Surgical Treatment

The use of surgery depends on the primary pathology and is considered only if the medical management fails. The main principle of surgery is to excise or plicate the redundant bowel to prevent postoperative incontinence or constipation. Resection or tailoring of the ectatic segment should be an integral part of the primary reconstructive procedure if rectal ecta-sia is recognized perioperatively in association with anomalies like ARM or anal stenosis.

In selected cases with a prominent posterior shelf (suggesting the selective dilation of the posterior rectal wall), a rectal wall plication procedure would be therapeutic. Similarly, a midsphincteric defect, if detected on surgical dissection, can be repaired in layers.

Several investigators have described varying techniques for dealing with rectal ectasia:

1. Anterior resection [26]. This is a major procedure that would be indicated only for patients with a hugely dilated rectum, and is not amenable to evacuation and medical management. In this technique, excision of the dilated bowel is performed to leave a normal-sized bowel, which is anastomosed to the distal rectum at the peritoneal reflection (Fig. 12.5).

2. Endorectal pull-through [27]. Resection of the abnormal bowel by an endorectal pull-through procedure has been reported to give good to excellent results [20].

3. Swenson's pull-through.

Ineffective Peristalsis
Fig. 12.5 Perioperative photograph showing the ectatic rectosigmoid segment filled due to fecal impaction (A), and with prominent but ineffective peristalsis (B)

Tailoring and tapering of the dilated segment of rectum via the PSARP route is also a preferred method with desirable results [28]. Duhamel's pull-through has also been tried in few cases with good postoperative results [27].

Tailoring and tapering of the dilated segment of rectum via the PSARP route is also a preferred method with desirable results [28]. Duhamel's pull-through has also been tried in few cases with good postoperative results [27].

Rectosigmoid Cancer Research

References

Fig. 12.6 A, B Deficient rectal wall, as identified using a posterior sagittal approach, being plicated to strengthen the defect. The thin rectal wall has been highlighted with the artery forceps

Fig. 12.6 A, B Deficient rectal wall, as identified using a posterior sagittal approach, being plicated to strengthen the defect. The thin rectal wall has been highlighted with the artery forceps

6. Resection of the terminal bowel down to the dentate line when associated with low ARM [19].

7. Plication of the dilated segment through the PSARP route. The author prefers this method as it is associated with lower morbidity, preserves the sphincter complex, leaves the pelvic nerve plexus undisturbed, strengthens the deficient rectal muscle, and has been found to produce good postoperative results (Fig. 12.6).

12.2.7 Summary

Rectal ectasia is focal dilatation of the rectum due to either a primary muscle defect or a secondary response to an obstructive anorectal condition. Ectasia should be suspected in all patients with chronic constipation in association with ARM. Postoperative anal stricture after an otherwise good surgical repair of ARM may also result in rectal ectasia.

Barium studies of the posterior shelf require careful evaluation for midsphincteric and rectal wall defects. An effective medical therapy would be helpful in the majority of cases; however, surgery may be needed if the ectasia is too severe or present for too long, where the symptoms are not likely to improve with conservative medical management.

References

Dorairajan T (1988) Anorectal atresia. In: Stephens FD, Smith ED, Paul NW (eds) Anorectal Malformations in Children: Update 1988. Liss, New York, NY, pp105-110 Martinez-Frontanilla LA (1991) Double atresia of the hindgut. J Pediatr Surg 2:811

Ein SH (1997) Imperforate anus (anal agenesis) with rectal and sigmoid atresias in a newborn. Pediatr Surg Int 12:449-451

Gangopadhyay AN, Sinha CK, Sahoo SP (1997) Combined rectal atresia and rectal stenosis. Pediatr Surg Int 12:605-606

Sharma A.K, Chaturvedi V, Wakhlu A (1995) Anal agenesis with rectal atresia. J Pediatr Surg 30:113-114 Magnus RV (1968) Rectal atresia as distinguished from rectal agenesis. J Pediatr Surg 3:593-598 Saxena AK, Morcate JJ, Schleef J, Reich A, Willital GH (2004) Rectal atresia, choanal atresia and congenital heart disease: a rare association. Technol Health Care 12:343-345

