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PURPOSE: To suggest a classification, describe the risk factors and management of rectal prolapse after anorectoplasty for anorectal malformations (ARMs). METHODS: We classified prolapse as minimal (rectal mucosa visible with Valsalva manoeuvre), moderate (prolapse <5 mm without Valsalva), evident (>5 mm without Valsalva) and compared patients with and without prolapse within our ARM-population. RESULTS: Among 150 patients, 40 (27 %) developed prolapse: 25 minimal, 6 moderate, 9 evident. Prolapse affected 33 % of males (9 % of perineal fistulas, 38 % of bulbar, 71 % of prostatic, 60 % of bladder neck and 13 % without fistula) and 21 % of females (9 % of perineal, 30 % of vestibular, 50 % of cloacas, and 25 % without fistula). Risk factors for prolapse were: tethered cord (40 vs 24 %), vertebral anomalies (39 vs 24 %), laparoscopic-assisted anorectoplasty (LAARP) (75 vs 25 %), and colostomy at birth (49 vs 9 %). Redo anorectoplasty was not associated with prolapse. Symptoms were present in 11 patients (28 %): in 7 % with minimal, 33 % with moderate and 77 % with evident prolapse. Nine patients (2 moderate, 7 evident) underwent surgical correction. CONCLUSION: Severe ARMs, tethered cord, vertebral anomalies, colostomy, and LAARP predispose to rectal prolapse. Classifying prolapse allows to predict symptoms and need for surgical correction, and to compare outcomes among different centers.

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Rectal prolapse is protrusion of the rectum throuhg the anal sphincter. If the protrusion is made up to the entire thickness of the rectal wall, it constitutes a complete prolapse; is called partial, incomplete or mucosal. Rectal prolapse was described in the Ebers Papyrus, 1500 years B.C. is an uncommon pathology frequently incapacitating, and many aspects are still ignored. Complete rectal prolapse predominantly affects adults and usually is associated to fecal incontinence, but also can affect children, generally before five years of age. Rectal prolapse is several times more common in women than in men. The symptoms that patients with complete rectal prolapse present are the actual prolapse itself, with fecal incontinence and altertion of bowel habits. Numerous procedures are available to treat complete rectal prolapse, which can be done through the abdominal or the perineal approaches. Before subjecting these patients to surgery, they should be carefully evaluated to select the surgical procedure to be used. Abdominal procedures are the most usually used and offer beter results. The numerous surgical procedures by the abdominal approach can be synthesized as follows: the Orr procedure or lateral fixation, the Muir procedure (resection without fixation), Dissection of the sigmoid with sacral fixation (Frykmann & Goldberg), De Wells procedure or posterior fixation. The anterior rectopexy or the Ripstein procedure is the preferred technique, especially in the U.S.A., and shows good results; the Ripstein procedure consists in mobilization of the rectum down to the elevator ani muscles. The rectum is fixed to the sacral cavity by means of a piece of Marlex mesh which surrounds the anterior and lateral rectal walls.

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El prolapso rectal continúa siendo una patología que genera controversias a pesar del tiempo trascurrido. La etiopatogenia no es aún bien conocida y se manifiesta como un trastorno del piso pelviano asociado a otras patologías, además se suman la incontinencia y la constipación que generan mayor complejidad al momento de decidir el tratamiento adecuado. Durante el desarrollo del relato se analizan las diferentes series y sus resultados, con el objetivo de arribar a conclusiones que definan si la mejor operación existe. Debido a la falta de publicaciones que presenten series numerosas y seguimiento adecuado, como así también a resultados basados en evidencia, el tratamiento ideal del prolapso rectal es aún cuestionado. Concluimos que se evidencia algún cambio respecto a las vías de abordaje, con una reivindicación de las técnicas perineales y un incremento de la vía laparoscópica con tendencia a proyectarse como el estándar oro. Pero creemos todavía que cada cirujano deberá decidir la conducta quirúrgica caso por caso.

