Endoscopic Management of Valvulus, Rectal Prolapse, Rectocele, and Intussusception

ABBREVIATIONS

CRA

colorectal anastomosis

CV

cecal volvulus

PEC

percutaneous endoscopic colostomy

STARR

stapled trans-anal rectal resection

SV

sigmoid volvulus

INTRODUCTION

Causes of Obstructive Defecation

VOLVULUS

Voluvus is defined as a tortion of the gastrointestinal (GI) tract, with common locations at the sigmoid colon and cecum. Sigmoid volvulus (SV) is the third leading cause of colonic obstruction worldwide, affecting mainly the elderly (>70 years old) population. In SV, an air-filled loop of the sigmoid colon twists along its mesenteric axis. While partial SV causes partial bowel obstruction, complete SV (≥360 degrees) leads to complete obstruction and compromised mesenteric blood flow. Cecal volvulus can occasionally occur. Common symptoms are nausea, vomiting, abdominal pain, bloating, and obstipation.

Reported risk factors include chronic constipation, a high-fiber diet, frequent use of laxatives, a history of laparotomy, and a redundant sigmoid colon with a narrow mesenteric attachment. Elderly male patients with chronic constipation are more likely to have an elongated colon. ^, These patients, along with females with a capacious pelvis with lax abdominal muscles, may be prone to the development of SV. Colonic dysmotility, especially sigmoid dyskinesia, may be a risk factor for SV.

The management of SV depends on the presence or absence of clinical and radiographic alarm signs of peritonitis, perforation, or bowel compromise. The presence of these alarm signs indicates immediate surgery, that is, subtotal colectomy and ileostomy for those with vascular compromise of the proximal colon or segmental colectomy for those without compromised vasculature. In patients without alarm signs, endoscopic detorsion was performed with the placement of a decompression tube ( Fig. 25.1 ). Following successful endoscopic detortion, patients would go through bowel preparation followed by sigmoid colectomy during the index admission or shortly thereafter to prevent a recurrence. If the patients are not candidates for surgical intervention, percutaneous endoscopic colostomy (PEC) or percutaneous endoscopic pexy are recommended in patients with recurrence (≥episodes) of SV. ^,

Traditional surgical intervention involves sigmoid colectomy with primary colorectal anastomosis, with a small number of patients at risk for anastomosis complications having diverting stoma. Approximately 85% of patients having endoscopic detortion but not sigmoid colectomy would have a recurrence. Recurrence rates increase with subsequent episodes. It appears that recurrent SV is uncommon after sigmoid colectomy. In a retrospective study of endoscopic detortion and surgical therapy (e.g., mesosigmoideopexy, exteriorization for late sigmoidectomy, sigmoidectomy and Hartmann procedure, Mikulicz procedure, or primary colorectal anastomosis [CRA]) of 827 patients with SV, recurrence in the surgical treatment group is low. Late (after hospital discharge) recurrence only occurred in those with endoscopic detortion (9/25) or mesosigmoidopexy (5/31) and in none with sigmoidectomy (0/99) during the follow-up period.

Endoscopic Detortion and Decompression

Endoscopic detorsion with or without placement of a decompression tube is the first-line treatment option for index or recurrent, uncomplicated SV ( Fig. 25.1 ). In addition to detortion and decompression, endoscopy can also assess the viability of the colon mucosa. The reported success rate of endoscopic detorsion of SV ranged from 55% to 94%. In a retrospective study of 83 patients with successful or unsuccessful endoscopic detortion, the presence of previous abdominal surgery and a cecum diameter over 10 cm were seen as predictive factors for the failure of the procedure. Despite the lack of data from randomized controlled trials, the guideline from the American Society for Gastrointestinal Endoscopy recommends the placement of a decompression tube with the tip at the colon proximal to the twisted point at the sigmoid colon. In the cecal volvulus, endoscopy has no role, and surgery is the rule.

Endoscopic Banding, Septectomy, and Plication

Anastomotic complications such as bleeding, strictures, or leaks after sigmoidectomy and end-to-end or side-to-end CRA are not common. However, the left colon proximal to the CRA may have mucosal prolapse, partially blocking the lumen of the anastomosis and causing symptoms of partial bowel obstruction. The mucosal prolapse in the area can be treated with endoscopic band ligation of the prolapse.

