Rectal Prolapse Rapid Fire: Update Course 2015

I was asked to speak about was on rectal prolapse, tremendous amount of literature on this in the pediatric population. Um, I'm kidding. We, we have room to improve here. Um, so first thing when you're dealing with rectal prolapse is to discern whether it's full thickness prolapse as seen on the pictures, uh, the two pictures on top of each other, or a partial thickness prolapse or mucosal prolapse is seen. Uh, under the wording and so this is the patient could be of any age, um, but I wanted to ask the question of what workup do you perform for patients with rectal prolapse? Do you scope the patient rigid or flexible? Do you do a contrast enema? Do you do anal physiologic testing which could include manometry? Um, EMG, etc. or, or do you do a combination of testing, and we could go back to that later in, in maybe in the talk. The other question I wanted to ask the audience was, do you test for CF? I was trained to test for CF. I answered the question on my boards to check. For CF, I've never picked up a patient with CF, um, in my practice, and reading the literature, neither has many other people picked up patients. You might have a CF patient that presents to you with rectal prolapse, but have you picked up a case of CF? So I think that'll be interesting to learn, but the million dollar question is next. If medical management is not successful, so I think many of us would treat the patient for constipation, sit, have him only sit on the toilet for 5 minutes, and, but you, you went through that process and you went through it for 6 months, 1 year, 2 years, and it's still going on. What operation would you perform? And I, I didn't include laparoscopy versus not, but just would you do a recopexy, a recopexy, and resection. Uh, a DeLorme, an Altmeyer inject sclerosing agents or others as there's newer gold standard operations in the adult literature right now, uh, mostly a ventral rectopexy, which I don't think the has hit the pediatric literature too much yet. Rapid fire and does anyone do anything, so I do, I do a resection and a rip stain recopexy. OK. Anyone do anything else different? OK. OK. Anyone else? David, I haven't done many of these, but I've done, uh, I haven't done many, but I've done a few anal circles, uh, which actually works well, especially in the small babies. Um, I get achondrocendment if there's a huge redundant segment resect, but definitely laparoscopic rectopexy to promontory. So the liter injection of sclerotic agent, you've injected sclerotic agents in fellowship at least. I, I haven't had, I haven't had to do it yet, but that's actually it was filled because out of peanut oil and I haven't done that. What's that hypertonic saline. I can tell you when it recurs to re-operate on those patients is not going to matter at all. Yeah, a lot of people, I'm just looking at this, a lot of people did the sclerosing agent. I, I have not had success with, I can't think of a patient that I didn't end up doing a rectopexy on. So the literature and some of it's, most of it is in the adult literature, but I'll share with you, even in the pediatric literature, it sounds like the transabdominal approaches are have less of a recurrence rate whether you do a resection and rectopexy or recopexy alone, but going through the abdomen has a About a 5% recurrence rate versus somewhere between 15 and 20% with the transanal approaches, whether you're doing a transanal pull through or a um an Altmeyer type procedure, um, has a higher recurrence rate, at least in the literature. The literature also states that because I used to do a resection and erectopexy, so if you're having problems controlling the constipation, that might be a better procedure, but there's a higher. Um, complication rate with patients who are having a resection, obviously a resection and a and a Pepy versus just epy alone. There's literature now where patients go home the next day after a rectopexy or even same day surgery, so that seems to be the the theme. The only other thing I wanted to talk about, and that's demonstrated in this cartoon here, um, which is a newer. procedure in the in the literature in the adult literature and really popularized by the group in at the Cleveland Clinic and a few other centers is the ventral mesh rectopexy, and I think many of us are afraid to use mesh and there's definitely reports of erosion in the population, but I have one patient where I've operated on twice through the abdomen and then the. The operation was this ventral mesh rectopexy, which seemed to have solved the problem, at least for now, and it's basically putting a piece of mesh on the anterior surface of the rectum, bringing the rectum up, not dissecting posteriorly, and then tacking the mesh to the sacral promontory is the basic description of the procedure, and you can do that open or laparoscopically. So the idea is that change some of the angulation, change some angulation, and the literature, if, if you want to go into the pathophysiology of rectal prolapse, especially in the younger patient, they think the angle of the rectum to the anal canal is more of a straight shot when you're younger and it becomes more of an angle as you get older and so this is sort of trying to change that, although this is the procedure used in many. Women, you know, many adult, older adult patients, primarily women who have, uh, pelvic floor relaxation issues. So I think those are the things that are up to date in rectal prolapse. There's no perfect operation. If you know of one, let me know. That was great. That was a good summary.