Indian Journal of Surgery Medknow Publications on behalf of Association of Surgeons of India ISSN: 0972-2068 Vol. 67, Num. 2, 2005, pp. 100-101

Indian Journal of Surgery, Vol. 67, No. 2, March-April, 2005, pp. 100-101

Case Report

Giant villous adenoma in an incarcerated rectal prolapse: A clinical conundrum!

Shah PR, Joseph A, Haray PN, Kiberu S

North Glamorgan NHS Trust, Merthyr Tydfil
Correspondence Address:North Glamorgan NHS Trust, Merthyr Tydfil, CF47 9DT Email: mr.haray@nglam-tr.wales.nhs.uk

Code Number: is05024

Abstract

Rectal prolapse is a distressing condition associated with incontinence. However, incarcerated rectal prolapse is a rather rare entity. We had a 75-year-old man with irreducible rectal prolapse who required recto-perineal sigmoidectomy (Altemeier's procedure) after failure of initial conservative treatment. Histology showed rectal tubulo villous adenoma with moderate to severe dysplasia. This case is unusual as it is a rare combination of irreducible rectal prolapse, which appears to have been caused by a large neoplastic change.

Rectal prolapse represents full-thickness protrusion of the rectum through the anal sphincter mechanism. Rarely, the prolapsed portion of the rectum can become incarcerated or even strangulated. The exact incidence of rectal prolapse although unknown, it is a rather rare entity. We hereby report a case of a rectal prolapse with incarceration and neoplastic change.

Keywords: Rectal prolapse, incarceration, perineal recto-sigmoidectomy, giant villous adenoma

Rectal prolapse represents full-thickness protrusion of the rectum through the anal sphincter mechanism. Rarely, the prolapsed portion of the rectum can become incarcerated or even strangulated. The exact incidence of rectal prolapse although unknown, it is a rather rare entity. We hereby report a case of a rectal prolapse with incarceration and neoplastic change.

CASE REPORT

A 75-year old man was admitted as an emergency with an irreducible rectal prolapse of 24 hours duration. He had had this prolapse and significant rectal bleeding for five years but this was the first episode of incarceration. Past medical history included several resections for small bowel Crohn's disease. He also had significant co-morbidity from chronic obstructive airways disease.

Inspection revealed a incarcerated rectal prolapse of over 10 cm [Figure - 1]. There was considerable sero-sanguinous discharge with mucosal congestion. The entire exposed mucosa was carpeted with a villous lesion. Conservative methods and an attempt under general anaesthesia failed to achieve reduction. An emergency perineal recto-sigmoidectomy (Altemeier's procedure) was undertaken. At operation, the villous lesion was seen to be extending well into the upper rectum. The entire rectum and the distal sigmoid colon were mobilised and 25 cm of bowel was resected perineally. The operation was completed with a hand-sewn colo-anal anastomosis. The patient recovered satisfactorily and was discharged home on the sixth postoperative day. The postoperative period was unremarkable. Histology revealed a giant tubulo-villous adenoma with moderate to severe dysplasia [Figure - 2]. There was no invasion of lamina propria. No recurrence or incontinence has been seen during the follow-up period of two years.

DISCUSSION

Incarcerated rectal prolapse is not a common condition. One of the earliest reports describes a case of prolapse with threatened gangrene.[1] An incarcerated prolapse can generally be reduced by gentle pressure. When extensive oedema is present, the application of granulated sugar for 15-20 minutes will reduce the oedema and may allow reduction.[2] The use of hyaluronidase has also been described in the literature for reduction of prolapse.[3] The majority of these can be reduced manually under anaesthesia after failed initial conservative treatment. If the reduction is impossible, as in this case, a perineal recto-sigmoidectomy is one of the best options,[4] with a low recurrence rate and a low mortality rate.

Perineal recto-sigmoidectomy or Altemeier's procedure can be done with the patient in the lithotomy or prone jack knife position and under either general or regional anaesthesia. The rectum is prolapsed and the outer cylinder of the bowel is divided approximately 1.5 cm to 2.0 cm proximal to the dentate line. The inner cylinder of the rectum and sigmoid is placed on traction, and mesenteric vessels are sequentially ligated and divided. When the proximal bowel cannot be pulled down any further, it is ready for division. At this point in the operation, levator repair can be done anteriorly or posteriorly or in both positions. The specimen is then amputated, taking care to prevent retraction of the proximal colon into the abdomen. The anastomosis can be completed with either a sutured or stapled technique.[4]

Rectal villous adenomas can sometimes present in cases with prolapse of the rectum; however, only two cases have been reported with giant villous adenomas causing incarceration of the prolapse with one case each in the English and the non-English literature.[5],[6]

This case is of particular interest because of an unusual combination of incarcerated rectal prolapse with giant villous adenoma in which incarceration appears to have been caused by a large neoplastic lesion. The clinicians should be aware of the possibility of adenomatous changes in such a lesion, which require appropriate treatment in the form of perineal recto-sigmoidectomy.

References

Copyright 2005 - Indian Journal of Surgery

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