Laparoscopic suture rectopexy for full-thickness anorectal prolapse in children: an effective outpatient procedure

Outcomes of Laparoscopic Suture vs Mesh Rectopexy for Complete Rectal Prolapse

Objective To compare outcomes of laparoscopic suture and laparoscopic mesh rectopexy for the treatment of complete rectal prolapse in adults. Materials and methods This study was conducted between December 2020 to December 2022, involving 75 patients (Group A: 34; Group B: 41). Inclusion criteria encompassed confirmed complete rectal prolapse. Preoperative measures included comprehensive assessments, mechanical bowel cleansing, prophylactic antibiotics, and rectal irrigation. Surgical techniques involved laparoscopic suture rectopexy for Group A and laparoscopic mesh rectopexy for Group B. Postoperative care and follow-up evaluations were conducted. Results Group A demonstrated advantages in terms of shorter operative times, quicker bowel activity resumption, and reduced hospital stays. Intraoperative bleeding was absent in Group A, while wound-related complications were higher in Group B. Recurrence rates were lower in Group A (2.9%) compared to Group B (9.8%). Both groups exhibited improvements in incontinence grades postoperatively. Constipation increased in both groups. Conclusion Both techniques are effective in treating complete rectal prolapse, each with its advantages and considerations. Group A showed potential benefits in terms of operative efficiency and fewer complications, albeit with a potential for increased recurrence. The study emphasizes the need for individualized patient care, considering factors such as operative characteristics, postoperative outcomes, and patient preferences.

Approach to the Adult Colorectal Patient with a History of Pediatric Abdominal Surgery

Children with colorectal diseases often undergo operative management in their youth. As these patients become adult, it is important for surgeons to understand their postoperative anatomy as well as the pathophysiology of their diseases. Here, we present a description of common colorectal diseases of childhood that may have significant impact on patients' presentations as adult. We also discuss the diagnosis and management of conditions that are usually seen early in life but may present during adulthood as well.

Prolapsed Rectum and Risk Factors in Prader-Willi Syndrome: A Case-Based Review

A 14-year-old male adolescent patient with Prader-Willi syndrome (PWS) with maternal disomy 15 was reported with rectal prolapse as only the second patient in the literature. With predisposing risk factors present for rectal damage and prolapse in this syndrome, the incidence must be higher and therefore underreported. These risk factors include skin and rectal picking, self-stimulation, altered pain sensation, decreased muscle mass, strength and physical activity with hypotonia, and gastrointestinal (GI) disturbances. Pertinent literature was reviewed and analyzed that focused on clinical features and behavior seen in PWS as underrecognized risk factors for developing rectal damage and prolapse. An illustrative case is presented as the second patient reported with PWS and a prolapsed rectum. A discussion of predisposing behavioral and clinical risk factors is presented including for self-stimulation, rectal picking, chronic constipation, decreased gut motility, reduced water intake, and a restricted diet. Although a paucity of cases do exist, physical, behavioral, and GI findings common in PWS may contribute to rectal prolapse requiring better awareness and proactive surveillance, management, and treatment protocols for patients affected with this rare obesity-related genetic disorder.

Case report: Gross persistent rectal prolapse. A case treated without mesh using deep retrorectal dissection/suturing

