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Intrarectal intussusception of the rectal mucosa
Intrarectal
Intussusception Mucosa
A COMPLICATION
OF THE
THIERSCH
M. T. KHILNANI, M.D.,A. S. LYONS, M.D. AND ROBERT From tbe Departments of Surgery and Radiology, Mount Sinai Hospital, New York, New York.
or incompIete protrusion of one or more Iayers of the rectum associated with or without protrusion of the anus” [I]. ProIapse may be simpIe or massive (procidentia) in type. Moschcowitz [2] described procidentia as an anterior sIiding hernia of the pouch of DougIas through a weakened peIvic fascia. In procidentia the ana sphincter and Ievator ani muscIe may be extremeIy hypotonic in the presence of a norma ana reflex. Over fifty surgica1 technics have been described in the Iiterature for the treatment of procidentia. This shows that no one operation, no matter how simpIe or extensive, is curative of this Iesion in a11 cases [3]. As earIy as 1891, Thiersch [d] described an extremeIy simpIe circumana1 and perisphincteric wiring technic using siIver wire, which controIIed proIapse and its accompanying annoying symptoms in most cases. We [5] have empIoyed this operation (I) either as a temporary or sometimes as a soIe procedure in chiIdren, for the treatment of recta1 proIapse that cannot be controIIed by conservative measures; (2)as a paIIiative operation in aduIts considered poor risks; (3) as an adjunctive procedure to other operative technics in the presence of marked ana patuIosity, and (4) as a tria1 operation in patients deemed good surgica1 risks prior to attempting more formidabIe operative procedures. CompIications of the Thiersch procedure, such as feca1 impaction, breakage of wire, mucosa1 proIapse and sinus formation posteriorIy in the area of the twisted wire are fairIy we11 known. This presentation describes of Surgery,
Volume
107, May
1964
TURELL, M.D., New
York, New York
compIication heretofore not reported, as far as we can determine. Two patients who couId not defecate spontaneousIy foIIowing the Thiersch operation presented a clinica picture of organic coIonic obstruction. This was the resuIt of intrarecta1 mucosa1 intussusception which obturated the recta1 Iumen.
ROLAPSE of the rectum has been defined as
Journal
OPERATION
an additiona
Tbe
P “a compIete
American
of the Rectal
CASE REPORTS CASE I. A forty-five year old man was admitted for repair of chronic massive recta1 proIapse. The patient was markedIy obese and the genera1 appearance suggested a “Pickwickian” habitus. After a Thiersch operation was performed the cIinica1 picture of coIonic obstruction and dif&uIty in micturition deveIoped. The coIonic obstruction associated with distention of the abdomen became progressiveIy worse. Simple enemas were not effective in reIieving the distention. A pIain, simple fiIm of the abdomen taken two days after surgery showed moderate distention of the coIon with no significant amount of feca1 matter in the sigmoid and rectum. The bIadder outIine couId be seen and overlying the urinary bIadder a sharpIy outlined, round mass with the density of fat was seen in the midline. DigitaI examination and sigmoidoscopy were carried out with ease and showed no unusua1 features except redundant recta1 mucosa in and above the ampuIIa. Barium enema examination showed distention of the coIon above the rectum with feca1 retention. A Iarge smooth defect was seen in the rectum arising from the right and anterior waIIs. (Fig. IA and B.) This defect corresponded in size to the Iucent mass seen on the preIiminary Mm. Air contrast study (Fig. z) showed this mass to be within the ampuIIa. The diagnosis of intrarecta1 intussusception was suggested. There was no visibIe protrusion of the recta1 mucosa through the anal orifice. Recta1 irrigations as we11as an indweIIing recta1
754
Intrarectd
Intussusception
B
A
I. 4, barium enema .examin:ition in the I_“,stcro~lIr~crirlr vic\v sho\\s :I large, sharply outlined, oval-fdllnA defect within the rectum iarro~ s). The right 1;1(..
margin of this relatively lucent mass is seen ovcrlving the body of the right. pubic bone. The irrcgulnr barium collection seen first to the left of the symphysis pubis represents the remaining recta1 Iumen. B, barium cnerna study in the m:rrkctl left anterior oblique view rcvcals the mass to be arising on a broad base (arrows) from the anterior rectal wall and markedly cncronching upon the rectal lumen. This Iumen is represented by the crescentic, posteriorly located, barium colIection.
3
2
FIG. 2. Air contrast
studies outline the smooth,
sIightIy wavy margin of the intrarectal
FIG. 3. FiIm of the abdomen taken in the erect position shows a round mass (arrows) periorIy by a smaII amount of air in the coIon. The proxima1 colon is markedly dilated.
