What is the best course of treatment for a patient with a CT (computed tomography) showing severe narrowing at the rectosigmoid junction, a history (hx) of rectal prolapse with 2 previous surgeries, and a family history (fh) of colon cancer?

Management of Severe Rectosigmoid Junction Narrowing with History of Rectal Prolapse and Family History of Colon Cancer

For a patient with severe narrowing at the rectosigmoid junction on CT, history of rectal prolapse with two previous surgeries, and family history of colon cancer, urgent surgical intervention with an abdominal approach is recommended.

Initial Assessment and Diagnostic Workup

• Perform an urgent contrast-enhanced abdomino-pelvic CT scan to evaluate the extent of narrowing, detect possible associated complications, and assess for the presence of colorectal cancer 1
• Request complete blood count, serum creatinine, and inflammatory markers (C-reactive protein, procalcitonin, lactates) to assess the patient's clinical status 1
• Consider colonoscopy to evaluate the narrowing and obtain biopsies if not already performed, as rectal prolapse patients have a 4.2-fold increased risk of colorectal cancer compared to the general population 1, 2

Treatment Algorithm

Step 1: Evaluate for Emergency Indications

• Immediate surgical treatment is indicated if there are signs of:
  • Bowel obstruction due to the severe narrowing 1
  • Perforation or peritonitis 1
  • Hemodynamic instability 1

Step 2: Determine Surgical Approach

• Abdominal approach is recommended for this patient with:

  • Severe narrowing at the rectosigmoid junction 1
  • History of recurrent rectal prolapse after two previous surgeries 1
  • Family history of colon cancer requiring thorough evaluation 2, 3

• The decision between open or laparoscopic surgery should be based on:

  • Patient's clinical condition 1
  • Surgeon's expertise and skills 1
  • Extent of the narrowing and adhesions from previous surgeries 1

Step 3: Select Specific Surgical Procedure

• For rectosigmoid narrowing with history of rectal prolapse, consider:

  • Resection rectopexy with or without mesh (removes the narrowed segment while fixing the prolapse) 1
  • Suture rectopexy if narrowing is not due to intrinsic pathology 1
  • Mesh rectopexy techniques if additional support is needed 1

• For cases with suspected malignancy at the narrowing:

  • Low anterior resection with appropriate oncologic margins 1, 4
  • Consider neoadjuvant therapy if locally advanced rectal cancer is found 1

Special Considerations

• The rectosigmoid narrowing may be related to:

  • Scarring from previous prolapse surgeries 5
  • Potential colorectal malignancy (given family history) 3
  • Chronic intussusception from recurrent prolapse 2

• Patients with rectal prolapse should undergo thorough evaluation for colorectal cancer, as studies have shown a 5.7% prevalence of rectosigmoid cancer in these patients compared to 1.4% in control groups 1

• If the patient is unstable or has signs of complete obstruction, consider temporary diverting ostomy before definitive treatment 1

Postoperative Management

• Monitor for complications including anastomotic leak, recurrent prolapse, and bowel dysfunction 5
• Implement bowel management protocols to prevent constipation, which can lead to recurrent prolapse 6
• Establish regular surveillance for colorectal cancer given the family history and increased risk associated with rectal prolapse 1, 3