
==== Front
Int J Surg Case Rep
Int J Surg Case Rep
International Journal of Surgery Case Reports
2210-2612
Elsevier

S2210-2612(24)00991-X
10.1016/j.ijscr.2024.110210
110210
Case Report
Strangulated rectal prolapse in adult: Altemeier cure about two cases and literature review
Niasse Abdou niasseabdou30@gmail.com
⁎
Faye Papa Mamadou
Ndong Abdourahmane
Thiam Ousmane
Konate Ibrahima
Alioune Diop University Of Bambey, General Surgery Unit of Cheikh Ahmadoul Khadim Hospital in Touba, Diourbel, Senegal
⁎ Corresponding author. niasseabdou30@gmail.com
23 8 2024
10 2024
23 8 2024
123 11021019 1 2024
18 8 2024
22 8 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction and importance

Rectal prolapse is the protrusion of the rectum through the anus. It is a rare condition in young adults. Strangulation is rare but it's a serious complication imposing emergency surgery. Altemeier's recto-sigmoidectomy seems to be an appropriate surgical method for strangulation. The aim of our work was to evaluate this technique in two cases of strangulated rectal prolapse in young adults.

Case presentation

This report is of two men aged 37 and 29. They were seen for the management of irreducible rectal prolapses. They both men gave a long history of constipation and rectal prolapse since childhood. The physical examination found complete rectal prolapse of 13 cm and 15 cm in length respectively. One person had necrosis of the rectal mucosa. The manual reduction failed, why perineal recto-sigmoidectomy was performed. Postoperative course was uneventful. After 24 months follow-up, there was no disorder of anal continence or recurrence.

Clinical discussion

Strangulated rectal prolapse is rare. This makes consensus in treatment difficult. The risk of necrosis explains the need for surgical excision of the rectum.

Conclusion

Altemeier's technique is a good procedure for the management of strangulated rectal prolapse.

Highlights

• Rectal prolapse is a rare benign pathology in adults.

• Strangulation from rectal prolapse is rare.

• The treatment possibilities are multiple, ranging from reduction with corticosteroid therapy to surgical resection

• After the edema has disappeared, we believe that the Altemeier recto-sigmoid resection gives good results.

Keywords

Strangulated rectal prolapse
Altemeier
Delorme
Case report
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pmc1 Introduction

Rectal prolapse is the protrusion of the rectum through the anus [1]. It is a rare situation in adult under 30 years-old (about 5 to 23 %) [1,2]. Chronic constipation is one of the main etiological factors [1]. Its diagnosis is essentially clinical [1]. Strangulation of rectal prolapse is a rare complication with a frequency of 2 to 4 % [1]. The problem of the management of this condition is to restore an anatomy and a satisfactory function of the perineum without inducing deleterious effects [2]. The aim of our study was to bring our experience on the rectal strangulated prolapse in adult by rectosigmoidectomy according to Altemeier procedure. This work has been reported in line with the SCARE criteria [3]. We report the observations of 2 young adults managed by Altemeier procedure for strangulated rectal prolapse.

1.1 Patients and methods

We previously have carried out a retrospective study over 10 years (January 2010 to December 2020) which included all adults with strangulated rectal prolapse. we studied the symptoms, the clinical examination data, the emergency procedures, the treatment initiated as well as the results over 1 year of follow-up. We had 2 cases of strangulated rectal prolapse during this period which are reported. This work has been reported in line with the SCARE criteria [3].

2 Case 1

He was a 28 years-old man. He was followed for hemorrhoidal disorder and hallucinatory psychosis. He was treated by anxiolytics and neuroleptics since 10 years. He presented in emergency for irreducible rectal prolapse during 24 h. The examination found a stable patient, with a temperature at 37.2 ° C, a blood pressure of 120mmg / 90mmg. The examination of the abdomen was normal. One ano-perineal examination found a complete prolapse of the rectal wall on 15 cm with a hyperemic mucosa. Prolapse was irreducible, painful, and edematous (Fig. 1). Twenty-four hours after admission, the strangulation of prolapse persisted with necrotic sites on the rectal mucosa motivating a Altemeier rectosigmoidectomy (Fig. 2). The postoperative course was evenful. Pathological examination of the specimen showed multiple venous thrombosis with partial parietal mucosa necrosis and nonspecific acute inflammatory reaction. After 24 months follow-up, there was no recurrence or disorders of anal continence. After 1 month, the laxatives were stopped because defecation was normal.Fig. 1 Picture of our first patient: Strangulated rectal prolapse.

Fig. 1

Fig. 2 colo-rectal anastomosis and enfouissement after Altemeier's rectosigmoidectomy.

Fig. 2

3 Case 2

He was a 37 years-old man. He presented in emergency for strangulated rectal prolapse, painful and haemorrhagic. In his history we noted a rectal prolapse evolving since childhood with rectorrhagies and chronic constipation. Physical examination found a stable patient, with a temperature at 36.8 ° C, a blood pressure of 110mmg/90mmg. Abdominal examination was normal. Ano-perineal examination founded a complete rectal prolapse measuring 13 cm and haemorrhoidal disease. Prolapse was irreducible and without pain. Rest of exam was normal. The blood test was normal. After intravenous corticotherapy, during 10 days with analgesic and antibiotics. During follow-up, prolapse became strangulated motivating indication of an emergency surgical cure. A Altemeier rectosigmoidectomy was performed. Postoperative course was evenful. Pathological examination of the specimen showed a nonspecific acute inflammatory reaction. After 24 months follow-up, there was no recurrence or disorders of anal continence. The After 1 month, the laxatives were stopped because defecation was normal.

