Rectal prolapse as a complication of transrectal NOTES in an experimental porcine model

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Background : Rectal prolapse is the protrusion of one or more layers of the rectum through the anal sphincter. Some of the possible causes are tenesmus, endoparasitism and large bowel inflammation. Natural orifice transluminal endoscopic surgery (NOTES) consists of advanced techniques to gain access to body cavities through natural openings without skin incision. Different access routes may be used. However, transrectal NOTES has not been often reported. This paper reports a case of rectal prolapse after transrectal NOTES in a porcine model. Case : A healthy, female domestic swine underwent experimental peritoneoscopy through transrectal route. The animal weighed 20 kg and was approximately 90 days old. Under general anesthesia, a pneumoperitoneum was created and, after this, the rectal lining was pulled out and incised so that the endoscope could be introduced into the abdominal cavity. Subsequently, the cavity was deflated and the rectal wall was sutured under direct viewing with single-layer extramucosal sutures closed with 3-0 polyglactin 910 and simple continuous pattern in the muscular region and submucosa. There was edema of the rectal lining with a slight protrusion and was reduced manually. There was prolapse recurrence and a pursestring suture was placed around the anus. The suture ruptured about 72 h after the endoscopic procedure and self-mutilation of the perineal region aggravated the animal’s condition. The swine was then euthanized. Discussion : The external exposure of the animal’s rectal lining immediately after the surgical procedure initially suggested incomplete or mucosal rectal prolapse because, in such cases, only rectal lining protrudes out of the anus insofar as any portion of the anal circumference may be affected. The probable cause of the rectal prolapse in this case may be related to the incision performed in the rectal wall, which might have reached branches of the cranial rectal artery and/or caudal mesenteric artery, which supply the distal rectum. C-reactive protein level is used as an early marker of inflammation. The levels of this inflammatory biomarker in this animal confirmed an increased acute inflammatory response because there was a significant increase in the level of C-reactive protein 24 h after the procedure when compared with baseline level (baseline level: 0.34 mg/L-1; 24-h level: 2.36 mg/L-1). C-reactive protein remained increased 48 h after the surgery (2.17 mg/L-1), even after the animal received anti-inflammatory drugs daily. The prolapse was manually reduced without surgery during the immediate postoperative period. Prolapse recurrence occurred 24 h after the endoscopy. Therefore, the animal was anesthetized again for the performance of a purse-string suture technique around the anus. The authors believe that the reason for the animal’s self-mutilation in the perineal region was discomfort and/or itching in the rectal region due to the suture in the rectum. This may have caused the rupture of the purse-string suture with consequent self-mutilation and trauma of the perineal region. In these situations, the prognosis becomes reserved or unfavorable. The authors decided for euthanasia based on the severity of the injury and because the animal had undergone an experimental procedure. Therefore, transrectal NOTES may be a promising method, nevertheless, further experimental studies should be conducted to investigate its complications, including the possibility of rectal prolapse.

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