A previously well 15-year-old male presented with a history of gross rectal prolapse (GRP) involving full-thickness rectal prolapse of increasing severity and incidence over 6 months that occurred with every bowel motion, varying from 10 to 40 cm. He denied constipation and passed a soft motion once daily, adeptly reducing his prolapsed rectum after each motion. This case illustrates technical challenges and planning for surgical intervention for optimal treatment in keeping with an FDA alert issued April, 2019 banning surgical mesh for pelvic organ prolapse. Preoperative fluoroscopic defecography confirmed rectal prolapse beginning with eversion of the anal verge identified on inspection. For surgery, general anesthesia was induced, he was placed in a Trendelenburg position, and four ports were inserted. The peritoneum was incised and blunt dissection used to expose the levator ani complex (LAC) taking care to prevent lateral nerve injury and preserve regional vascularity. Seven polypropylene sutures were used to fix the seromuscular posterior wall of the rectum to the median raphe of the LAC, the presacral fascia, and the periosteum of the sacral promontory. Operative time was 170 min. Postoperative recovery and progress were unremarkable. Currently, 5 years postoperatively, defecation is regular without recurrence of prolapse. For prolapse involving protrusion of the upper rectum without eversion of the anal verge, rectal fixation to the sacral promontory without further dissection beyond the peritoneal reflection is adequate, but when extensive prolapse is associated with eversion of the anal verge, more extensive blunt dissection from the peritoneal reflection to the LAC with multiple rectopexy sutures is valid for reducing risks for recurrence and eliminating mesh-related complications.

Surgical Management of Rectal Prolapse in Infants and Children

The surgical management of children with rectal prolapse is wide ranging and without consensus within the pediatric surgical community. While the majority of rectal prolapse in infants and children resolves spontaneously or with the medical management of constipation, a small but significant subset of patients may require intervention for persistent symptoms. In this review, we discuss the etiology and pathophysiology of rectal prolapse in both infants and children, options for medical management, described interventions and surgical options and their outcomes, and future avenues for research and investigation.

Laparoscopic Suture versus Mesh Rectopexy for the Treatment of Persistent Complete Rectal Prolapse in Children: A Comparative Randomized Study

Purpose

To compare laparoscopic mesh rectopexy with laparoscopic suture rectopexy. Patients and Methods. The prospective study was conducted at Pediatric Surgery Department, Al-Azhar University Hospitals, Cairo, Egypt between Feb 2010 and Jan 2015. Seventy-eight children with persistent complete rectal prolapse were subjected to laparoscopic rectopexy. Fourteen parents refused to participate. All patients received initial conservative treatment for more than one year. The remaining 64 patients were randomized divided into two equal groups. Group A; 32 patients underwent laparoscopic mesh rectopexy and group B, 32 underwent laparoscopic suture rectopexy. The operative time, recurrence rate, post-operative constipation, and effect on fecal incontinence, were reported and evaluated for each group.

Results

Sixty-four cases presented with persistent complete rectal prolapse were the material of this study. They were 40 males and 24 females. Mean age at operation was 8 (5–12) years. All cases were completed laparoscopically. Mean operative time in laparoscopic suture rectopexy was shorter than laparoscopic mesh rectopexy group. No early post-operative complications were encountered. No cases of recurrence with mesh rectopexy group while in suture rectopexy group it was 4 cases (14.2%). Post-operative constipation occurred in one case (3.57%) in suture rectopexy group and occurred in one case (3.3%) in mesh rectopexy group. Fecal incontinence improved in 26/28 cases (92.8%) in suture rectopexy while in mesh rectopexy it was improved in 30/30 cases (100%) of cases.

Conclusion

Both laparoscopic mesh and suture rectopexy are feasible and reliable methods for the treatment of complete rectal prolapse in children. However, no recurrence, low incidence of constipation and high improvement of incontinence at follow up more than 36 months with mesh rectopexy accordingly, we considered mesh rectopexy to be the procedure of choice in treatment of complete rectal prolapse.

Simplified Laparoscopic Suture Rectopexy for Idiopathic Rectal Prolapse In Children: Technique and Results

BACKGROUND

Laparoscopic suture rectopexy is safe and effective treatment option for pediatric rectal prolapse. We performed this study to compare the outcome of modified laparoscopic suture rectopexy (MLSR) versus Classical Laparoscopic suture rectopexy (CLSR).

MATERIAL AND METHODS

The study was conducted between June 2015 to May 2019 including all the patients with persistent rectal prolapse who underwent surgery managed by either MLSR (Group A) or CLSR (Group B). The groups were compared for constipation, operative time, blood loss, length of stay, postoperative complications.