Zia-ul-Miraj A, Brereton RJ, Huskisson L (1995) Rectal atresia and stenosis. J. Pediatr Surg 30:1546-1550 Roesner D (2001) [The reconstruction of rectal atresia. Diagnostics, therapy and prognosis of anorectal malformations] (in German). Zentralbl Chir 126 Suppl 1:50-54

Devendra K. Gupta and Shilpa Sharma: Rectal Atresia and Rectal Ectasia

10. Dias RG, Santiago Ade P, Ferreira MC (1982) Rectal atresia: treatment through a single sacral approach. J Pediatr Surg 17:424-425

11. Vinograd I, Lernau OZ, Nissan S (1983) High anorectal atresia - surgical treatment through a sacro-coccygeal-perineal approach. Z Kinderchir 38:359-360

12. Vaneerdeweg W, Hubens G, Deprettere A (1995) Mucosal proctectomy and coloanal anastomosis as treatment of rectal atresia. J Pediatr Surg 30:1722-1723

13. Gauderer MWL, Izant RJ (1984) String placement and progressive dilatations in the management of high membranous rectal atresia. J Pediatr Surg 19:600-602

14. Upadhyaya P (1990) Rectal atresia: transanal, end-to-end, rectorectal anastomosis: a simplified, rational approach to management: J Pediatr Surg 25:535-537

15. Upadhyaya Purushottam (1996) Rectal Atresia. In: Prem Puri (ed) Newborn Surgery. Butterworth-Heinemann, Oxford, UK, pp 395-398

16. Chiba T, Albanese CT, Jennings RW, Filly RA, Farrell JA, Harrison MR (2000) In utero repair of rectal atresia after complete resection of a sacrococcygeal teratoma. Fetal Di-agn Ther 15:187-190

17. Brent L, Stephens FD (1976) Primary rectal ectasia: a quantitative study of smooth muscle cells in normal and hypertrophied human bowel. In: Rickham PP, Hecker W, Prevot J (eds) Progress in Pediatric Surgery. Urban and Schwarzenberg Berlin, pp 41-62

18. Stephens FD (1988) Rectal ectasia: primary and secondary associated with anorectal anomalies. Birth Defects Orig Artic Ser 24:99-104

19. Cloutier R, Archambault H, D'Amours C, Levasseur L, Ouellet D (1987) Focal ectasia of the terminal bowel accompanying low anal deformities. J Pediatr Surg 22:758-760

20. Powell RW, Sherman JO, Raffensperger JG (1982) Megar-ectum: a rare complication of imperforate anus repair and its surgical correction by endorectal pullthrough. J Pediatr Surg 17:786-795

21. Peña A, El Behery M (1993) Megasigmoid: a source of pseudoincontinence in children with repaired anorectal malformations. J Pediatr Surg 28:199-203

22. Upadhyaya P (1984) Mid-anal sphincteric malformation, cause of constipation in anterior perineal anus. J Pediatr Surg 19:183-186

23. Stephens FD (1980) Anorectal continence and idiopathic constipation. In: Holter TM, Ashcraft KW (eds) Pediatric Surgery. WB Saunders, Philadelphia, pp 418-428

24. Cuffari C, Bass J, Rubin S, Krantis A (1997) Dysplastic nitrergic neurons in the rectum of a patient with rectal ectasia. J Pediatr Surg, 32:1237-1240

25. Gattuso JM, Kamm MA (1997) Clinical features of id-iopathic megarectum and idiopathic megacolon. Gut 41:93-99

26. Hallows MR, Lander AD, Corkery JJ (2002) Anterior resection for megarectosigmoid in congenital anorectal malformations. J Pediatr Surg 37:1464-1466

27. Zia-ul-Miraj A, Brereton RJ (1997) Rectal ectasia associated with anorectal anomalies. Pediatr Surg 32:621-623

28. De Vries PA, Peña A (1982) Posterior sagittal anorecto-plasty. J Pediatr Surg 17:638-643

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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