Despite the time that has passed, rectal procidencia continues to be an entity that gives rise to controversy. Pathogenesis is not yet well know and is manifested as a disorder of the pelvic floor associated with other diseases, besides incontinence and constipation are added that generate even higher complexity when having to decide on the appropriate treatment. Along this review, different series and its results have been analyzed with the objective of finding out conclusions that define if the best surgery exists. Due to the lack of publications with extensive series and appropriate monitoring, as well as to results based on evidence, the ideal treatment of rectal procidence is still questioned. We conclude that some change is evidenced according to the technique or approach selected with a revindication on perineal techniques and an increase on laparoscopic approach tending to project itself as the gold standard. We still believe that each surgeon must decide the conduct of surgery on a case by case basis.

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It is not so much the diagnosis that offers the surgeon a wide range of opportunities in the technical solutions of rectal prolapse. Currently there are at least 130 different techniques used in the surgical treatment of rectal prolapse and in fact none of these procedures has been shown most effective for any one patient. In this study, our intent is to describe the experiences of the authors with the treatment of rectal prolapse, to estimate the actual level of expertise of the surgeons in treatment of rectal prolapse, and to describe in which way to proceed in the future (Tab. 4, Fig. 3, Ref. 27). Full Text (Free, PDF) www.bmj.sk.

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PURPOSE: Haemorrhoid prolapse is an indication for surgery. A correlation between worsening anatomy and increasing symptoms is commonly assumed. We developed a classification algorithm of prolapse and external component, and evaluated its correlation to symptoms before and after surgery. METHOD: A study population comprising 180 patients operated for haemorrhoids in a multicentre randomized trial plus a validation set comprising 90 patients operated by us. The classification used three items: (i) patient self-report of prolapse requiring manual reposition; (ii) surgeon assessment of prolapse when patient negated manual reposition; (iii) surgeon assessment of external component. Patient self-reported were rated by frequency (never, 0 points; monthly, 1 point; weekly, 2 points and daily, 3 points). The algorithm yielded three grades: 1, no prolapse; 2, spontaneously reducing prolapse and 3, prolapse needing manual repositioning. The degree of external component was affixed as A, none; B, one or few tags and C, circumferential. RESULTS: Anatomical grades did not differ between the two sets of patients before or after surgery. Preoperatively, 69% had grade 3 prolapse. Postoperatively, 89% were classified as grades 1A or B. The symptom load was similar for grades 2 and 3; mean 6.5 points preoperatively and 1.8 points postoperatively. CONCLUSION: This anatomical classification, based on strict criteria, reliably staged the haemorrhoid prolapse. There was no unique preoperative symptom profile associated with any degree of prolapse with or without an external component. Restored anal anatomy relieved symptoms. The classification also defined recurrence of haemorrhoids.

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Hemorrhoidal disease is one of the most frequent disorders in western countries. The aim of individual therapy is freedom from symptoms achieved by normalisation of anatomy and physiology. Treatment is orientated to the stage of disease: haemorrhoids 1 are treated conservatively. In addition to high-fibre diet, sclerotherapy is used. Haemorrhoids 2 prolapse during defecation and return spontaneously. First-line treatment is rubber band ligation. Haemorrhoids 3 that prolapse during defecation have to be digitally reduced, and the majority need surgery. For segmental disorders, haemorrhoidectomy according to Milligan-Morgan or Ferguson is recommended. In circular disease, Stapler hemorrhoidopexy is now the procedure of choice. Using a therapeutic regime according to the hemorrhoidal disease classification offers high healing rates and low rates of complications and recurrence.

