This article explains the guidelines from the World Society of Emergency Surgery (WSES) and the American Association for the Surgery of Trauma (AAST) that provides the key recommendations for the management of full-thickness prolapse.

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What is rectal prolapse?

Surgery is the definitive treatment for rectal prolapse, and several operative procedures are available, each with its own pros and cons. In critically ill patients, antimicrobial therapy should be started immediately. Judicious use of antimicrobials can minimize the risks associated with the selection of resistant pathogens and should be an integral part of good clinical practice.

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Guideline updates

Guidelines from the World Society of Emergency Surgery (WSES) and the American Association for the Surgery of Trauma (AAST) provide key recommendations for the management of full-thickness prolapses.

Clinical examination and biochemical investigations in patients with a suspected complicated rectal prolapse.

In patients with suspected complicated rectal prolapse, a complete blood count should be carried out. Apart from this, serum creatinine and inflammatory markers such as C-reactive protein, procalcitonin and lactates should be evaluated to assess the status of the patient.

Imaging investigations in patients with a suspected complicated rectal prolapse.

1. An urgent contrast-enhanced abdominopelvic CT scan should be carried out in hemodynamically stable patients with irreducible or strangulated rectal prolapse. CT scan can help detect the complications associated with the condition as well as evaluate the presence of colorectal cancer.
2. The scan should be performed whenever available and without delaying appropriate treatment.

Non-operative management in patients with complicated rectal prolapse

1. In patients with incarcerated rectal prolapse without signs of ischemia or perforation, it is suggested to carry out conservative measures and gentle manual reduction under mild sedation or anaesthesia.
2. In hemodynamically unstable patients with complicated rectal prolapse, surgical management to attempt conservative management should not be delayed.

Surgery in patients with complicated rectal prolapse

1. Surgery is the definitive treatment for rectal prolapse. Several operative procedures are available, each with its own pros and cons.
2. In the elective setting, rectal prolapse surgical repair can be carried out through the abdomen or through the anus (perineal approach). When selecting the best approach for a patient, it is important to consider the severity of symptoms, the patient’s fitness and preferences.

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The perineal techniques

The perineal techniques are as follows:

• Anal encirclement (Thiersch procedure)
• Mucosal sleeve resection (Delorme’s procedure)
• Perineal proctosigmoidectomy (Altemeier’s procedure)

The abdominal procedures can be performed via either an open or laparoscopic/robotic approach and are as follows:

• Suture rectopexy
• Mesh rectopexy includes

1. Rectopexy with posterior fixation and anterior mesh sling (Ripstein’s procedure)
2. Rectopexy with posterior fixation and posterior mesh sling (Wells’ procedure)
3. Rectopexy with ventral fixation and double anterolateral mesh sling and modified ventral rectopexy (Orr-Loygue’s procedure)

• Resection rectopexy with or without mesh

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Immediate surgical treatment:

Immediate surgical treatment is recommended in patients with complicated rectal prolapse and signs of shock or gangrene/perforation of prolapsed bowel.

1. Patients with complicated rectal prolapse and bleeding, acute bowel obstruction or failure of non-operative management should undergo urgent surgical treatment. While in patients with complicated rectal prolapse and no signs of peritonitis or hemodynamic instability, the decision between abdominal and perineal procedures should be based on the specific patient’s characteristics and on the surgeon’s skills and expertise.
2. The abdominal approach is suggested in patients with complicated rectal prolapse and signs of peritonitis. The abdominal open approach is recommended in patients with complicated rectal prolapse and hemodynamic instability. In patients with complicated rectal prolapse undergoing resectional surgery, the decision between primary anastomosis, with or without diverting ostomy, and terminal colostomy should be based on the patient’s clinical condition and on the individual risk of anastomotic leakage.
3. During an emergency, perineal procedures can be carried out using spinal anaesthesia. They are associated with lower operative morbidity and mortality including a lower rate of damage to the nerve plexus and sexual dysfunctions. However, perineal procedures have higher recurrence rates than abdominal procedures; they also need to be carried out by experts. The perineal technique could thus be a good option for elderly or medically unfit patients when appropriate skills and expertise are available.
4. Abdominal approaches are carried out by entering the abdominal cavity, hence they may be the best choice in patients with associated peritonitis. Hartmann’s procedure can be used in cases with rectal incontinence and sepsis. The procedure can be safely performed by emergency general surgeons.

Pharmacological regimen in patients with complicated anorectal prolapses

In patients with strangulated rectal prolapse, it is suggested to use empiric antimicrobial therapy due to the risk of intestinal bacterial translocation. When developing the appropriate pharmacological regimen, the following factors should be considered:

• The clinical condition of the patients
• The individual risk for the multidrug-resistant organism (MDRO)
• The local resistance epidemiology

As per the WSES guidelines for the management of intra-abdominal infections, judicious use of antimicrobials can minimize the risks associated with the selection of resistant pathogens. This should be an integral part of good clinical practice.

1. In critically ill patients, antimicrobial therapy should be started immediately. The pathophysiological status of the patient and the pharmacokinetic properties of the antibiotic used should be considered to ensure timely and effective administration of antibiotics.
2. In patients with complicated intra-abdominal infection undergoing an adequate source-control procedure, a short course of antibiotic therapy (3–5 days) is recommended. Post-operative antibiotic therapy is not necessary in patients with uncomplicated intra-abdominal infections, where the source of infection is treated definitively.
3. Diagnostic investigations should be carried out in patients who show signs of peritonitis or systemic illness (ongoing infection) for more than 5 to 7 days of antibiotic treatment.

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The guidelines for the management of anorectal issues by WSES and AAST will be discussed in this series pertaining to different conditions-Click here to read the previous parts-Management of Perineal necrotizing fasciitis: Guideline by WSES/AAST

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Disclaimer- The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of M3 India.