4 mass (arrows). in the rectum
outIined
su-
FIG. 4. Barium enema reveaIs a sharp but IobuIated upper margin of the intraluminal mass which prevents fiIIing of the rectum. A round area, the size of the mass seen in Figure 3. between the Thiersch wire and the Iower margin of the barium-filled coIon, appears more Iucent than adjacent soft tissues on the original film.
755
KhiInani,
Lyons and TureII The proxima1 opening of the ampuIIa becomes “pIugged” with redundant mucous membrane or bowe1 waI1, obstructing the dista1 movement of flatus, Iiquid or formed feces but without causing impediment to the retrograde introduction of recta1 tubes or endoscopes. Roentgen ray differentia1 diagnosis Iies between mucosa1 (e.g., adenomas), submucosa1 (e.g., carcinoid) and connective tissue tumors of the recta1 waII (e.g., myosarcoma). A simiIar appearance can be caused by tumors of the peIvic floor which protrude into the rectum, such as neurofibroma, metastatic carcinoma or extension of prostatic neopIasm. These Iesions may be dificuIt to differentiate from each other on the roentgenograms onIy but offer no diagnostic probIem, since the preoperative clinica story and picture are known and the Thiersch wire is seen.
tube reheved the abdomina1 distention. Because of compIete Iack of cooperation on the part of the patient, the Thiersch wire was removed some seventy-two hours after insertion. Some twentyfour hours after remova of the wire, the patient had a spontaneous bowel movement with but sIight recta1 proIapse.
CASE II. A robust, taI1 man, forty-three years of age, had marked abdomina1 distention two days after a Thiersch operation was performed for massive recta1 proIapse of ten years’ duration, necessitating nasogastric suction and intravenous aIimentation for twenty-four hours. A pIain fiIm of the abdomen showed pronounced distention of the coIon down to the rectum. On the erect Mm a sharpIy marginated soft tissue mass outIined by a smaI1 amount of gas was seen in the rectum. (Fig. 3.) A barium enema (Fig. 4) showed nonfXing of the dista1 rectum with barium by an intramura1 mass. The upper margin of the mass was outIined by the barium in the proxima1 rectum and the mass was essentiaIIy of the same size as seen on the erect fiIm of the abdomen. Because of nonfiIIing of the ampuIIa the inferior margin of this intrarecta1 intussusception couId not be determined. The patient was unabIe to evacuate the barium which had to be siphoned off. The digita recta1 and sigmoidoscopic examinations reveaIed redundant rectal mucosa within the ampuIIa. No obstruction was encountered on sigmoidoscopy. Recta1 irrigation and recta1 intubation yieIded feces and gas and Ied to rapid improvement. The enema fluid, however, had to be siphoned off each time because of the patient’s inabiIity to evacuate spontaneousIy. The patient was foIIowed for about three weeks in the hope of obtaining a cIinica1 cure by these maneuvers. Because of faiIure to contro1 the distention, the wire was removed. After remova1 of the wire, the patient was abIe to move his boweIs without difEcuIty but with recurrence of proIapse.
SUMMARY
After a Thiersch operation for recta1 procidentia, a cIinica1 syndrome resembIing intestina obstruction occurred in two patients. AIthough the ana opening and recta1 Iumen easiIy permitted the passage of the sigmoidoscope, recta1 tube and index finger after operation, ffatus, Iiquid or formed feces couId not be passed by the patient. This compIication, apparentIy caused by an intrarecta1 intussusception, has not been hitherto described. REFERENCES I. TURELL, R.
Treatment in Proctology. Baltimore, 1949. WiIliams & WiIkins Co. 2. MOSCHCOWITZ, A. V. Pathogenesis, anatomy, and cure of proIapse of rectum. Szcrg. Gynec. e? Obst., 15: 7, 1912. 3. DUNPHY, J. E. and PIKULA, J. V. Rectal ProIapse. In: Diseases of CoIon and Anorectum. Edited by Robert TureII. PhiIadeIphia, rg5g. W. B. Saunders Company. 4. KIRSCHNER, M. Operative Surgery: The Abdomen and Rectum, vo1. 2, p. 363. TransIated by I. S. Ravdin. PhiIadeIphia, 1933. J. B. Lippincott Co. 5. TURELL, R. Thiersch operation for rectal proIapse and anaI incontinence. New York J. Med., 54: 791, 1954.
COMMENT
The mechanism of this compIication is not altogether cIear. The possibIe expIanation is that after insertion of the periana1 wire the proIapsed segment of bowe1 remains arrested in the ampuIIa in an accordian-Iike fashion.
