Laparoscopic rectopexy for solitary rectal ulcer syndrome without

Laparoscopic rectopexy for
solitary rectal ulcer syndrome without
overt rectal prolapse
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A case report and review of the literature
Ann. Ital. Chir.
Published online (EP) 20 February 2014
pii: S2239253X14022208
www.annitalchir.com
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Ebru Menekse*, Mehmet Ozdogan*, Faruk Karateke*, Sefa Ozyazici*, Pelin Demirturk**,
Adnan Kuvvetli*
Numune Training and Research Hospital, Adana, Turkey
*General Surgery Clinic
**Department of Pathology
Laparoscopic rectopexy for solitary rectal ulcer syndrome without overt rectal prolapse. A case report and review of the literature
Solitary rectal ulcer syndrome is a rare clinical entity. Several treatment options has been described. However, there is
no consensus yet on treatment algorithm and standard surgical procedure. Rectopexy is one of the surgical options and
it is generally performed in patients with solitary rectal ulcer accompanied with overt prolapse. Various outcomes have
been reported for rectopexy in the patients with occult prolapse or rectal intussusception. In the literature; outcomes of
laparoscopic non-resection rectopexy procedure have been reported in the limited number of case or case series. No study
has emphasized the outcomes of laparoscopic non-resection rectopexy procedure in the patients with solitary rectal ulcer
without overt prolapse. In this report we aimed to present clinical outcomes of laparoscopic non-resection posterior suture rectopexy procedure in a 21-year-old female patient with solitary rectal ulcer without overt prolapse.
KEY
WORDS:
Laparoscopic rectopexy, Prolapse, Rectal ulcer, Rectum, Solitary
Introduction
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Solitary rectal ulcer syndrome (SRUS) has been identified by Cruvilhier in 19th century while diagnostic histopathological features have been defined by Madigan and
Morson in 1969. Etiology of SRUS is yet unclear and
there is no consensus on its treatment options 2.
Successful outcomes have been obtained by rectopexy
procedure in the patients accompanied with overt rectal
prolapse in the treatment of SRUS. However, conclusions on rectopexy procedure in the patients without overt
rectal prolapse are conflicting3 Additionally, laparoscopic
Pervenuto in Redazione Settembre 2013. Accettato per la pubblicazione
Novembre 2013
Correspondence to: Ebru Menekse, MD, Genel Cerrahi Klinigi, Numune
Egitim ve Arastirma Hastanesi Serinevler Mahallesi Ege Bagtur Bulvari
Üzeri Yüregir, Adana, Turkey (e-mail: [email protected])
non-resection rectopexy for treatment of SRUS have been
reported in limited number of case series 4,5. In this case
report, we aimed to present clinical outcomes of the
laparoscopic non-resection posterior rectopexy (LNRPR)
procedure that we performed in a patient with SRUS
without overt rectal prolapse and reviewed the outcomes
of the rectopexy operations performed for SRUS in the
literature.
Case Experience
A 21-year-old female patient was admitted to the General
Surgery Clinic with complaints of constipation and rectal bleeding. She has been using fiber diet and laxatives
regularly for about 5 years and also she described self
digitation. On physical examination, polypoid lesions
with irregular bleeding beginning from 5th centimeter
of the anal wedge were palpable. No prolapse was detecPublished online (EP) 20 February 2014 - Ann. Ital. Chir
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ted. Laboratory findings revealed hypochromic microcytic anemia. Colonoscopy revealed 5-6 ulcers and ulcerovegetation mass at a distance of 5-10 cm from anal verge that surrounded the lumen completely (Fig. 1).
Endoscopic biopsy obtained from rectum demonstrated
ulcer, crypt hyperplasia, increased muscular fibers in
lamina propria, fibrosis and irregular thickening in the
muscularis mucosae proved “solitary rectal ulcer” (Fig.
2). Defecography demonstrated rectal intussusception
and no overt prolapse was existing. Surgical treatment
was planned because of reluctance of the patient to the
medical treatment. Written informed consent was
obtained from the patient for surgical procedure. After
insertion of laparoscopic ports – one at the umbilicus,
two in the right and one in the left iliac fossa, rectum
was mobilized routinely down to the pelvic floor using
ultrasonic dissection with only partial division of the
‘lateral ligaments’ and careful preservation of the superior rectal artery, ureters and autonomic nerves. Rectum
was sutured to presacral fascia using 2/0 prolene suture
without using a mesh. No complication developed in the
peroperative and postoperative period. The patient was
discharged in the 5th day with laxative treatment. She
defined reduction in her complaints of rectal bleeding
and constipation and also postoperative 15th month control rectoscopy demonstrated that ulcerovegetating and
polypoid massive appearance completely have disappeared (Fig. 3).