RESULTS

19 patients from MLSR and 22 patients from CLSR were evaluated. The mean operative time in MLSR group was 41.5 ± 6.2 min which was significantly lesser than CLSR group with a mean operative time of 78.6 ± 14.2 (p = 0.001). The blood loss was also less in MLSR group compared to CLSR group (p = 0.013). At three months of follow up, the constipation was less in MLSR group compared to CLSR group (p = 0.041).

CONCLUSION

The modification makes the procedure technically easy, minimizes the chances of complications and retaining all the advantages of suture rectopexy.

LEVEL OF EVIDENCE

Level II.

Same-Day Discharge and Quality of Life for Primary Laparoscopic Rectopexy for Rectal Prolapse in Children: A 10-Year Experience

Introduction: Rectal prolapse (RP) in pediatric patients may require surgical intervention. Varying surgical approaches and heterogenous patient populations have resulted in difficulty defining surgical outcomes and superiority of technique. We sought to review our surgical and self-reported outcomes of patients who underwent laparoscopic rectopexy for idiopathic RP. Methods: Records of children <18 years who underwent primary laparoscopic rectopexy between March 2009 and March 2019 were retrospectively reviewed. Patients with redo rectopexy were excluded. Demographics, pre- and postoperative treatment, and outcome data were collected and reported using descriptive statistics. Qualitative analysis of a quality of life (QoL) questionnaire administered to patients and parents 2-10 years postoperatively was performed. Results: Fifteen patients were included. Median age at surgery was 5 years (interquartile range [IQR] 3, 12.5); 60% were male and median weight was 22 kg (IQR 16.4, 39.2). Median length of stay was 6 hours (IQR 4, 22) with 9 (60%) discharged the same day. Perioperatively, 73% were on laxative for constipation, whereas only 33% were on laxative therapy at 6 months postrectopexy. Median follow-up was 19 months (IQR 8, 39). Three patients (20%) suffered recurrent RP (2 required redo rectopexy), and 2 patients self-limited urinary retention. Respondents to the QoL questionnaire indicated improvement in symptoms after surgery. No patient reported fecal incontinence, smearing, or leakage of stool. Conclusion: Laparoscopic rectopexy is a safe minimally invasive approach for children with idiopathic RP that offers high patient satisfaction with same-day discharge, early recovery, and low recurrence.

Surgical management of pediatric rectal prolapse: A survey of the American Pediatric Surgical Association (APSA)

INTRODUCTION

Many management options exist for the treatment of refractory rectal prolapse (RP) in children. Our goal was to characterize current practice patterns among active members of APSA.

METHODS

A 23-item questionnaire assessed the management of full-thickness RP for healthy children who have failed medical management. The survey was approved by our IRB and by the APSA Outcomes committee.

RESULTS

236 surgeons participated. The respondents were geographically dispersed (44 states, 5 provinces). 32% of respondents had twenty or more years of clinical experience. 71% evaluated 1-5 RP patients in the last 2 years, while 5% evaluated >10. 71% performed 0-1 procedure (operation or local therapy [LT]) for RP over 2 years. 59% would treat a 2-year-old patient differently than a 6-year-old with the same presentation, and were more likely to offer up-front surgery to a 6-year-old (26% vs 15%, p = 0.04), less likely to continue medical management indefinitely (2% vs 7%, p=0.01), and more likely to perform resection with rectopexy (30% vs. 15%, p=0.01). 71% perform LT as an initial intervention: injection sclerotherapy (59%), anal encirclement (8%), and sclerotherapy + anal encirclement (5%). 70% consider LT a failure after 1-3 attempts. If LT fails, surgical management consists of transabdominal rectopexy (46%), perineal proctectomy or proctosigmoidectomy (22%), transabdominal sigmoidectomy + rectopexy (22%), and posterior sagittal rectopexy (9%).

CONCLUSIONS

There is wide variability in the surgical management of pediatric rectal prolapse. This suggests a need for development of processes to identify best practices and optimize outcomes for this condition.

