On Channel 4’s Embarrassing Bodies programme on 28th January 2011, Dr Dawn Harper interviewed a scleroderma patient who had a rectal prolapse. Following examination, Dr Harper referred the patient to Mr Andrew Clarke, a Consultant Surgeon based at Poole Hospital NHS Foundation Trust with a private practice in Poole and Bournemouth. Mr Clarke is a member The Association of Coloproctology of Great Britain and Ireland, a professional society representing more than 1000 Colon and Rectal specialists, dedicated to advancing and promoting the science and practice of the treatment of patients with diseases and disorders affecting the colon, rectum, and anus.
On the programme, Mr Clarke was seen performing a laproscopic ventral rectopexy. The operation went smoothly and the prolapse was successfully repaired but the incontinence continued. The patient is now waiting to have a temporary Sacral Nerve Stimulator (SNS) implanted, which if proved to be beneficial, will lead to her having a permanent implant. If a prolapse is present this needs to be resolved before SNS can be considered.
Rectal Prolapse in Scleroderma Patients
One of the problems in scleroderma is the large bowel involvement with severe constipation and obstipation (extreme constipation), managed with multiple regimens. There is no easy remedy. A lot of these problems with the intestines are not associated with severe pain; so one shouldn’t assume that if you have a lot of pain it is just related to the scleroderma gastrointestinal problem.
Rectal problems have become a major difficulty for many limited scleroderma patients. They have rectal prolapse (protrusion of part of the rectum through the anus to the outside of the body) but also have lots of seepage of stool, which can be very embarrassing. It is important to differentiate diarrhoea from just losing some stool.
Scleroderma of the colon is commonly associated with constipation but chronic constipation may be the cause of a rectal prolapse. However, the onset of the prolapse and scleroderma at about the same time, suggests that scleroderma may have been a causative factor.
Rectal dysfunction and weakness of the anal sphincters are important factors contributing, respectively, to altered bowel movements and faecal incontinence. Rectal prolapse worsens anal sphincter dysfunction needs attention as is a treatable factor, aggravating faecal incontinence in patients with this condition.
Laparoscopic Ventral Rectopexy
When is laparoscopic ventral rectopexy performed?
This operation is commonly performed for patients with external rectal prolapse and patients with incontinence and internal or external prolapse may also benefit.
What does the operation involve?
The operation is performed under general anaesthetic by keyhole surgery. The surgeon then frees the rectum from the pelvis but operates only in front of the rectum and away from the nerves supplying the bowel and genitalia. A piece of mesh is stitched to the front of the rectum and this mesh is in turn secured to the sacrum (lower backbone). The effect of this is to pull the bowel up out of the pelvis and prevent it from telescoping down, restoring it to its normal anatomical position.
What is the recovery like after surgery?
Patients are typically in hospital for 24 - 48 hours after surgery. On the first morning after your operation, your catheter will come out and your drip will usually be taken down. You will be able to eat and drink. You will be discharged on laxatives (usually movicol) to continue for six weeks, to avoid constipation and straining in the first few weeks after surgery. You may be fit to drive or return to work after two weeks but should not do any lifting for at least six weeks.
Temporary (Test wire) Sacral Nerve Neuromodulation
When is this procedure performed?
Sacral nerve stimulation (SNS) is mainly used as a treatment for certain patients with faecal incontinence. Patients most likely to benefit are those with intact muscles that do not work very well, though sometimes patients with damaged muscles can benefit. It is occasionally used for patients with constipation.
What other tests are necessary before the procedure?
You will need tests to identify you as likely to derive benefit from the procedure. These tests include anorectal physiology, endoanal ultrasound, proctography and transit studies.
What does the procedure involve?
A Neuromodulation electrode is implanted into your lower back while you are sedated or under a general anaesthetic, with you lying on your front. This electrode stimulates the sacral nerve which is involved in the function of the muscles around your anal canal, bladder and the pelvic floor. The surgeon performing the operation will establish where the nerves supplying the anal sphincter are located by passing a very low power electrical current down the needle. The needle is then switched for a flexible wire which is taped to the skin of the buttock. The electrode is connected via the wire to an external test neuromodulator, which is the size of a small walkman or iPOD, that is worn on a belt or strap around the waist for the test period.
What is the recovery like after surgery?
You will go back to the ward to recover from the anaesthetic. You may feel some discomfort from the area where the electrode has been placed. Later the same day a healthcare practitioner will connect the electrode to a test stimulator on the ward. One discharged from hospital it is advised to carry on with normal life as much as possible but avoid lifting anything.
You will be asked to keep a diary of your bowel control and episodes of incontinence. If your control is improved with the wire in place, then you may be considered for implantation of a permanent implant. The temporary electrode is removed after two to three weeks. Approximately two thirds of patients having a temporary wire, proceed to a permanent implant.
Permanent Sacral Nerve Neuromodulation
When is this performed?
All patients having a permanent implant will first have had a temporary test wire. Those benefiting from this will be offered a permanent stimulator.
What tests are necessary prior to the operation?
You will have had all the pelvic floor tests you need prior to your temporary test wire.
What should the anaesthetist know?
The permanent sacral nerve stimulator is inserted under general anaesthetic and so you will need routine investigations needed by everyone before a general anaesthetic to determine your general fitness. If undergoing surgery of any kind involving an anaesthetic, make sure that your anaesthetist is aware that you have Raynaud’s and/or scleroderma. The main issues for the anaesthetic are to try and warm any iv fluids, to have steroid cover for surgery and for the anaesthetist to be aware of the slower healing in scleroderma. If you have any heart or lung problems take your latest test results with you if possible.
What does the operation involve?
The permanent sacral nerve stimulator is inserted under a general anaesthetic. A fine needle is passed through the skin of the buttock with you lying on your front, as for the temporary wire. Rather than bringing the stimulator wire out through your skin, however, it is tunnelled under the skin and connected to a little box surgically inserted through a 5 cm long incision in your upper buttock. This box looks like a cardiac pacemaker and is the size of a small matchbox. Apart from the small scars, there are no external wires or equipment after permanent implantation of sacral nerve stimulator.
What is the recovery like after surgery?
Post-operative recovery is rapid and the patient will usually be allowed home on the same day or after a one night stay in hospital.
For details of other gastrointestinal treatments click here.
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