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E. Menekse, et al.
Fig. 2: Hematoxylin-eosin section ( original magnification,x10). The rectal mucosa showing smooth muscle prolifearation in the muscularis mucosa and extending in between the mucosal glands.
Discussion
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SRUS is a rare clinical entity with incidence of
1/100,000 6,7. Due to its low incidence; there is not a
complete consensus achieved on etiology and an appropriate treatment procedure 8. It has been generally
Fig. 1: Preoperative colonoscopic examination revealed polypoid mass
with ulceration and mucosal erythema at the rectum.
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Ann. Ital. Chir - Published online (EP) 20 February 2014
Fig. 3: Postoperative fifteen months colonoscopic examination; complete
regression of polipoid mass with solitary surface ulceration at the rectum.
accepted that recurrent mucosal trauma and local ischemia at the rectal wall lead to development of SRUS 9.
Occult or overt rectal prolapse and anorectal outlet obstruction caused by paradoxal contraction of pelvic wall
muscles were accepted responsible for formation of this
mucosal trauma and ischemia 10,11. SRUS is generally
presented by the symptoms such as bloody and mucous passage, constipation, tenesmus, anorectal pain and
sensation of insufficent defecation and straining during
defecation 12. Lesions may appear as erythema, single or
multiple ulcers, polypoid lesions or combination of those 13,14. An accurate histopathological examination is
required to diagnose SRUS 15. Optimal treatment procedure of SRUS is controversial. It is known that other
surgical procedures for abdominal rectopexy and prolapse can be successful in the patients with overt rectal prolapse. However laxatives, steroids, sulphasalazine and
straining-preventing treatments can be initially given in
absence of prolapse. Biofeedback treatment is also used
in treatment of functional defecation disease underlying
SRUS. However, it is difficult to make decision for sur-
Laparoscopic rectopexy for solitary rectal ulcer syndrome without overt rectal prolapse
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SRUS and rectal prolapse is not clear 15. However, prolapse is found by several grades in SRUS. Binnie et al
have found in their study that anterior mucosal fold prolapse, full thickness prolapse and rectal intussusception
in 22%, 24% and 54% of the patients with SRUS, respectively 10. Success rate of rectopexy operations ranges
between 25-85% in the patients with SRUS accompanied with occult rectal prolapse. However, comparison
between overt and occult rectal prolapse in the patients
performed rectopexy for SRUS is not sufficient 20,21 (Table
I). Nicholls and Simson have obtained successful outcomes by rectopexy operation in the patients with SRUS
unaccompanied with overt rectal prolapse 22 (Table I).
Underlying factor of successful outcomes for rectopexy in
occult rectal prolapse and intussusception may be treatment of rectal intussusception due to existing mesorectal sacral fixation and anorectal redundancy by rectopexy
and consequently prevention of rectal trauma. Also failure of rectopexy operation may not be only due to
whether prolapse is overt or not. Because, it is known
that especially paradoxal contraction of pelvic wall muscles in relaxation leads to pelvic outlet obstruction and
contributes to local trauma as well as intussusception and
prolapse are the factors in formation of SRUS in several grades. Binnie et al have found significantly reduced
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gical indications in occult prolapse and intussusception.
Generally, it should be taken into account in patients
resistant to conservative treatment 9,16.
Rectopexy has been performed in the patients with SRUS
accompanied by overt rectal prolapse with low recurrence
of ulcer and regression of symptoms within long period
have been observed 3-5,17. Transsacral rectopexy, Ripstein
and Orr-Loygue methods were most commonly used for
this aim 2,5,18. Additionally, laparoscopic non-resection
rectopexy has been popular recently as a simple and safe
method in the patients with SRUS, especially in presence of overt rectal prolapse. Nonnecessity of a separate resection of the specimen and absence of potential
anastomotic leakage are the factors in reduction of morbidity with laparoscopy. Also, laparoscopic methods decreases operation time and postoperative hospital stay
when compared with open surgical procedure. In addition, laparoscopic rectopexy has superiority on open surgical procedure with respect to short-term outcomes.