756
Intussusception Mucosa
A COMPLICATION
OF THE
THIERSCH
M. T. KHILNANI, M.D.,A. S. LYONS, M.D. AND ROBERT From tbe Departments of Surgery and Radiology, Mount Sinai Hospital, New York, New York.
or incompIete protrusion of one or more Iayers of the rectum associated with or without protrusion of the anus” [I]. ProIapse may be simpIe or massive (procidentia) in type. Moschcowitz [2] described procidentia as an anterior sIiding hernia of the pouch of DougIas through a weakened peIvic fascia. In procidentia the ana sphincter and Ievator ani muscIe may be extremeIy hypotonic in the presence of a norma ana reflex. Over fifty surgica1 technics have been described in the Iiterature for the treatment of procidentia. This shows that no one operation, no matter how simpIe or extensive, is curative of this Iesion in a11 cases [3]. As earIy as 1891, Thiersch [d] described an extremeIy simpIe circumana1 and perisphincteric wiring technic using siIver wire, which controIIed proIapse and its accompanying annoying symptoms in most cases. We [5] have empIoyed this operation (I) either as a temporary or sometimes as a soIe procedure in chiIdren, for the treatment of recta1 proIapse that cannot be controIIed by conservative measures; (2)as a paIIiative operation in aduIts considered poor risks; (3) as an adjunctive procedure to other operative technics in the presence of marked ana patuIosity, and (4) as a tria1 operation in patients deemed good surgica1 risks prior to attempting more formidabIe operative procedures. CompIications of the Thiersch procedure, such as feca1 impaction, breakage of wire, mucosa1 proIapse and sinus formation posteriorIy in the area of the twisted wire are fairIy we11 known. This presentation describes of Surgery,
Volume
107, May
1964
TURELL, M.D., New
York, New York
compIication heretofore not reported, as far as we can determine. Two patients who couId not defecate spontaneousIy foIIowing the Thiersch operation presented a clinica picture of organic coIonic obstruction. This was the resuIt of intrarecta1 mucosa1 intussusception which obturated the recta1 Iumen.
ROLAPSE of the rectum has been defined as
Journal
OPERATION
an additiona
Tbe
P “a compIete
American
of the Rectal
CASE REPORTS CASE I. A forty-five year old man was admitted for repair of chronic massive recta1 proIapse. The patient was markedIy obese and the genera1 appearance suggested a “Pickwickian” habitus. After a Thiersch operation was performed the cIinica1 picture of coIonic obstruction and dif&uIty in micturition deveIoped. The coIonic obstruction associated with distention of the abdomen became progressiveIy worse. Simple enemas were not effective in reIieving the distention. A pIain, simple fiIm of the abdomen taken two days after surgery showed moderate distention of the coIon with no significant amount of feca1 matter in the sigmoid and rectum. The bIadder outIine couId be seen and overlying the urinary bIadder a sharpIy outlined, round mass with the density of fat was seen in the midline. DigitaI examination and sigmoidoscopy were carried out with ease and showed no unusua1 features except redundant recta1 mucosa in and above the ampuIIa. Barium enema examination showed distention of the coIon above the rectum with feca1 retention. A Iarge smooth defect was seen in the rectum arising from the right and anterior waIIs. (Fig. IA and B.) This defect corresponded in size to the Iucent mass seen on the preIiminary Mm. Air contrast study (Fig. z) showed this mass to be within the ampuIIa. The diagnosis of intrarecta1 intussusception was suggested. There was no visibIe protrusion of the recta1 mucosa through the anal orifice. Recta1 irrigations as we11as an indweIIing recta1
754
Intrarectd
Intussusception
B
A
I. 4, barium enema .examin:ition in the I_“,stcro~lIr~crirlr vic\v sho\\s :I large, sharply outlined, oval-fdllnA defect within the rectum iarro~ s). The right 1;1(..
margin of this relatively lucent mass is seen ovcrlving the body of the right. pubic bone. The irrcgulnr barium collection seen first to the left of the symphysis pubis represents the remaining recta1 Iumen. B, barium cnerna study in the m:rrkctl left anterior oblique view rcvcals the mass to be arising on a broad base (arrows) from the anterior rectal wall and markedly cncronching upon the rectal lumen. This Iumen is represented by the crescentic, posteriorly located, barium colIection.
3
2
FIG. 2. Air contrast
studies outline the smooth,
sIightIy wavy margin of the intrarectal
FIG. 3. FiIm of the abdomen taken in the erect position shows a round mass (arrows) periorIy by a smaII amount of air in the coIon. The proxima1 colon is markedly dilated.