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Despite progress in modern surgery, the choice of the surgical procedure of rectal prolapse is regarded with controversy. Selection criteria between the abdominal or perineal approach or between rectopexy and resection rectopexy are not yet proven. This article gives a review of the literature about rectal prolapse and an analysis of the outcome of posterior rectopexy and resection rectopexy--partly conventionally and partly laparoscopically--in 25 patients with rectal prolapse III degrees and IV degrees. All except for one patient were examined during a mean follow-up of 5.5 (3.1) years for the rectopexy group and 2.1 (0.7) years for the resection rectopexy group. Recurrence occurred in one patient in each group respectively. There was no significant difference concerning the continence function (p = 0.32) and constipation (p = 0.36) between both groups. No mesh-related complications such as infection, fistula or rectum stenosis were observed. According to the review of the literature and our data, we believe that the choice of the operative procedure for rectal prolapse should be based on individual criteria. Fit patients should be offered laparoscopic procedures such as resection rectopexy and rectopexy without colonic resection.

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Selection of an appropriate approach to treat full thickness rectal prolapse remains problematic and controversial. We propose that rectal prolapse may be classified as 'low type' (true rectal prolapse) or 'high type' (intussusception of the sigmoid with a fixed lower rectum). This assessment can be made via a simple clinical test of digital rectal assessment of lower rectal fixity ('the hook test') based on anatomic changes in rectal prolapse to guide the selection process. In cases with the low-type prolapse, a perineal approach is appropriate (either Delorme's procedure, or rectosigmoidectomy with or without pelvic floor repair). For the high type, an abdominal rectopexy with or without high anterior resection is needed. Retrospective analysis of our cases treated over the last 6 years showed a recurrence rate of 6% in perineal procedures and 0% in abdominal rectopexy combined with resection to date. We believe that employing our simple test and classification can contribute to better patient selection for either approach, minimize anaesthetic and surgical risks and also result in lower recurrence rates.

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Hemorrhoidal disease results from the pathological enlargement and distal displacement of the upper hemorrhoidal plexus. This disorder is very widespread in modern industrial society. Hereditary predisposition, malnutrition with constipation and abnormal bowel habits seem to be the most relevant causes for pathogenesis. The exact classification of hemorrhoids according to the degree of prolapse as well as the correct evaluation of accompanying anal diseases are very important in order to choose the appropriate conservative or surgical treatment with the goal of long-term avoidance of recurrence.

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The spectrum of procedures for haemorrhoidal disease can deal with all developmental stages if done in a differentiated way. The possibilities, limitations, and risks of the different methods are described. The catalogue stretches from relatively simple operations (Milligan-Morgan, stapler haemorrhoidectomy), which every general surgeon should be able to perform, to extensive anoplastic reconstruction, which is limited to specialists. Although the global risks of the more simple operations make them suitable for outpatient procedures, there are--at least in Germany--severe reservations, as there is the danger of inadequately therapy in more advanced cases, overcharging a lot of patients, lack of cooperation and knowledge about the necessities of early postoperative care by the local practitioners, problems in follow-up in patients living far away, and inadequate payment for the therapeutical costs by the health insurance companies.

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The paper gives colonic X-ray findings in 39 patients with rectal prolapse. Of them, 20 and 19 patients were found to have internal and external rectal prolapse, respectively. Studies were conducted by the modified irrigoscopy developed by the State Coloproctology Research Center, Ministry of Health of the Russian Federation, to explore the anatomic and functional status of the rectum and the fundus of the pelvis in patients with impaired defecation. The X-ray sign of circular invagination that had been detected by the authors allowed them to make the diagnosis of internal rectal prolapse with the greatest assurance. The modified irrigoscopy in combination with oral enterography for external rectal prolapse could show associated changes, including enterocele and sigmocele.

