Thiersch wiring as a temporary procedure in a haemodynamically unstable patient with an incarcerated rectal procidentia

Abstract

DESCRIPTIONA 35-year-old man presented with complete rectal prolapse which was irreducible for 2 days. He was diagnosed to have a rectal prolapse 6 years ago when he noticed a mass protruding through the anus. Initially, the mass protruded from the anus only after a bowel movement and retracted spontaneously. As the disease progressed, the mass protruded more often, especially with straining and sneezing or coughing and he had to manually replace it. The patient never came for follow-up in 6 years. He does not have bleeding per rectum or pain in the abdomen. He does not have faecal incontinence. On examination the patient was anxious and dehydrated. His pulse rate was 100/ min and his blood pressure was 90/60 mm Hg. He had a full thickness rectal procidentia with mucosal congestion and oedema with whitish flakes over the rectal mucosa (figure 1). There was no evidence of ulceration or bleeding. Routine blood investigations revealed iron-deficient anaemia (haemoglobin: 9 g %) and elevated blood urea nitrogen (urea: 40 mg %). The patient was anxious and the mass could not be reduced at the bedside; hence he was shifted to the operation theatre where he was sedated, 2% lignocaine jelly was applied over the rectum and the mass was reduced with gradual pressure.Decreased anal sphincter tone was noted. Two per cent lignocaine was infiltrated around the anal orifice and 1'0 prolene suture was placed around the anal orifice in subcutaneous plane and tightened over a finger (as a purse string suture; figure 2) to prevent excessive narrowing of the anal orifice. The rectal procidentia was completely reduced (figure 3). Postprocedure there was no rectal prolapse after performing a Valsalva manoeuvre. The patient was resuscitated meanwhile and planned for elective abdominal rectopexy on a later date.Rectal prolapse is a condition in which the entire layer of the rectal wall protrudes through the anal canal. Haemorrhage occurs frequently in cases in which the prolapsed rectum is left unreduced. If severe haemorrhage or strangulation is detected, emergency treatments should be administered. Thiersch procedure (anal encirclement) is performed frequently in patients with old age or high risks with rectal prolapse. It is a simple procedure using a suture or prosthesis that narrows the anus. When it was reported for the first time by Figure 1 Full thickness rectal procidentia (12×6 cm) with mucosal congestion and oedema associated with whitish flakes over the mucosa.Figure 2 1-0 prolene placed around the anal orifice in the subcutaneous plane and then tightened over a finger (as a purse string suture).

Two Rings, Two Recoveries: Exploring the Thiersch Method in Complicated Cases

“…It is a quick and minimally invasive procedure. It can also be used temporarily until definitive treatment is planned, as demonstrated by Naalla et al [ 10 ]. In their case report, a 35-year-old man with complete rectal prolapse underwent a Thiersch procedure as a temporary measure due to hemodynamic instability.…”

“…Once the patient's condition stabilized, he was subjected to posterior prosthetic rectopexy through an abdominal approach. The intention was to provide time for planning a more effective and permanent procedure [ 10 ].…”

Thiersch Procedure for Rectal Prolapse: Experiences From a Single Institution

“…8 In addition, it can be performed as a temporary procedure for unstable patients. 9 Unfortunately, the Thiersch procedure entails complications such as high recurrence rates, infections, tissue erosion, and fecal impaction. 10 Literature review reveals that the recurrence rate is as high as 33%-44%.…”