This author has encountered multiple patients with recurrent SV following sigmoidectomy and CRA. The patients presented with bloating, dyschezia, and obstipation. Anorectal manometry often showed paradoxical and/or sawtooth contractions of pelvic muscles. Some of the patients may have rectal prolapse, rectocele, or rectal intussusception in addition to the twisted colon proximal to the CRA. This author found that endoscopic banding of twisted points has helped reduce episodes of SV. The rationale is to create fibrosis at the twisted point and stiffen the area ( Fig. 25.2 ). This author has also performed endoscopic septectomy to treat a twisted ileal pouch. The technique may be applied to uncomplicated, recurrent SV. This author also believes that the patient may benefit from endoscopic plication procedures (unpublished data).

Percutaneous Endoscopic Colostomy and Colopexy

Percutaneous endoscopic colostomy with the placement of a gastrostomy tube for decompression and colopexy has been performed for SV as well as colonic pseudoobstruction and neurogenic constipation. ^, However, morbidity and mortality after PEC were high. ^,

RECTAL PROLAPSE

Rectal prolapse can be full-thickness rectal prolapse (i.e., complete prolapse) or mucosal prolapse (i.e., partial prolapse). Patients with rectal prolapse can present with pelvic pain, bleeding, seepage, constipation, dyschezia, and incontinence.

Medical management of rectal prolapse includes adequate fluid and fiber intake, enemas, or suppositories (for constipation). Patients with refractory, symptomatic rectal prolapse may require surgical intervention. Commonly performed surgical procedures for full-thickness rectal prolapse include ransabdominal (anterior) rectopexy with concomitant sigmoid resection, transabdominal (anterior) rectopexy without concomitant sigmoid resection, ventral mesh rectopexy, perineal rectosigmoidectomy (Altemeier procedure), and perineal mucosal stripping and muscular plication (Delorme procedure). Native-tissue transvaginal rectocele repair, transanal rectocele repair, and stapled trans-anal rectal resection (STARR) are considered the gold standard for rectal prolapse.

Recurrent rectal prolapse after surgery is common. It appears that abdominal surgical procedures have lower recurrence rates than transperineal approaches. In addition, the presence of pelvic organ prolapse was associated with a higher rectal prolapse recurrence rate and earlier recurrence in females undergoing perineal, but not abdominal, repairs. A study of laparoscopic ventral rectal pexy in 919 consecutive patients (869 females and 50 males) with rectal prolapse syndromes who underwent laparoscopic ventral repair demonstrated a 10-year recurrence rate of 8.2% (95% confidence interval, 3.7–12.7). A prospective study of 70 females had rectal prolapse surgery and 45 had combined rectal prolapse and pelvic organ prolapse surgery, with a mean follow-up time of 208 days. Overall, 12% of this cohort had recurrent rectal prolapse, 11% in the rectal prolapse group, and 13% in the combined surgery group ( P = .76). A separate study of surgical treatment of pelvic organ prolapse was present in 33% of 112 females and was more prevalent among subjects with recurrent rectal prolapse (52.4% vs. 28.6%, P = .04).

Transanal rubber band ligation has been used in the treatment of rectal prolapse as well as hemorrhoids. These two anorectal disease conditions often coexist. Some patients require repeat banding ligation therapy. In a study of 160 patients with internal hemorrhoids, 43 of them also had rectal anterior mucosal prolapse, and 13 had prolapse alone. Additionally, 94 patients required repeated ligations. A follow-up of 25 ± 16 months with 153 patients showed favorable outcomes in 71% of the patients. The presence of constipation is a predictor of poor outcomes. Combined banding ligation and sclerosing therapy have been used for the treatment of hemorrhoids and incomplete mucosal prolapse.

Internal rectal prolapse can be viewed endoscopically forward ( Fig. 25.3A ) or retroflex ( Fig. 25.3B , C ). For subtle internal prolapse, the endoscopist may use air suction and tissue suction techniques to demonstrate rectal prolapse. The endoscopist can place the tip of the scope at the anal canal and perform air suction, often noticing whole or anterior distal wall collapse and block the outlet ( Fig. 25.3A ). Rectal prolapse often presents with floppy mucosa that can be demonstrated with suction of the tissue with an endoscopic tip ( Fig. 25.3A ). The tip of the prolapse may be ulcerated, reflecting a pattern of solitary rectal ulcer syndrome ( Fig. 25.3C ).