Treatment of Stromal Prolapse
Immediate surgical intervention is required for patients with stromal prolapse showing signs of shock, gangrene, perforation of rectal tissue, or hemodynamic instability. 1, 2
Initial Assessment and Management
- For uncomplicated stromal prolapse without signs of ischemia or perforation, attempt gentle manual reduction under mild sedation or anesthesia with the patient in Trendelenburg position 1, 2
- Conservative measures to reduce edema and facilitate manual reduction include:
- Conservative management should not delay surgical treatment when indicated, as the failure rate is high 1, 2
Indications for Immediate Surgical Intervention
- Signs of shock 1, 2
- Gangrene or perforation of prolapsed tissue 1, 2
- Hemodynamic instability 1, 2
- Strangulated prolapse with signs of ischemia 1
- Failure of conservative management 2
- Acute bleeding or bowel obstruction 2
Surgical Approach Selection
- For patients without peritonitis or hemodynamic instability, the choice between abdominal and perineal procedures should be based on patient characteristics and surgeon expertise 1, 2
- For patients with peritonitis, an abdominal approach is suggested 1, 2
- For hemodynamically unstable patients, an abdominal open approach is recommended 1, 2
- In cases of incarcerated rectal GIST (gastrointestinal stromal tumor) protruding from the anal canal, transanal excision with clean surgical margins may be performed under emergency conditions 3
Pharmacological Management
- Empiric antimicrobial therapy should be administered in cases with strangulated tissue due to risk of intestinal bacterial translocation 2
- The antibiotic regimen should be tailored based on the patient's clinical condition and individual risk factors 2
Important Considerations and Pitfalls
- Do not delay surgical management in unstable patients with complicated rectal prolapse to attempt conservative management 1
- The timing of surgical intervention after failed conservative management remains controversial, but surgery should not be delayed in cases with overt gangrene, perforation, or shock 2
- In patients requiring resectional surgery, the decision between primary anastomosis and terminal colostomy should be based on the patient's clinical condition and risk of anastomotic leakage 1, 2
- For specific cases like rectal GIST with prolapse, complete surgical resection with en bloc excision of the tumor is the treatment of choice 3
- Long-term follow-up is essential to monitor for recurrence, especially in cases of pelvic organ prolapse 4, 5