Laparoscopic Posterolateral Suture Rectopexy for Recurrent Rectal Prolapse in Children

Introduction: Laparoscopic rectopexy for recurrent rectal prolapse (RP) is more widely used nowadays. Strict indications are needed to get proper outcomes. The advantages rely on the careful dissection of peritoneal sac and fixation of rectum. One of the theories of recurrent RP is hernia-like physiology in front of the rectum. Purpose: The aim of this study is to present our experience of posterolateral laparoscopic suture rectopexy (LSR) in indicated children of recurrent RP. Patients and Methods: Sixteen patients were included with recurrent RP wherein all were subjected to LSR procedure after exclusion of other probable causes. Dissection of peritoneal sac anterior to the rectum was carried out followed by closure of the deep pouch by nonabsorbable sutures then fixation of the right side of rectum and sigmoid to the lateral wall of areolar tissue. Fixation to sacral promontory is done by Ethibond or Prolene sutures when redundancy is obvious. Results: The study included 11 girls and 5 boys with age ranging between 3 and 12 years in the past 5 years. Ten cases were treated earlier with injection therapy and 6 following Thiersh procedure after failure of conservative treatment for 6 months. Operative time ranged between 40 and 100 minutes. Follow-up period ranged between 6 and 36 months with mean of 19.5 months. Postoperative mucosal prolapse reported in 1 case 6 months postsurgery with no full thickness recurrence. Conclusions: LSR is an efficient technique in well-selected children of recurrent RP and could reverse this underlying pathology. Longer follow-up and evidence are needed to standardize the technique.

A systematic review of management options in pediatric rectal prolapse

PURPOSE

Rectal prolapse is a relatively common condition in infants and young children with a multifactorial etiology. Despite its prevalence, there remains clinical equipoise with respect to secondary treatment in pediatric surgery literature. We conducted a systematic review to evaluate methods of secondary treatment currently used to treat rectal prolapse in children.

METHODS

We searched Pubmed, Medline, and Scopus with the terms "rectal prolapse" and "children" for papers published from 1990 to April 2017. Papers satisfying strict criteria were analyzed for patient demographics, intervention, efficacy, and complications. Procedures were grouped by like type. Pooled success rates were calculated.

RESULTS

Twenty-seven studies documenting 907 patients were included. Injection sclerotherapy had an overall initial success rate of 79.5%. Ethyl alcohol seemed the best sclerosing agent due to a high first-injection success rate, low complication rate, and ready accessibility. Several perineal repairs were found, with operative success rates ranging from 60.8%-100%. Laparoscopic rectopexy with mesh was the most commonly reported transabdominal procedure and had an overall success rate of 96.1%. Postoperative complications from all procedures were comparable.

CONCLUSION

Though many secondary treatment options have been reported for rectal prolapse, sclerotherapy and laparoscopic rectopexy predominate in contemporary literature and appear to have high success and low complication rates.

LEVEL OF EVIDENCE

IV.

Transanal endorectal approach for the treatment of idiopathic rectal prolapse in children: Experience with the modified Delorme's procedure

BACKGROUND

Persistent or recurrent idiopathic rectal prolapse in children requires surgical intervention. Several techniques have been used to repair this problem. However, recurrence and complications continue to be a challenge in the management of this condition. Here we report our experience in using the modified Delorme's procedure to treat such patients.

METHODS

We conducted a retrospective observational study of patients with idiopathic rectal prolapse who underwent the modified Delorme's procedure during 2013-2017. We analyzed the clinical characteristics of the patients and the recurrence and complication rates during a follow-up of 15-68 months.

RESULTS

We included 14 patients. The age at operation ranged from 2 to 17 years, and the length of the prolapse was 3-15 cm. There were no intraoperative or postoperative complications. All patients achieved postoperative fecal control, and there were no recurrences.