4 Discussion

Our two patients were young (28 years old and 37 years old respectively). Strangulated rectal prolapse is exceptional in young adults [2]. In a study of 44 patients, less 23 % were under 30 years old [4]. They haven't evident causes of rectal prolapse in young people [3]. Marceau and al. studied the risk factors for rectal prolapse in people under 50 years old and reported presence of psychiatric illness requiring longterm treatment (neuroleptic or antidepressive) likely to induce severe obstructed defecation syndrome [5]. One of our patients had hallucinatory psychosis treated with anxiolytic and neuroleptic drug inducing constipation, was incriminated of his rectal prolapse. Other studies found in more than 41 % of cases, had chronic constipation since childhood treated by laxative drug and without psychiatric disorders [4,5]. Our second patient chronic constipation was incriminated.

Diagnosis was clinical and easy in both patients. No radiological or dynamic assessment was performed. Strangulation is probably due to a delay of consultation (table evolving since childhood, concept of herbal medicine first and long-term treatment of neuroleptic) and obstructed defecation syndrome (ODS). Strangulation requires emergency surgical treatment when reduction is impossible or the incarcerated rectum is necrotic [6]. Rectal prolapse in young adults is frequently associated with ODS [7]. Hygienic and dietary means and laxatives drugs normalized intestinal transit [5]. In our patients, laxatives treatment was purchase in postoperative period.

Diagnosis of strangulated rectal prolapse is clinical. Clinical examinations are part of the preoperative and impact assessment. Search for pelvic floor disorders was not urgent in this context of strangulation.

When the incarcerated rectum is non-necrotic (as in one of our patients), some technics can help reduce prolapse such as sedation, corticosteroid therapy and application of salt and sugar help to reduce edema and prolapse [8]. These procedures have failed in our patients. In case of failure of these procedures or in case of necrosis, surgical treatment becomes urgent [9].

There exist many perineal technics to treat rectal prolapses whose mucosectomy with perineal rectopexy (Delorme intervention), rectosigmoid resection (intervention of Altemeier) and anal cerclage or intervention of Thiersch [6]. Perineal procedure is done in patients with bad conditions and in cases of strangulation [1,6]. Either with preservation of the rectum or without preservation. The Delorme technique, which consists of a resection limited to the prolapsed rectal mucosa, is less aggressive. It gives similar results to total rectal resections on recurrence. However, in cases of transmural necrosis, it is not indicated because it will not remove all the necrosis. Presence of necrosis in our first patient and signs of pre-necrosis justified our choice of the Altermeier technique which involves the entire rectum and sigmoid colon. However, it is a poor technique. Perineal procedure is a good technic in younger patients without anal incontinence [1]. Perineal procedure is associated in long-term to recurrence and anal pain [1,10]. However, in this technic, they are less constipation and morbidity than abdominal procedure. The results of recent studies encouraged the perineal procedure after a rigorous selection of patients [11,12]. Necrosis and incarceration constitute emergency surgical indications and the perineal procedure is the best approach [11,12]. Anal strapping, after manual reduction of prolapse, exposed of recurrence in more than 90 % of cases in 3 months [13]. Our patients underwent perineal rectosigmoidectomy according to Altemeier. Altemeier rectosigmoidectomy was done in emergency because they have incarcerated rectum and necrosis in one patient and the failure of the attempt of manual reduction under corticotherapy in the other. A randomized evaluation of the various perineal surgical technics for the treatment of externalized and / or strangulated rectal prolapse, including a large number of patients (n = 200), concluded that the different methods (Delorme's mucosectomy and Altemeier's perineal recto-sigmoidectomy) provide comparable anatomical and functional results [14].

Risk of recurrence of prolapse in this procedure is frequent. After 1 month, the laxatives were stopped because transit normalized. One in two patients has recurrence after 2–5 years follow-up [14].

5 Conclusion

They have many procedures for the management of strangulated rectal prolapse. They have no consensus in the treatment. Risk of necrosis and failure of the reduction in strangulated rectal prolapse, indicated a perineal procedure in emergency. Anatomical and functional results in short and long term are efficient.

Consent of patients

Consent was obtained from the patient for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval

Ethic approval is done by Cheikh Anta Diop University ethic Commitee (number 1698 of 2012, July 12).

Funding

No applicable.

Author contribution

Abdou NIASSE: concept or design, data collection, data analysis or interpretation, writing the paper. Papa Mamadou FAYE: reading, correcting and approving, Abdourahmane NDONG: reading, correcting and approving, Ousmane THIAM: reading, correcting and approving, Ibrahima KONATE: reading, correcting and approving.

Guarantor

The corresponding author is the guarantor of this study. He accepts full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish.

Research registration number

1. Name of the registry: Research Registry (researchregistry.com).

2. Unique identifying number or registration ID: Research registry number 9879.

3. Hyperlink to your specific registration (must be publicly accessible and will be checked): https://www.researchregistry.com/browse-the-registry#home/?view_2_search=ABDOU%20NIASSE&view_2_page=1.

Conflict of interest statement

No Applicable.
==== Refs
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