By Amortegui, Jose D Solla, Julio A
Surgical management of imperforate anus and rectal mucosal prolapse has evolved significantly over the last two decades. The procedure for prolapsed hemorrhoids (PPH) is now widely used primarily for rectal mucosal prolapse and internal hemorrhoids. We describe the use of PPH in the management of symptomatic rectal mucosal prolapse in a 39-year-old man with a history of a high imperforate anus and pelvic floor reconstruction. At 4-year follow up, the prolapse has not recurred and the preoperative symptoms have resolved. To the best of our knowledge, this is the first report on the use of a PPH in the management of rectal mucosal prolapse in a patient with these characteristics. THE MANAGEMENT OF AN imperforate anus has evolved significantly over the last 25 years, especially by the development of the posterior sagittal anorectoplasty (PSARP) described by Pena and deVries in 1982.1, 2 Long-term complications after repair of an imperforate anus are common, including soiling, ectropion, fecal incontinence, and constipation.3 These patients are predisposed to rectal mucosal prolapse.
The procedure for prolapsed hemorrhoids (PPH) was first described by Longo in 1998.4 Today, the PPH is indicated in the management of rectal mucosal prolapse and internal hemorrhoids. Although not considered a traditional indication, the PPH has also been used for the treatment of rectal mucosal prolapse with outlet obstruction, other functional disorders of defection, and even rectocele.5-8 To the best of our knowledge, this is the first report of a PPH used for rectal mucosal prolapse in a patient with a history of a high imperforate anus.
Case Report
A 39-year-old white man presented in July 2003 with increasing rectal pain after bowel movements and sitting, worsening rectal mucosal prolapse, pruritus ani, soiling, and a significant amount of bright red blood with stools. His history included a high imperforate anus. He had a colostomy immediately after birth and during the next 4 years, he had multiple surgeries to reconstruct his anorectum and perineum. At the age of 4 years, continuity of the gastrointestinal tract was re-established. Since then, the patient has had chronic constipation with straining, and he averaged one to two bowel movements per week using an enema on a biweekly basis to evacuate. Once able to defecate, he had significant incontinence. His constipation-incontinence lasted until his latter 20s and had only recently reached a point where soiling and seepage was not a major problem. He has also had a long history of rectal mucosal prolapse, ectropion, pruritus ani, and occasional rectal pain and bleeding.
When asked the reason for delaying seeking out medical attention, he expressed to us that he had his symptomatic mucosal prolapse for years because of his fear that surgery would cause recurrence of his incontinence.
Avoiding incontinence or even seepage was very important because he is a maintenance technician in a nuclear plant; he works in radiation-contaminated areas, requiring the use of a bubble suit, which did not allow him to take breaks for cleaning purposes.
On physical examination, there was an obvious circumferential rectal mucosal prolapse exiting at least 1.5 cm with associated swelling and signs of pruritus ani. There was no evidence of full- thickness rectal prolapse. There was an ectropion secondary to his prior surgeries with erythema of the perineal area secondary to “wet anus syndrome” and pruritus ani. There was no evidence of hemorrhoids or an obvious sphincter complex and his squeeze pressure was very poor to almost absent (Fig. 1A). A proctoscopic examination up to 18 cm showed signs of nonspecific proctitis. After the initial evaluation, the patient was put on a high-fiber diet with psyllium supplementation and was scheduled for a PPH.
FIG. 1. (A) Preoperative findings; note the mucosal prolapse. (B) Postoperative results; the prolapse has resolved.
At surgery, there was incarcerated rectal mucosa with associated swelling in the area where one would expect hemorrhoids to be. Such findings explain the pain, bleeding, “wet anus syndrome,” and pruritus ani experienced by the patient. We proceeded with a standard PPH as described elsewhere with the intention of performing a mucoproctoplasty.9
The senior author (SJ) modifies the procedure by drawing a line in the pursestring suture anoscope at the point where it changes from a cylinder to a cone. This facilitates visualization of the point where the pursestring should be made; the residents routinely refer to this as “Solla’s line” (Fig. 2).
The postoperative period was uneventful with only mild discomfort during the first few postoperative days. Pain, bleeding, pruritus ani, “wet anus syndrome,” soiling, and rectal mucosal prolapse rapidly resolved after the surgery and have not recurred with 4 years of follow up (Fig. IB). His constipation improved as well with the diet modification and fiber supplementation. Most importantly for the patient, he maintained continence.
Discussion
There are a wide range of congenital anorectal malformations. Imperforate anus occurs in every 4000 to 5000 births. Sacral deformities, spinal abnormalities, esophageal atresia, cardiac malformations, and urologie defects are commonly associated.3,10 Surgical management is dictated by anatomy, associated malformations, and the patient’s condition. Consensus exists that patients with a perineal fistula can be repaired primarily in the newborn period without a colostomy. For all other anorectal defects, a three-step approach consisting of diverting colostomy shortly after birth, definitive surgical management of the defect at a later date, usually 4 to 8 weeks later, and, finally, colostomy closure.10 Most pediatric surgeons perform the PSARP to repair these malformations with or without laparotomy or laparoscopy.3,10
FIG. 2. (A) Line in the pursestring suture anoscope at the point where it changes from a cylinder to a cone. (B) Anoscope in a patient; the line facilitates visualization of the point where the pursestring should be made. (Note: This image is not from the case reported in this text.)