CONCLUSION

The modified Delorme's procedure was effective for the treatment of idiopathic rectal prolapse. There were no recurrences or complications. Because it is a perineal technique, the procedure avoids the risk of nerve injury that exists for transabdominal methods.

Laparoscopic Protack™ rectopexy: Early experience of a novel technique for full thickness rectal prolapse in children

BACKGROUND/PURPOSE

To review our early experience of laparoscopic ProTack™ rectopexy (LPR) in the management of full thickness rectal prolapse (FTRP) in children.

METHODS

Prospective case series of patients undergoing LPR between 2013 and 2017. Full laparoscopic mobilization of the rectum was performed from the sacral promontory to the pelvic floor. 'Wings' of the lateral mesorectal peritoneum left attached to the rectum are then fixed to the sacral promontory using ProTack™. Demographics, associated conditions, previous procedures for FTRP, follow up time, length of stay (LOS), short and long term complications and clinical improvement were assessed.

RESULTS

Seven consecutive patients with FTRP underwent LPR. The mean age was 9 years old (2-17) with a male to female ratio of 6:1. Median LOS was 1 day (1-2 days). Median follow up time was 17 months (10-38 months). All patients had complete resolution of symptoms within the follow up period.

CONCLUSIONS

LPR is a simple, safe and effective procedure showing promising results in children. It negates the risks associated with the use of mesh and has the potential to avoid the higher risk of failure associated with suture rectopexy. It is important to ensure patients receive adequate analgesia and management of postoperative constipation.

Pediatric Rectal Prolapse

Rectal prolapse is a common and self-limiting condition in infancy and early childhood. Most cases respond to conservative management. Patients younger than 4 years with an associated condition have a better prognosis. Patients older than 4 years require surgery more often than younger children. Multiple operative and procedural approaches to rectal prolapse exist with variable recurrence rates and without a clearly superior operation. These include sclerotherapy, Thiersch's anal cerclage, Ekehorn's rectopexy, laparoscopic suture rectopexy, and posterior sagittal rectopexy.

Laparoscopic posterior rectopexy (Well's procedure) for full-thickness rectal prolapse following laparoscopic repair of an anorectal malformation: A case report

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Laparoscopic repair of intermediate anorectal malformation (ARM) lead to full-thickness rectal prolapse (RP) in a boy.

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As conservative treatment modalities failed, the parents opted for surgical treatment at the patient’s age of 4 years.

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Intractable RP of 2 cm with ulcerations was successfully treated by Well’s laparoscopic posterior mesh-rectopexy.

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The mid-term outcome was favorable with no prolapse recurrence.

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Well’s procedure represents a feasible treatment option for RP secondary to ARM repair in children.

Introduction

Intractable full-thickness rectal prolapse (IRP) unresponsive to conservative treatment remains a major problem after anorectoplasty for high or intermediate anorectal malformation (ARM). Surgical management must aim for a permanent fixation of the rectum to the presacral fascia. While in children with IRP following ARM repair the optimal procedure has not been established yet, laparoscopic posterior mesh-rectopexy (Well’s procedure) has demonstrated efficacy in adults.

Presentation of case

A male infant with intermediate ARM received laparoscopic-assisted anorectal pull-through at the age of 4 months. Three months later he developed mucosal prolapse and received multimodal conservative treatment. Because of progression into a full-thickness RP with ulcerations, the parents opted for surgical management. Well’s procedure was performed at the age of 4 years. Using four ports, the rectum was circumferentially mobilized down to the pelvic floor and pulled inside. A 5 × 5 cm prolene mesh was tacked to the sacrum, enveloped posteriorly 270° around the rectum, fixed with interrupted prolene sutures on both edges and carefully covered with peritoneum. Any redundant external mucosa was excised from a perineal approach. There were no intra- and postoperative complications. Within 1.5 years of follow-up the boy had voluntary bowel movements and was toilet trained. No prolapse recurrence could be observed nor provoked.

