DOI:10.2214/AJR.06.1220
AJR 2007; 188:W396
© American Roentgen Ray Society
Appearance of the Rectum on Barium Enema Examination After the Delorme Procedure
Shalin Patel,
Marc S. Levine and
John L. Rombeau
Hospital of the University of Pennsylvania, Philadelphia, PA
19104
WEB—This is a Web exclusive article.
A 24-year-old man presented with a 3-month history of constipation (one
bowel movement every 2 days). He also was aware of tissue extruding from his
anus after bowel movements. His stools were soft, and he denied weight loss or
gastrointestinal bleeding. Anorectal examination revealed prolapse of the
rectum through the anus during a Valsalva maneuver. Excretory proctography
revealed poor squeeze of the proximal rectum with a normal opening of the anal
sphincter and normal relaxation of the puborectalis muscle. No evidence was
seen of rectal prolapse, possibly because of the soft consistency of the
barium administered into the rectum for the procedure. The patient's physical
findings persisted, however, and a diagnosis of rectal prolapse was made.
The patient underwent surgery and transanal repair of the rectal prolapse,
also known as perineal plication or the Delorme procedure
[1]. This form of repair was
chosen because it is performed entirely via the perineum and is associated
with relatively low recurrence rates
[2]. In the Delorme procedure,
the rectum is forcibly prolapsed to its maximal extent, and the mucosa is
circumferentially divided around the prolapsed portion of the rectum just
distal to the dentate line. The outer wall of the prolapsed rectum is then
excised from the circular muscle layer to the apex of the prolapsed segment.
Surgical sutures are used to plicate the rectal wall, and the sutures are
tied. The mucosa of the prolapsed segment is then excised from the lumen, and
the operation is completed by direct mucosa-to-mucosa suture between the inner
aspect of the reduced prolapse and the dentate line.
Because of 4 months of postoperative rectal bleeding and mucous discharge,
the patient underwent a single-contrast barium enema examination, which
revealed smooth, symmetric, funnel-shaped narrowing of the midportion of the
rectum (Fig. 1). A collar of
distal rectum had been surgically mobilized and used as a wrap that appeared
as a radiolucent defect encircling and narrowing the more proximal rectum to
prevent recurrent prolapse (Fig.
1). These surgical changes produced distinctive radiographic
findings analogous to those in a Nissen fundoplication in which there is
smooth, tapered narrowing of the distal esophagus due to the surrounding
gastric wrap [3].
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Fig. 1 —Appearance of rectum after Delorme procedure in 24-year-old man with
3-month history of constipation. Frontal slightly right posterior oblique spot
image of rectum from single-contrast barium enema examination shows smooth,
tapered, funnel-shaped narrowing (white arrows) of mid rectum.
Surrounding radiolucent defect (black arrows) is surgically mobilized
wrap of distal rectum encircling more proximal rectum to prevent recurrent
prolapse.
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To our knowledge, the appearance of the Delorme procedure on barium enema
examination has not been described previously in the radiology literature.
Radiologists should be aware of this appearance so that it is not mistaken for
a stricture or other abnormality in the rectum.
References
- Keighley MB, Williams NS. Surgery of the anus, rectum,
and colon, 2nd ed. Philadelphia, PA: Saunders, 1999:808
-812
- Watkins BP, Landercasper J, Belzer GE, et al. Longterm follow-up of
the modified Delorme procedure for rectal prolapse. Arch
Surg 2003; 138:498
-503[Abstract/Free Full Text]
- Yoo C, Levine MS, Redfern RO, Laufer I, Buyske J. Laparoscopic
Heller myotomy and fundoplication: findings and predictive value of early
postoperative radiographic studies. Abdom Imaging2004; 29:643
-647[CrossRef][Medline]
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