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Abstraction

Complete rectal prolapsus is a straitening status that represents full-thickness bulge of the rectum through the anal sphincters mechanism. Incarceration and choking of an acute rectal prolapsus is a instead unusual entity that represents a surgical exigency. We report a rare instance of an 80-year-old adult female on antiplatelet drug ( Clopidogrel ) showing with acute intestine obstructor secondary to a strangulated cringle of little intestine, entrapped in an irreducible hemorrhage rectal prolapsus. She required exigency transperineal little intestine resection and proctosigmoidectomy with colo-anal inosculation ( Altemeier ‘s process ) followed up by laparoscopic division of adhesions, control of little intestine inosculation and formation of a defunctioning loop colostomy. The patient had an uneventful post-operative recovery. Since closing of her colostomy five months subsequently her intestine motions are back to normal and she denies any residuary incontinency.

This instance is a really unusual presentation of a complicated ague rectal prolapsus dealt successfully with minimally invasive surgical attack that combined perineal intestine resections along with laparoscopy. Emergency processs tend to hold higher rates of post-operative complications as compared to elected 1s. Furthermore, with the widen usage of more efficient antiplatelet agents such as Clopidogrel, there is an increased hazard of meeting early per- or post-operative hemorrhage that might significantly decline patients ‘ result. Whenever possible, a planed more ‘conservative ‘ surgical attack should ever be attempted in exigency state of affairss as clearly demonstrated in our instance.

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KeywordsA

Rectal prolapsus, captivity, perineal recto-sigmoidectomy, perineal little intestine resection, minimally invasive surgery, laparoscopic colostomy, clopidogrel

Case study

A 80-year old adult female was admitted tardily at dark in our Department of Emergency with an irreducible rectal prolapsus of 24 hours continuance.

Her past medical history included shot for which she is on Clopidogrel, chronic irregularity, hypercholesterolaemia and osteoporosis. She had a old hysterectomy via an infraumbilical midplane laparotomy, every bit good as a laparoscopic cholecystectomy, umbilical hernia fix and hemorrhoidectomy.

Her medicine of Clopidogrel was stopped and initial efforts to manually cut down her prolapsus failed. Decision was so made to reiterate this tactic earlier in the forenoon under general anesthesia. Unfortunately, the patient developed bowel obstructor overnight secondary to the formation of a big hematoma in her prolapsed rectum and doing farther attempt to cut down it impossible. An exigency surgical drainage of the hematoma completed by an Altemeier ‘s perineal rectosigmoidectomy was undertaken. At operation, there was considerable congestion of the rectal mucous membrane and big measures of altered blood had to be evacuated. Unexpectedly, a cringle of ischemic little intestine was identified after gap of the herniated peritoneum, which was non feasible. These findings are illustrated in Figure1. A trans-anal little intestine resection with primary functional end-to-end inosculation was carried out, utilizing two size 75mm additive GIA stapling machines ( Figure 2 ) . The little intestine was so reduced back into the abdominal pit. The full rectum and the distal sigmoid colon were so mobilised and 25 centimeter of intestine was resected perineally after careful ligation of the mesorectum and mesosigmoid vass. The operation was completed by a hand-sewn colo-anal inosculation utilizing interrupted 2/0 Vicryl stitches. Finally, laparoscopic geographic expedition with division of adhesions from old surgery was made, demoing a healthy little intestine inosculation and no grounds of intraabdominal hemorrhage. A defunctioning cringle sigmoid colostomy was performed and fashioned at the degree of the left iliac pit for protective and repairing intent ( Figure 2 ) . Final histopathology study showed grounds of hemorrhagic misdemeanor of the mucous membrane and submucosa of both intestine sections, along with pronounced congestion of the mesentery. There was no grounds of malignance.

The patient recovered really good and was discharged place on the 6th postoperative twenty-four hours. Five months subsequently reversal of her colostomy was performed, following a satisfactory anal manometry and normal colonoscopy. No return or incontinency has been observed during her follow-up period of over two old ages.

Discussion

Incarcerated rectal prolapsus is an uncommon status chiefly observed in aged female patients. It can by and large be reduced manually by soft force per unit area either under mild sedation or general anesthesia after failed initial conservative intervention. If the decrease is impossible, as in this instance, a perineal proctosigmoidectomy or Altemeier ‘s process is the lone staying intervention option. This can be achieved with low return and mortality rates in aged bad patients.1

Clopidogrel is a thrombocyte inhibitor that selectively blocks the binding of adenosine diphosphate ( ADP ) to its thrombocyte receptor, thereby cut downing the possibility of thrombocyte adhesion and collection. Alteration of the thrombocyte ADP receptor is irreversible and accordingly, thrombocytes exposed to a individual dosage of Clopidogrel will be affected for the balance of their lifetime, which is about 7 to 10 days.2 Therefore, general consent among sawboness is to halt Clopidogrel for a lower limit of one hebdomad prior to any elected abdominal surgery. Clopidogrel is today one of the most widely used antiplatelet agents for the secondary bar of vascular ischemic events, such as myocardial misdemeanor or shot like in this instance. Patients on this medicine be given to see significantly more post operative complications with a higher opportunity of returning to the operating room.3

What makes this instance of peculiar involvement is the highly rare combination of incarcerated acute rectal prolapsus with little intestine choking caused by a big rectosigmoid hematoma. It makes no uncertainty that these clinical findings were related by her antiplatelet intervention and concerns are that similar types of presentation may go less uncommon with an on-going aging population.

The pick to execute a defunctioning cringle colostomy was motivated by several grounds including the age of the patient, the demand to protect a “ hard ” hand-sewn inosculation from the fecal watercourse and vascular compromise,1,4 the fact that the patient had an associated little intestine resection and eventually the increased hazard of postoperative anastomotic hemorrhage. Ramanujam et al 1 published a 22 % anastomotic leak rate necessitating deviating colostomy in nine patients with incarcerated rectal prolapsus. None of these aged patients were on antiplatelet agents. With all these concerns in head we opted for a laparoscopic attack, which offers important better results in footings of postoperative morbidity5,6,7,8 and mortality7,8 in comparing with unfastened surgical processs. The patient recovered satisfactorily.

In decision, we present a rare instance of incarcerated and strangulated hemorrhage rectal prolapsus complicated by little intestine ischemia, in an aged patient on clopidogrel and successfully treated with both, perineal and laparoscopic attack. This is to our cognition the first study of such a instance. It reinforces the fact that minimally invasive surgery should be offered to all patients who lack an absolute contraindication for laparoscopic attack, as stated by others.5

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