Discussion

We present the first pediatric case of IRP secondary to laparoscopic ARM repair which has been successfully treated by combined Well’s procedure and perineal mucosal resection.

Conclusion

Well’s procedure is a successful technique and should be further explored in children with ARM and IRP.

Laparoscopic Suture Rectopexy for Persistent Rectal Prolapse in Children: Is It a Safe and Effective First-Line Intervention?

BACKGROUND

Several techniques have been described for the surgical correction of rectal prolapse without any clear advantage for one technique over the other. We evaluated the use of laparoscopic suture rectopexy (LSRP) as a modality of treatment for rectal prolapse in children.

MATERIALS AND METHODS

Prospective data were collected for all children who presented to our center between 2011 and 2014 and required surgery for rectal prolapse. All children underwent LSRP with fixation of the mobilized rectum to the sacral promontory with multiple nonabsorbable sutures. The median follow-up period was 14 months (range, 6-29 months). The operative time, operative complications, length of hospital stay, and postoperative complications were recorded and analyzed.

RESULTS

Seventy-four patients presented with rectal prolapse during this period. Twenty patients (27%) required LSRP. Their median age at surgery was 4.4 years (range, 2-11 years), median operative time was 77.5 minutes (range, 30-150 minutes), and the median length of hospital stay was 1 day (range, 1-4 days). Only 1 patient had full-thickness recurrence that required redo surgery, and another had mucosal prolapse, which spontaneously resolved.

CONCLUSIONS

LSRP is a safe and effective technique for treating children with full-thickness rectal prolapse with the benefits of being minimally invasive, a short hospital stay, early recovery, and low recurrence rate.

Successful treatment of recurrent rectal prolapse using three Thiersch sutures in children

Many techniques are described to manage recurrent rectal prolapse in children, including repeated Thiersch stitch, phenol injections, Delorme and Altemeier procedures, and rectopexy. We describe a case of successful treatment of rectal prolapse by placing three Thiersch sutures circumferentially along the anal canal--a simple and novel modification of a well-known procedure. An 8-year-old boy with full-thickness rectal prolapse was treated with laxatives to no avail. He was subsequently treated with phenol-in-almond-oil injection and insertion of a 1/0PDS Thiersch suture. The effects were temporary with recurrence 3 months later. A further phenol-in-almond-oil injection was given and a 1/0PDS Thiersch suture placed, and the patient was discharged on laxatives. Recurrence occurred again at 3 months. This was treated with three circumferential Thiersch sutures along the anal canal--one Prolene 2/0 and two 1/0PDS. There has been no recurrence at follow-up. Placement of three sequential Thiersch sutures along the rectum is effective in treating recurrent rectal prolapse and a good alternative to major rectopexy.

Rectal prolapse in older children associated with behavioral and psychiatric disorders

PURPOSE

Rectal prolapse (RP) beyond infancy is challenging, and despite surgical correction, recurrences are not uncommon, suggesting that underlying contributing processes may have a role. This study highlights a previously poorly recognized relationship between RP in older children and behavioral/psychiatric disorders (BPD). We describe the incidence of recurrence and use of behavioral, psychological and physical therapeutic tactics in a multidisciplinary approach to pediatric RP.

METHODS

A retrospective 20-year review of RP in children >3 years of age was adopted. Charts were reviewed for gastrointestinal, connective tissue, and BPD conditions, incidence of recurrence, and therapies employed including surgery, behavioral, and physical therapy.

RESULTS

45 patients were included, ranging from 3 to 18 years of age; 29 males. Thirty-seven underwent surgery. Six of the 45 were excluded as they had gastrointestinal or connective tissue conditions placing them at risk for prolapse. Over half (21/39, 53%) had BPD. Slightly more than half of patients had a recurrence, but there was no increased risk in those with associated BPD. While all 21 underwent some therapy for their BPD, over the past 5 years we have enrolled eight of these patients into a program of behavioral and/or physical therapy with all reporting reductions in frequency and severity of prolapse after initiating pelvic floor strengthening, behavior modification, and biofeedback, and avoidance of surgery in three.

