Preventing Recurrence in Crohn

1
INTERNAL RECTAL PROLAPSE (Rectal
Intussusception) Mr J Graham Williams Consultant
Colorectal Surgeon New Cross Hospital Wolverhampto
n
2
Functional Bowel Disordersand the Colorectal
Surgeon
IBS
Constipation
Diarrhoea
Faecal incontinence
Rectal Prolapse
Rectocoel
Solitary Rectal Ulcer
Rectal Intussusception
Anal Pain
3
INTERNAL PROLAPSEWhat are we talking about?

• Thought to cause symptoms by
• Obstructing rectal ampulla
• Triggering the persistent desire to defaecate
• Triggering the sensation of prolapse

4
INTERNAL RECTAL PROLAPSE
Symptoms

• Pelvic dragging
• Tenesmus
• Straining
• Obstructed defaecation
• Digitation
• Mucus discharge
• Rectal bleeding
• Incontinence

5
INTERNAL RECTAL PROLAPSE
Associated Problems

• Perineal descent
• Gynaecological prolapse
• Rectocoel
• Solitary rectal ulcer

6
INTERNAL RECTAL PROLAPSE
Diagnosis

• History
• Examination
• S-oscopy proctoscopy
• Defaecography
• Dynamic MRI

7
INTERNAL RECTAL PROLAPSEDefaecography
Rest
Strain
Strain
Pictures courtesy of Lee Dvorkin, London Hospital
8
INTERNAL RECTAL PROLAPSEIncidence of
Intussusception During Defaecography in
Asymptomatic Subjects
Author Date Subjects Age No ve
Shorvon et al 1989 Students lt35 44 50
Goei et al 1989 Patients 41-78 32 22
Selvaggi et al 1990 Volunteers 25-64 10 50
Ikenberry et al 1996 Students lt30 20 30
9
INTERNAL RECTAL PROLAPSEDefaecography
Do symptoms correlate with defaecography?

• Qualitative and quantitative differences in
  features of internal prolapse between symptomatic
  and asymptomatic subjects

Thickness
Picture courtesy of Lee Dvorkin London Hospital
10
INTERNAL RECTAL PROLAPSEDefaecography
Do symptoms correlate with defaecography?

• Defaecography performed in 437 patients and 43
  asymptomatic controls
• Internal prolapse demonstrated in 35 patients and
  13 controls
• Rectal folding thickness significantly thicker in
  symptomatic individuals
• Intussusceptum lumen diameter significantly
  smaller in symptomatic individuals

Pomerri et al AJR 2001 176 641
11
INTERNAL RECTAL PROLAPSETreatment
Medical

• Explanation reassurance
• Diet Laxatives
• Suppositories enemas
• Sympathetic ear
• Biofeedback

Poor response (lt30 improvement)
12
INTERNAL RECTAL PROLAPSETreatment
Surgical
Trans-abdominal

• Rectopexy
• Anterior resection
• RBL mucosa
• Delorme
• Pelvic suspension (EXPRESS)

Perineal
13
INTERNAL RECTAL PROLAPSEAbdominal Rectopexy

• Abdominal procedure
• Incontinence improved in 70
• Constipation
• Mechanical (mesh sling)
• Functional (rectal mobilisation)

14
INTERNAL RECTAL PROLAPSEDelormes Operation

• Perineal procedure
• Low morbidity
• Fiddly operation
• Reduction in rectal reservoir
• Stretching of anal sphincter

15
INTERNAL RECTAL PROLAPSEDelormes Operation

• Phosphate enema
• Prone jack-knife position
• Head light (essential)
• Lone Star retractor
• Selection of anal retractors (Sawyer,
  Hill-Ferguson, Pratt bi-valve)
• Saline with 1100,000 adrenalin
• Knife or scissors to dissect mucosa
• Duval to retract mucosal tube

16
INTERNAL RECTAL PROLAPSEDelormes Operation (JGW
experience)

• 20 Symptomatic patients 1995-2003
• All female, median age 64 (range 30-73)
• 2 Patients suture line sepsis
• 1 patient 1o haemorrhage, I patient 2o
  haemorrhage
• Same time period
• Delorme on 24 patients with full thickness
  prolapse
• Delorme operation of 19 patients with mucosal
  prolapse
• Altemeier on 27 patients with full thickness
  prolapse
• Rectocoel repair in isolation on 28 patients
• Rectopexy 11 FT prolapse, 1 Internal prolapse
• 2 solitary ulcer

17
INTERNAL RECTAL PROLAPSEDelormes Operation (JGW
experience)
Symptoms
Number of patients with symptom
18
INTERNAL RECTAL PROLAPSEDelormes Operation (JGW
experience)
Early result 2 months
85 Grade 12
Late result gt12 months
Number of patients
75 Grade 12
Outcome
1- Symptoms resolved
2- Symptoms improved, but still some problems
3- Symptoms unchanged
4- Symptoms worse
19
INTERNAL RECTAL PROLAPSEDelormes Operation (JGW
experience)
Comments

• Irritable bowel syndrome influences outcome
• ? Placebo effect
• Deterioration in anal control noted in 4 patients
  following surgery
• Results deteriorate with time
• Operation does not address perineal descent

20
INTERNAL RECTAL PROLAPSEDelormes Operation
Author Date Number Grade 12
Berman et al 1990 21 71
Sielezneff et al 1999 11 100
Liberman et al 2000 34 76
Williams 2004 19 79
21
AVOIDING MILLSTONES IN SURGERY OF FUNCTIONAL
BOWEL DISORDERS
22
INTERNAL RECTAL PROLAPSEDelormes Operation -
Case Selection
Features with poor outcome

• Chronic diarrhoea
• High origin of intussusception
• Wide recto-sacral separation on defaecography
• Pre-existing incontinence
• Gross perineal descent

23
(No Transcript)
24
OTHER THINGS TO LOOK OUT FOR

• Problem transference behaviour
• Spread sheets, poems and paintings of their bowel
  function

25
AVOIDING MILLSTONES IN SURGERY OF FUNCTIONAL
BOWEL DISORDERS
Fairy Godmother Questions
Which of all the problems you are experiencing
gives you the most trouble If I had a magic
wand, what would you want me to make better
26
INTERNAL RECTAL PROLAPSEEXPRESS Procedure

• External Pelvic Rectal Suspension
• Developed using stabilised collagen implants
  (Permacol) 3700

27
INTERNAL RECTAL PROLAPSESummary

• Challenging condition to diagnose
• Challenging condition to treat
• Usually part of wider disorder of pelvic and
  anorectal dysfunction
• Surgical approach helps some patients
• Careful case selection important

28
Sweet Jesus! Heal this sinners constipation