4 mass (arrows). in the rectum
outIined
su-
FIG. 4. Barium enema reveaIs a sharp but IobuIated upper margin of the intraluminal mass which prevents fiIIing of the rectum. A round area, the size of the mass seen in Figure 3. between the Thiersch wire and the Iower margin of the barium-filled coIon, appears more Iucent than adjacent soft tissues on the original film.
755
KhiInani,
Lyons and TureII The proxima1 opening of the ampuIIa becomes “pIugged” with redundant mucous membrane or bowe1 waI1, obstructing the dista1 movement of flatus, Iiquid or formed feces but without causing impediment to the retrograde introduction of recta1 tubes or endoscopes. Roentgen ray differentia1 diagnosis Iies between mucosa1 (e.g., adenomas), submucosa1 (e.g., carcinoid) and connective tissue tumors of the recta1 waII (e.g., myosarcoma). A simiIar appearance can be caused by tumors of the peIvic floor which protrude into the rectum, such as neurofibroma, metastatic carcinoma or extension of prostatic neopIasm. These Iesions may be dificuIt to differentiate from each other on the roentgenograms onIy but offer no diagnostic probIem, since the preoperative clinica story and picture are known and the Thiersch wire is seen.
tube reheved the abdomina1 distention. Because of compIete Iack of cooperation on the part of the patient, the Thiersch wire was removed some seventy-two hours after insertion. Some twentyfour hours after remova of the wire, the patient had a spontaneous bowel movement with but sIight recta1 proIapse.
CASE II. A robust, taI1 man, forty-three years of age, had marked abdomina1 distention two days after a Thiersch operation was performed for massive recta1 proIapse of ten years’ duration, necessitating nasogastric suction and intravenous aIimentation for twenty-four hours. A pIain fiIm of the abdomen showed pronounced distention of the coIon down to the rectum. On the erect Mm a sharpIy marginated soft tissue mass outIined by a smaI1 amount of gas was seen in the rectum. (Fig. 3.) A barium enema (Fig. 4) showed nonfXing of the dista1 rectum with barium by an intramura1 mass. The upper margin of the mass was outIined by the barium in the proxima1 rectum and the mass was essentiaIIy of the same size as seen on the erect fiIm of the abdomen. Because of nonfiIIing of the ampuIIa the inferior margin of this intrarecta1 intussusception couId not be determined. The patient was unabIe to evacuate the barium which had to be siphoned off. The digita recta1 and sigmoidoscopic examinations reveaIed redundant rectal mucosa within the ampuIIa. No obstruction was encountered on sigmoidoscopy. Recta1 irrigation and recta1 intubation yieIded feces and gas and Ied to rapid improvement. The enema fluid, however, had to be siphoned off each time because of the patient’s inabiIity to evacuate spontaneousIy. The patient was foIIowed for about three weeks in the hope of obtaining a cIinica1 cure by these maneuvers. Because of faiIure to contro1 the distention, the wire was removed. After remova1 of the wire, the patient was abIe to move his boweIs without difEcuIty but with recurrence of proIapse.
SUMMARY
After a Thiersch operation for recta1 procidentia, a cIinica1 syndrome resembIing intestina obstruction occurred in two patients. AIthough the ana opening and recta1 Iumen easiIy permitted the passage of the sigmoidoscope, recta1 tube and index finger after operation, ffatus, Iiquid or formed feces couId not be passed by the patient. This compIication, apparentIy caused by an intrarecta1 intussusception, has not been hitherto described. REFERENCES I. TURELL, R.
Treatment in Proctology. Baltimore, 1949. WiIliams & WiIkins Co. 2. MOSCHCOWITZ, A. V. Pathogenesis, anatomy, and cure of proIapse of rectum. Szcrg. Gynec. e? Obst., 15: 7, 1912. 3. DUNPHY, J. E. and PIKULA, J. V. Rectal ProIapse. In: Diseases of CoIon and Anorectum. Edited by Robert TureII. PhiIadeIphia, rg5g. W. B. Saunders Company. 4. KIRSCHNER, M. Operative Surgery: The Abdomen and Rectum, vo1. 2, p. 363. TransIated by I. S. Ravdin. PhiIadeIphia, 1933. J. B. Lippincott Co. 5. TURELL, R. Thiersch operation for rectal proIapse and anaI incontinence. New York J. Med., 54: 791, 1954.
COMMENT
The mechanism of this compIication is not altogether cIear. The possibIe expIanation is that after insertion of the periana1 wire the proIapsed segment of bowe1 remains arrested in the ampuIIa in an accordian-Iike fashion.
756