CONCLUSIONS

This study highlights an important group of pediatric patients with RP that may well benefit from a combination of behavioral therapy, physical therapy as well as surgical intervention to obtain the most optimal outcome.

Laparoscopic modified Orr-Loygue mesh rectopexy for rectal prolapse in children

AIM

We present an operating technique inspired from the Orr-Loygue mesh rectopexy adapted for laparoscopy, and detail the technical steps that differ from laparoscopic posterior suture rectopexy more commonly described in the paediatric literature.

METHOD

We present a retrospective study of all children who underwent a modified Orr-Loygue procedure for recurrent complete rectal prolapse from 1999 to 2012 after failure of conservative treatment. Pathological conditions, technical details of the procedure (excision of the Douglas pouch, use of a prerectal non-absorbable mesh to suspend the rectum to the presacral fascia and promontory avoiding any tension on the rectal wall) and postoperative results were reviewed.

RESULTS

Eight patients were included, median age 6.5 years (range, 2-17). Median symptoms duration before surgery was 14 months (range, 6-24). Four patients presented with associated pathological conditions: 1 neurological impairment (Williams-Beuren syndrome), 1 severe malnutrition (mental anorexia), 1 solitary rectal ulcer with frequent bleeding, 1 syringomyelic cavity in the spinal cord. All procedures were completed laparoscopically with a median operative time of 98 minutes (range, 80-125). Median hospital stay was 3.5 days (range, 2-5). No postoperative constipation or recurrence was reported during the median follow-up period of 6 years (range 2-13).

CONCLUSION

The laparoscopic modified Orr-Loygue mesh rectopexy is a simple operating technique, reproducible and efficient as surgical treatment of nonresolving recurrent complete rectal prolapse in children. To avoid postoperative constipation, it is important to perform a tension-free rectopexy which can be achieved by the use of a mesh to simply suspend and not "fix" the redundant rectosigmoid. Nonetheless, a greater number of patients as well as colorectal electromyography or anorectal manometry would be necessary to prove the absence of postoperative deleterious functional disorder.

Laparoscopic rectopexy for external prolapse in children

PURPOSE

This study reports the results of laparoscopic rectopexy in children.

METHODS

Results were obtained from a prospective database for all laparoscopic rectopexy procedures performed for external prolapse in a tertiary referral centre from 2006 to 2013. Outcomes included recurrence of symptoms and/or visible prolapse as well as the need for further surgery

RESULTS

Eighteen procedures including both suture and mesh rectopexy were performed in 11 patients. Six had solitary rectal ulcers. All patients had failed conservative management, including laxative therapy, and one patient had previously had a trial of injection of hypertonic saline. At a median follow up of 33months (6-75) complete resolution was seen in 7 cases and partial resolution, with some continuing symptoms, was seen in 1 patient. All suture rectopexy cases ultimately failed and required a redo rectopexy procedure. Three patients had persistent failure with recurrence of prolapse during the study period despite repeated procedures. There were no serious complications.

CONCLUSIONS

Laparoscopic mesh rectopexy can be safely performed in children and can lead to complete resolution of external prolapse. There is a cohort for whom it fails to relieve the problem. In this series there was a trend towards less recurrence with mesh rectopexy.

Rectopexy for paediatric rectal prolapse: good outcomes but not without postoperative problems

PURPOSE

Rectopexy is a simple treatment of persisting complete rectal prolapse (RP) or related functional disorders in children. The results of rectopexy have been encouraging with few complications. We describe the postoperative complications and outcome of rectopexy in our institution from 2002 to 2013.

