk factors for anastomotic leak or a delay in diagnosis has occurred, a colostomy is
Is patient stable?
Yes No
Bedside extraction with
local ± conscious
sedation —successful
removal?
Yes No
Laparotomy
T
ABLE 25-1:
of
Trauma Rectum Injury Scale
Grade Description of Injur
I C
American
Association for the Surgery
y
ontusion or hematoma without devascularization or
partial-thickness laceration of wall
II Full-thickness laceration, <50% of circumference
III Full-thickness laceration, >50% of circumference
IV Full-thickness laceration, extends into perineum
V Devascularized portion of rectum
ata from Moore EE, Cogbill TH, Malangoni MA, etal. Organ injury scal-
D
ing, II: pancreas, duodenum, small bowel, colon, and rectum. J Traum a.
1990;30:1427.
Endoscopy—successful removal?
Yes No
General anesthesia—successful removal?
Yes No
Laparoscopy— successful removal?
Yes No
Observe
FIGURE 25-2 Alg
orithm for extraction of foreign bodies.
120
Rect
Reign Bodies
al Fo
s
trongly encouraged. A loop colostomy is favored over a Hartmann
procedure because of the morbidity associated with Hartmann reversal. If the rectal injury is not seen or is dicult to access, rectal repair
is not mandatory and proximal diversion is an option.
Presacral drainage and distal washout are rarely used except in
certain cases in the literature. In a randomized prospective study by
Gonzalez etal, diversion was compared with diversion with presacral
drainage; results showed no dierence in morbidity or mortality with
diversion alone. Presacral drainage has not been shown to prevent
infectious complications for penetrating rectal injuries and currently is
considered only for destructive injuries of the extraperitoneal rectum
that communicate with the presacral space, or where an injury cannot
be identied or repaired. When a drain is placed, the disrupted space
should be carefully identied. Similarly, distal rectal washout has fallen
out of favor, with no established protective eect against infection. It is
only used with high-energy or destructive injuries.
POSTEXTRA
M
ajor complications aer foreign body removal are rare but may be
CTION CARE
life threatening if missed. Aer foreign body removal, patients should
be monitored with serial abdominal examinations for at least several
hours for an uncomplicated extraction and at least 24 hours for more
complicated cases. e rectum should be evaluated with a rigid or exible sigmoidoscope and plain lms to evaluate for perforation, ischemia,
or bleeding prior to discharge. Perforation may result from extraction
of the foreign body and would require a laparotomy with possible
diversion. Bleeding is usually self-limiting and rarely requires further
intervention. Sphincter damage may result from foreign body insertion
and may occur during extraction. Surgical correction of the sphincter
injury should be deferred initially to allow for time for healing.
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