For our patient, a colostomy was required at birth and he had multiple surgeries throughout his first years of life. Eventually, the colostomy was closed when he was 4 years old. Unfortunately, old records from our patient were lost. We speculate that he had a high and complex defect based on the course of his management. At the time of our patient’s birth, the PSARP had not been described; we could not tell what kind of definitive repair he had.
Most patients who undergo repair of an anorectal malformation have some degree of a functional defecating disorder with an abnormal fecal continence mechanism. Long-term results vary depending on the type of defects; patients with a bladder neck fistula have a worse prognosis than those with perineal fistula. Thirty-five per cent to 100 per cent of patients have voluntary bowel movements. Total continence ranges from O per cent to 100 per cent and constipation (65%) is the most common sequelae seen in patients after the repair of an imperforate anus.3,10 Our patient had lifelong constipation that required biweekly enemas to evacuate.
Rectal mucosal prolapse is a common condition that is frequently confused with prolapsing hemorrhoids. Rectal mucosal prolapse is characterized by prolapse of the rectal mucosa below the dentate line spontaneously or during straining on defecation. It may or may not be associated with internal prolapsed hemorrhoids and causes itching, wet anus, and bleeding. All these symptoms were experienced by our patient. In his case, there were no hemorrhoidal cushions with the prolapsed mucosa. The most common condition that causes rectal mucosal prolapse is constipation and chronic straining; other causes include anal sphincter dysfunction and descending perineum syndrome. The treatment is based on the severity of symptoms and findings on examination and can range from conservative measures to surgical excision of the prolapsed mucosa.
The PPH was first described by Longo in 1998(4); in his initial series, he reported on 144 patients with mucosal and hemorrhoidal prolapse who underwent PPH with good results. The therapeutic premise for the procedure is that the reduction of the prolapse, restoring the normal anatomical relationship between the anal mucosa and the hemorrhoidal piles with the anal sphincters, allows a better venous return; there is also a blocking of the end branches of the upper rectal artery and, as a consequence, the regression of the symptoms of the hemorrhoidal disease, anal prolapse, and bleeding. After this initial report, there have been randomized trials comparing the PPH with different techniques used in the management of hemorrhoidal disease.11-18 The trials have proven that the PPH is safe procedure; it is at least as effective as the traditional methods in the surgical management of internal hemorrhoidal disease and rectal mucosal prolapse and has the same complication rates as the open techniques. Advantages of the PPH over open techniques include less postoperative pain, fewer analgesics, early discharge, less time off work, and less pain at first bowel movement. These advantages result as a result of the fact that the highly innervated peri-anal skin and anoderm are not incised or removed. One of the author’s (SJ) personal experience with more than 600 PPH mirrors these results with 50 per cent of the patients back to their normal activities in 3 days and 95 per cent within 1 week. A recent meta- analysis of stapled hemorrhoidectomy done by the Cochrane group19 showed a higher long-term risk of hemorrhoidal recurrence and the symptoms of prolapse. This study has been widely criticized because it draws conclusions from heterogeneous patients and techniques compared. We inform the patients that the PPH has a higher recurrence rate for hemorrhoids, but we also believe that the advantages mentioned outweigh any increase in the recurrence rate. Altomare et al.20 reported the successful treatment of 18 patients with overt rectal mucosal prolapse without hemorrhoids using the PPH stapler. All patients were fully satisfied with the results and the prolapse was eliminated in all except two who required one rubber band ligation. Similar good results were reported more recently in a small series of eight patients without recurrence of rectal mucosal prolapse.21
We were able to use to use the PPH technique to maximally benefit our patient. Left with the undesirable complications of soilage, constipation, prolapse, and pain after imperforate anus reconstruction, the PPH has successfully eliminated these symptoms. After a 4-year follow up, the prolapse has not recurred and the preoperative symptoms have resolved. The PPH technique should be considered in similar cases.
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JOSE D. AMORTEGUI, M.D., JULIO A. SOLLA, M.D.
From the Department of Surgery, University of Tennessee Graduate School of Medicine,
Knoxville, Tennessee
Presented at the Annual Scientific Meeting and Postgraduate Course Program, Southeastern Surgical Congress, Birmingham, Alabama, February 9-12, 2008.
Address correspondence and reprint requests to Jose D. Amortegui, M.D., 1924 Alcoa Highway, Box U-11, Knoxville, TN 37920. E-mail: [email protected].
Copyright Southeastern Surgical Congress May 2008
(c) 2008 American Surgeon, The. Provided by ProQuest Information and Learning. All rights Reserved.
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