Outcomes for treatment and recurrence of the disease is
similar with those of open rectopexy operation in also
patients who underwent LNRPR operation for rectal prolapse and SRUS 18,19 (Table I). On the other hand, rectopexy operation is controversial in the patients without overt rectal prolapse. In fact, association between
TABLE I - Review of previous surgical series for SRUS with and without overt rectal prolapsus
Reference
Year
Total
(n)
Operation
Sucess reported
(n, %)
No overt
prolapsus
(n)
Operation
Sucess
reported
(n, %)
Keighley&Shouler [6]
Stuart [ 21]
Nicholls&Simson[22]
Tjandra et al. [12]
Binnie et al. [10]
Sitzler et al. [8]
1984
1984
1986
1992
1992
1998
14
16
14
18
19
66/49
66/9
66/2
Rectopexy
Rectopexy
Rectopexy
Ripstein
Rectopexy
Rectopexy
Delorme
Restorative
resection
7 (50)
11 (69)
12 (85)
7 (39)
14 (74)
22(45)
5(44)
8
1
14
–
unknown
unknown
Rectopexy
Rectopexy
Rectopexy
–
–
–
2 (25)
0 (0)
12 (85)
–
–
–
66/1
Postanal
repair
Puborectalis
division
Rectopexy
(orr-loygue)
2(67)
3
Rectopexy
2(67)
5(62)
7
–
25(96)
6 (86)
6 (86)
49(92)
unknown
unknown
unknown
unknown
Modified
Delorme
–
–
–
–
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2(100)
Marchal et al. [20]
66/1
2001
13/3
Modified
13/8
Simsek et al. [17]
Tweedie&Varma[5]
Choi et al. [3]
Kargar et al. [4]
2004
2005
2005
2010
26
7
7
54
Rectopexy
LNRPR*
Rectopexy
LNRPR*
–
–
–
–
*LNRPR: Laparoskopik Non Rezeksiyonel Posterior Rektopeksi
Published online (EP) 20 February 2014 - Ann. Ital. Chir
3
E. Menekse, et al.
rectopexy for solitary rectal ulcer syndrome. Colorectal Dis, 2005; 2;
7:151-55.
6. Keighley MR, Shouler P: Clinical and manometric features of the
solitary rectal ulcer syndrome. Dis Colon Rectum, 1984; 8; 27:507-12.
7. Martin CJ, Parks TG, Biggart JD.: Solitary rectal ulcer syndrome
in Northern Ireland. 1971-1980. Br J Surg, 1981; 10; 68:744-47.
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8. Sitzler PJ, Kamm MA, Nicholls RJ, McKee RF: Long-term clinical outcome of surgery for solitary rectal ulcer syndrome. Br J Surg,
1998; 9; 85:1246-250.
9. Morio O, Meurette G, Desfourneaux V, D’Halluin PN,
Bretagne JF, Siproudhis L: Anorectal physiology in solitary ulcer
syndrome: A case-matched series. Dis Colon Rectum, 2005; 10;
48:1917-22.
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recurrence by addition of biofeedback methods to conservative and surgical treatment methods in the patients
with SRUS 10. Even though association between functional defecation disorders and SRUS has been known,
functional defecation disorders were found in only 67%
and 60% of the patients with rectal prolapse and rectal
intussusception, respectively 23.
The complaints of our patient decreased and a remarkable regression was found in rectoscopic findings during the
follow-up time. However, addition of biofeedback methods
to surgical methods may provide better outcomes.
In conclusion, LNRPR may be considered as a surgical
option in patients with SRUS in whom resistant to conservative treatment without overt rectal prolapse. A treatment algorithm may be established with clarifying the
ethology and presenting the outcomes of patients underwent surgical treatment with SRUS.
10. Binnie NR, Papachrysostomou M, Clare N, Smith AN: Solitary
rectal ulcer: the place of biofeedback and surgery in the treatment of
the syndrome. World J Surg, 1992; 5; 16:836-40.
11. Garrigues JM, Nicaud P: Solitary ulcer of the rectum. Ann Chir,
1994; 2; 48:140-49.
Riassunto
La sindrome dell’ulcera rettale solitaria è di raro riscontro clinico, e sono state decritte diverse opzioni terapeutiche. Peraltro non vi è un consenso sui procedimenti
chirurgici standard e sulla sequenza dei trattamenti.
La rettopessi rappresenta una dello opzioni chirurgiche e
viene generalmente eseguita in pazienti con ulcera solitaria
del retto che si accompagna ad un franco prolasso.
Gli sono i risultati riferiti in caso di rettopessia eseguita in pazienti con prolasso occulto oppure con intussuscezione rettale. In letteratura si trovano poche casistiche con limitato numero di casi trattati con rettopessia laparoscopica conservativa, senza cioè resezione. n
particolare nessuno studio ha evidenziato i risultati delle procedure laparoscopiche conservative nei pazienti con
ulcera solitaria del retto senza evidente prolasso.
Lo scopo del nostro studio è quello appunto di presentare i risultati clinici della procedura laparoscopica della
rettopessia posteriore conservativa con sutura posteriore
in una giovane donna di 21 anni affetta da ulcera solitaria del retto senza prolasso.
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