Sigmoid colon cancer presenting as complete rectal prolapse

Bounovas, Anastasios; Polychronidis, Alexandros; Laftsidis, Prodromos; Simopoulos, C.

doi:10.1111/j.1463-1318.2007.01234.x

Cited by 16 publications

(20 citation statements)

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“…Re: Sigmoid colon cancer presenting as complete rectal prolapse doi:10.1111/j. 1463-1318.2007.01444.x Dear Sir, We read with interest the case described by Bounavas et al [1]. Whilst there is limited literature describing the association of concomitant rectal prolapse and rectal adenocarcinoma, our experience illustrates that this association is not as rare as the authors suggest.…”

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confidence: 64%

Re: Sigmoid colon cancer presenting as complete rectal prolapse

2008

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bound cyanocobalamin. We accept that gastric biopsies to test for achlohydria ⁄ hypochlorhydria and faecal elastase tests to exclude chronic pancreatitis as causes would have strengthened the study. Although not stated in our article, none of patients were taking H2-antagonists.We recognize that folate deficiency may result in falsely low serum cobalamin levels and these figures from our cohort will be included in a comprehensive paper describing the outcome of all haematological parameters following restorative proctocolectomy, currently being prepared for submission to Colorectal Disease. We will also be describing our results using the more sensitive indicator, plasma homocysteine, to diagnose subclinical cobalamin deficiency in our cohort.Dear Sir, We read with interest the case described by Bounavas et al. [1]. Whilst there is limited literature describing the association of concomitant rectal prolapse and rectal adenocarcinoma, our experience illustrates that this association is not as rare as the authors suggest. As well as the three articles describing the association of colonic adenocarcinoma with rectal prolapse, colonic lipomas [2] and adenomas [3] resulting in complete rectal prolapse have also been described. Furthermore we have been involved in two cases within the last year where complete rectal prolapse led to the diagnosis of primary sigmoid or rectal adenocarcinoma.Most recently, a 72-year-old lady was referred to the general surgeons with a 5-month history of complete prolapse of the rectum and associated procidentia (Fig. 1). On examination it was immediately apparent that there was an 8 · 4 cm fungating cancer at the apex of the rectal prolapse. Biopsies confirmed invasive adenocarcinoma and staging investigations were initiated. Barium enema failed because of complete lack of anal tone. Flexible sigmoidosocopy revealed a synchronous sigmoid adenocarcinoma. CT scanning revealed a possible single liver metastasis; the patient therefore underwent resection. The operation performed was Hartmann's procedure with end colostomy, total hysterectomy, pelvic floor repair, repair of rectocele and cystocele. The histology of the rectal tumour was pT3N2, that of the sigmoid lesion pT2N0. She made an excellent recovery from surgery and has had no further problem with prolapse. In view of the histology, she was referred for adjuvant chemotherapy. Unfortunately, 2 months later she was found to have multiple liver metastases and has now been converted to second-line chemotherapy.The fourfold increase in risk of colorectal cancer in the series of patients with symptomatic prolapse presented by Rashid and Basson [4] provides a compelling argument for the routine preoperative assessment of these patients, and has indeed influenced routine practice in some colorectal units. Barium enema is likely to prove futile in these cases as the anal tone is decreased. Flexible sigmoidoscopy therefore offers the most useful screening. In view of our recent experiences, we would certainly concur that all patients with rectal...

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confidence: 64%

Re: Sigmoid colon cancer presenting as complete rectal prolapse

2008

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“…Only five other cases exist of sigmoid and rectal adenocarcinomas detected in a full-thickness rectal prolapse [1][2][3][4][5]. This is the first case with rectal cancer in a prolapsed rectal stump following a Hartmann's procedure.…”

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confidence: 98%

Rectal adenocarcinoma in prolapsed rectal stump following Hartmann’s procedure

Nabi

2014

Int J Colorectal Dis

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Dear Editor:A 77-year-old female with numerous medical comorbidities (predominantly cardiac and respiratory) was referred by her general practitioner to the colorectal outpatient clinic at Fremantle Hospital with a symptomatic full-thickness rectal prolapse. The patient had a Hartmann's procedure performed approximately 35 years prior at a peripheral hospital after an obstetric injury rendered her completely incontinent of faeces. At that time, attempts at sphincter repair unfortunately failed and, consequently, the Hartmann's procedure was performed as a last resort. This procedure had been performed purely for symptomatic relief of her socially debilitating incontinence and no colonic pathology was identified clinically or pathologically.The patient stated that she first noticed prolapse of her rectal stump approximately 5 years prior to her referral to see us in colorectal clinic. At that time, her then general practitioner felt that her medical comorbidities excluded her from having any surgical intervention and, consequently, no referral had been made for specialist review.Examination of the patient's perineum confirmed the presence of a full-thickness rectal stump prolapse, with 15 cm of rectum prolapsing through the patient's anus. Examination of the anus established that the patient had no sphincter tone. Interestingly, a large mass (up to 35-mm diameter) emanating from the rectal mucosa was identified in the distal end of the prolapsing rectal stump-this was clinically suspicious for malignancy. Biopsies of the mass taken in the clinic confirmed the presence of adenocarcinoma.Preoperative staging computer tomography (CT) scanning confirmed that the entire rectal stump had prolapsed from the anus. No disseminated disease or suspicious lymphadenopathy was identified on this CT.Given the patient's numerous medical comorbidities-and subsequent discussions with anaesthetics-a collaborative decision was made to resect the patient's pathology via a perineal approach and avoid any abdominal incisions. This was deemed to be the safest approach given her medical fragility. Consequently, an intersphincteric perineal proctectomy was performed with high ligation of the mesorectum achieved with the use of an energy device through the perineum. The use of the energy device facilitated for a greater lymph node yield with more complete resection of the mesorectum and rectal vessels.The patient recovered well following this novel approach to her highly unusual pathology and no short-term complications were noted at 30 days. The pathology of the resection specimen confirmed the complete resection of a moderately differentiated rectal adenocarcinoma with invasion into the muscularis propria (pT2) and none of the 12 lymph nodes in the specimen involved (pN0).A literature search was performed using PubMed and MEDLINE databases looking for previous cases of colorectal adenocarcinomas in full-thickness rectal prolapse. Only five other cases exist of sigmoid and rectal adenocarcinomas detected in a full-thickness rectal prolapse...

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“…21,22 Although uncommon, a neoplasm may form the lead point for a rectal intussusception. 23 For this reason, and because this problem often occurs in the older population, colonoscopy should be performed based on existing guidelines of appropriate screening for colorectal cancer. A significant finding on colonoscopic inspection may change the operative approach.…”

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confidence: 99%