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The aim of the therapy of piles is to cure the complaints of the patient by reducing the enlarged haemorrhoidal plexus according to the stage (1 degree to 3 degrees) to a nearly physiological size and in case of a prolapse to replace the sensitive anoderma. The basic therapy consists of regulating the bowel function and avoiding straining. A high fibre diet or bulk laxatives may be necessary. If this fails 1 degree haemorrhoids should be treated in the office by sklerotherapy, 2nd or 2nd to 3rd degree haemorrhoids by rubber band ligation from the very beginning. The Haemorrhoidal Artery Ligation (HAL) and the circular mucosectomy with a stapling device can be done as an office procedure too. An anal prolapse of 1 or 2 segments should be treated as outpatient surgery in an "open" technique (Milligan-Morgan), more than 2 segments in a "closed" (Ferguson) or better in a "semi-closed submucosal" technique (Parks) in the hospital. A cicular anoplasty preserves the anoderma and enables its reposition as well as the excision of perianal skin tags and fibromata. This is not an office procedure.

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Se presentan 9 casos de Prolapso Rectal completo, que fueron sometidos a cirugía durante un período de 10 meses. La Rectosigmoidectomía Perineal o Técnica de Altemeier se realizó en 6 casos,la operación de Ripstein en uno y Cerclaje Anal tipo Thiersch en dos. Todas fueron del sexo femenino. La edad promedio fue 68 años. En cuatro se determinó incontinencia fecal. No hubo mortalidad ni morbilidad. El seguimiento promedio a la fecha es de 10 meses. Se tuvo una recurrencia del Cerclaje Thiersch que fue tratada con la Operación de Altemeier. Se logró continencia fecal en el 80 de los pacientes. Se concluye que la Operación de Altemeier es una buena alternativa quirúrgica para el Prolapso Rectal Completo, con poca morbilidad y bien tolerado por pacientes de edad avanzada y/o con alto riesgo quirúrgico

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The management of rectal internal mucosal prolapse (RIMP) is not based on an accepted classification of the lesion which helps to choose the appropriate treatment. The aim of this prospective study was to report a new endoscopic grading of RIMP and to evaluate its clinical value. Thirty-two patients (7 men, 25 women; mean age 56 years, range 28-72) affected by symptomatic RIMP were prospectively classified as follows: RIMP was defined as first degree when detectable below the anorectal ring on straining, as second degree when it reached the dentate line, and as third degree when it reached the anal verge. Anal manometry was carried out in 26 patients, and anal ultrasound and defecography in 6 prior to surgery. A correlation was found between the occurrence and severity of symptoms and the degree of the prolapse as obstructed defecation, bleeding and fecal soiling affected mainly patients with third-degree RIMP. At manometry the maximal resting tone was 60+/-23 mm Hg and voluntary contraction 96+/-41 mm Hg (mean+/-SEM). At anal ultrasound the mean internal sphincter thickness was 2.1+/-0.2 mm, and external sphincter thickness was 7.0+/-0.8 mm. A significant rectocele and rectal intussusception (n = 2) and a nonrelaxing puborectalis muscle on straining (n = 2) were observed at defecography in cases with third-degree RIMP. The anorectal angle was 100+/-75 degrees at rest, 63+/-20 degrees on squeezing, and 115+/-9 degrees on straining. A conservative treatment with high-fiber diet and/or rubber band ligation was carried out in all cases of first and in most patients with second-degree RIMP (n = 26). Those who required surgery, i.e., stapled transanal excision of the prolapse (n = 6), had either severely symptomatic third-degree RIMP with solitary ulcer syndrome (n = 4) or second-degree RIMP (n = 2). A positive outcome was achieved in 71% of cases. The proposed classification evaluated by the present study may be of clinical value in managing rectal internal mucosal prolapse.

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Having analyzed the experience with examination and treatment of 182 patients with rectal prolapse the authors are presenting a clinical classification including the main criteria of the disease: stage of prolapse, degree of incompetence of the anal sphincter, phase of compensation of the pelvic fundus muscles. On the basis of the classification proposed the adequate method of treatment of such patients can be chosen. In 97% of patients the prolapse of the rectum have been liquidated, in 92,5% of them the function of its closing apparatus have been completely recovered.

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