Table Sugar as a Bridge from Emergency to Elective Perineal Proctosigmoidectomy for Incarcerated Rectal Prolapse

Complete external rectal prolapse is characterized by a circumferential, full-thickness protrusion of the rectum through the anus. A socially debilitating condition, mainly affecting older women with a relatively low prevalence, estimated to occur in <0.5% of the general population overall [1]. Rectal prolapse can present with a wide range of symptoms from a palpable self-reducible perianal mass, fecal incontinence, rectal bleeding, obstructive defecation, and painful irreducible perianal mass. Surgery is the mainstay for treatment of rectal prolapse. If left untreated, rectal prolapse may present as an emergency being it incarceration or strangulation. In an emergency presentation for incarcerated rectal prolapse every attempt should be taken to reduce the prolapsed rectum, if not successful, emergency surgery is indicated, with perineal approach being the first choice in the elderly with multiple comorbidities. Herein, we present a case of 85 years old female patient with multiple comorbidities whereby table sugar was used to shift an emergency surgery for incarcerated rectal prolapse to an elective one.

An 85-year-old female patient Gravida 3 Para 3 (normal vaginal delivery), ASA physical status IV with asthma-COPD overlap syndrome (ACOS), congestive heart failure (EF = 20%), with mild aortic regurgitation and mitral regurgitation, hypothyroidism (last TSH = 7.44 mIU/L), and osteoporosis admitted to the emergency department with perianal pain and palpable bulging mass diagnosed with incarcerated rectal prolapse. Patient reported a long history of chronic constipation associated with recurrent perianal bulging mass that the she was always able to self-reduce and hence attributed it to hemorrhoidal disease. Couple of hours prior to presentation she reported severe perianal pain associated with the inability to self-reduce the prolapsed mass. In the emergency department, the patient was hemodynamically stable. Upon physical examination, the abdomen was soft, non-distended, and bowel sounds were normal on auscultation. Whereas on perineal examination, identification of around 16 cm of the recto sigmoid colon protruding out of the anal canal, with concentric circular folds, engorged and tender to palpation, and irreducible. Laboratory workup was within normal range. Table sugar applied on the prolapsed mucosa and left for 10–15 min in an attempt to manually reduce the prolapse. Reduction was successfully achieved and patient was admitted for further management. In view of all the comorbid conditions classifying the patient as a high-risk operative candidate, decision for perineal approach was taken, and perineal proctosigmoidectomy scheduled after the edema subsides. Preoperative work-up was done including colonoscopy and anorectal manometry. Colonoscopy was negative for a mass or other pathology and identification of an inflamed circumferential mucosa of the rectum. Anorectal manometry failed to study the anal tone due to recurrent prolapse during the procedure. Three days after being admitted to our hospital patient was taken to the operating theater for perineal proctosigmoidectomy (Altemeier procedure). Under spinal anesthesia, patient in modified lithotomy position, delivery of the prolapsed rectum using Allis forceps (shown in Fig. 1), and a full-thickness circumferential incision made 1 cm above the dentate line. The rectum was dissected proximally circumferentially to clear the mesorectum until entering the peritoneal cavity (shown in Fig. 2). For delivery of the recto sigmoid colon, absorbable 3.0 sutures were applied at 12, 3, 6, and 9 o’clock near the anal margin in order to avoid retraction of the proximal end of the colon after resection. Figure 3 shows transection of the redundant and floppy bowel where no further giving was observed. Specimen was resected (shown Fig. 4). Handsewn coloanal anastomosis was done by suturing the proximal margin to the anal canal (shown Fig. 5). A levatorplasty was performed and before completion of the coloanal anastomosis the levator muscles were sutured together anteriorly. Uneventful postoperative stay and she was discharged on the fourth postoperative day in good medical condition. At 1-year follow-up, there is no recurrence and anal continence is maintained.

Surgical intervention is usually required to correct rectal prolapse. The choice of surgery depends mainly on the patient’s age, comorbid conditions, coexisting functional symptoms, including incontinence or constipation, and the surgeon’s familiarity with a particular surgical approach. Two major surgical approaches are used in treatment of rectal prolapse, the abdominal approach versus the perineal approach. The abdominal approach is considered a major operation in elderly patients with multiple comorbidities and frailty. In these patients with significant comorbidities that pose an anesthetic risk, precluding a general anesthesia, perineal proctosigmoidectomy under spinal anesthesia is favored due to a lower operative morbidity rate and quicker recovery compared to the abdominal approach [2]. The advantage of perineal proctosigmoidectomy lies in the presence of a coloanal anastomosis and hence, when there is a leak in the anastomosis it will naturally drain through the anus. If left untreated, rarely rectal prolapse can present as incarceration, which is an emergency. Since incarcerated prolapsed is rare, there is no agreement on its management. Even rarer is the irreducible incarcerated prolapse and hence, the big challenge in its management. The literature describes several methods for reducing an incarcerated rectal prolapse. The many methods actually bear testimony to the fact that no single method is very attractive. Consequently, surgeons have little experience and management is controversial [3]. Since surgery is unavoidable, the procedure should be safe and effective. From here, perineal proctosigmoidectomy is an attractive option. We believe that every attempt should be taken to reduce the prolapsed rectum to avoid progression into strangulation and necrosis on one hand. And on the other hand, the risk of anastomotic complication in emergency perineal proctosigmoidectomy has been reported to be around 25% [4] as compared to 2–6% in the elective setting [5, 6]. This increased risk of anastomotic complications is attributed to edema and fragility in the rectal and perineal tissues and the impaired blood flow leading to higher rate of anastomotic complications in the acute stage of incarcerated rectal prolapse. Thus, the traditional single-stage perineal proctosigmoidectomy is apparently unsafe for treating incarcerated rectal prolapse associated with severe edema. However, reduction of an acute incarcerated rectal prolapse is often rendered difficult by edema of the rectal tissue superimposed on the length of the rectum that has prolapsed [7]. Hence, the urgent need to reduce the prolapse and consequently decrease edema, so that the surgery can be switched from an emergency surgery with high risk of complication and possible 2 stage surgery to an elective one where the rate of complications is much lower. Edema may be reduced by the application of sugar [8], by the injection of hyaluronidase [7], or by applying an elastic compression wrap [9]. We opted for the use of table sugar because it was readily available and has been studied more in such cases. Application of sugar to the mucosal surface of the prolapsed segment results in a dramatic decrease in bowel edema facilitating manual reduction. Hence, avoiding the ischemia that may result due to irreducible incarceration, edema and compromise in blood supply with its devastating consequences of ischemia and possible perforation. In brief, the use of table sugar shifted the surgery from an emergency one to an elective one, with better local conditions as the edema has subsided and consequently lower complication rate.

Incarcerated rectal prolapse is a rare clinical entity that continues to arouse the enthusiasm of colorectal surgeons. This conditions requires emergency surgery; however, the use of table sugar can aid in shifting the surgery from an emergency one with high complication rate and possibly 2 stage surgery to an elective one with lower complication rate.

The patient has given her written informed consent to publish her case, including all associated images. This case report was reviewed and approved by the Ethics Committee at Saint George Hospital University Medical Center with ethics approval not required.

The authors have no conflicts of interest to declare.

No funding was obtained. The authors handled everything regarding the paper.

All authors contributed equally towards writing this paper.

All data are available upon request.