METHODS

Ethical committee accepted the study. Hospital records of 27 successive patients (16 males), median age 7.2 (range 2.8-17) years, who underwent rectopexy (25 laparoscopic, 2 open) were reviewed. Indication for rectopexy included RP (n = 24), solitary rectal ulcer with enterocele (n = 2) and rectocele (n = 1). Nine patients (39 %) were healthy. In the remaining 14 patients, RP was secondary to anorectal malformation (n = 2), bladder exstrophy (n = 1), sacrococcygeal teratoma (n = 1) and myelomeningocele (n = 1) or associated with mental retardation (n = 8) and Asperger's syndrome (n = 1). Five (18 %) patients had constipation. Unexpected postoperative events and complications were rated by Clavien-Dindo classification (Grades I-V).

RESULTS

Seventeen (61 %) patients had postoperative complications (Grade I n = 5, II n = 2 and III n = 7). Readmission was required in 11 (41 %) and reoperation, endoscopy or other surgical procedure in 9 (33 %) patients. Complications included severe faecal obstruction (n = 2), constipation (n = 3), faecal soiling (n = 1) urinary retention (n = 2), enuresis (n = 1), infection (n = 2), residual mucosal prolapse (n = 5), discomfort at defecation (n = 1) and recurrent RP (n = 2). Reoperations included sigmoid resection with re-rectopexy (n = 1), resection of mucosal prolapse (n = 1), suprapubic urinary catheter (n = 2), evacuation of faecal impaction (n = 2), colonoscopy (n = 3), appendicostomy for antegrade continence enema (n = 1). Mental retardation or behavioural disorder increased the risk of postoperative faecal obstruction and constipation RR = 84 (95 % CI 4.3-1600), p = 0.0035. After median follow-up of 4.1 (range 0.6-11) years RP or related condition was cured in 26 patients. Constipation and faecal soiling require management in a total of seven patients.

CONCLUSIONS

Long-term results of rectopexy were good. Postoperative complications from mild to moderate grade were unexpectedly frequent. Preoperative neurobehavioural disorder and constipation increase the risk of postoperative problems and should be mentioned in patient counselling.

Dynamic defecography in the diagnosis of paediatric rectal prolapse and related disorders

BACKGROUND AND AIM

Paediatric rectal prolapse (RP) is rarely a diagnostic problem and resolves often spontaneously. We studied whether the assessment of recurrent RP (RP), postoperative relapsed RP (RRP) or anorectal discomfort without RP (ARD) benefits from dynamic defecography (DD) and describe DD findings in relation with outcome.

PATIENTS AND METHODS

Fifteen patients (7 males), median age of 10 (range 3.7-15) years, underwent 19 DD with a synchronic small bowel contrast study. Indications for DD were RP (n = 11), RD (n = 3) and RRP (n = 1). Three patients had solitary rectal ulcer and one juvenile rectal polyps (n = 1). Three patients underwent a total of four postoperative DD because of suspected relapse.

RESULTS

In 11 patients with a clinically diagnosed prolapse DD displayed a simple prolapse (n = 3), prolapse with enterocele (n = 1), prolapse with small bowel interposition (n = 1), rectal intussusception with anterior rectocele (n = 1) and rectal intussusception (n = 1) and no pathology (n = 4) (37 %). In four patients with ARD DD displayed rectal prolapse originating from sigmoid intussusception (n = 1), enterocele (n = 1) and anterior rectocele (n = 1) and no pathology in one. Median follow-up was 8.1(range 3.0-44) months. Ten patients underwent surgery. Three patients with RP underwent simple laparoscopic rectopexy, five with RP or RD with enterocele or anterior rectocele had rectopexy with anterior peritoneoplasty and two (RP n = 1, RRP n = 1) with sigmoid intussusception had sigmoid resection with rectopexy. Two symptomatic patients (RP, negative DD) are scheduled for rectopexy. Three patients PPRP (n = 2) RD (n = 1) had spontaneous cure. Postoperative DD confirmed relapsed RP in one patient.

CONCLUSION

In patients, RP and associated disorders' DD can disclose significant pathology (enterocele, rectocele or sigmoid intussusception) and thereby guide surgical treatment, and should be included in the pre-treatment assessment.