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.

Postoperative complications and long-term functional outcome in children operated for idiopathic rectal prolapse

PURPOSE

The aim of the present study was to evaluate the postoperative complications and the long-term gastrointestinal functional outcome after surgical treatment for rectal prolapse on a strategy with stapled anopexy for short (< 5 cm) prolapse and Delormes procedure for longer (> 5 cm) rectal prolapse.

METHODS

A total of 38 patients were included with a postoperative follow-up period ranging from 1 month to 9.1 years. Thirty patients (83%) completed the Rome III questionnaire on gastrointestinal function, with the follow-up period ranging from 2 months to 7 years.

RESULTS

Thirty-five patients were treated with stapled anopexy as a primary surgical treatment. One minor complication with slight postoperative bleeding was observed, but the recurrence rate was 34.3%. Treatment of recurrence with re-stapling gave success rate of 44.4%. Ten patients (3 primary and 7 with recurrence after stapled anopexy) were treated with Delormes procedure with no observed complications or recurrence. Four out of nineteen patients treated with stapled anopexy fulfilled the criteria for functional gastrointestinal symptoms and in 3 out of 8 treated with Delormes procedure. No patients reported continence problems.

CONCLUSION

The recurrence rate for stapled anopexy was high and none with Delormes procedure. The functional outcome was comparable with a healthy population of children.

Rectal Prolapse in Children: Significance and Management

Rectal prolapse is a herniation of the rectum through the anus. It is rare in children. When it does occur, it is usually prior to 4 years of age and due to anatomical variants. A few conditions predispose children to rectal prolapse, the most common being constipation. Cystic fibrosis used to be commonly associated with rectal prolapse, but with the advent of cystic fibrosis newborn screening, this association is no longer as frequently seen. Many recent case reports, detailed in this chapter, describe conditions previously unknown to be associated with rectal prolapse. Management is usually supportive; however, rectal prolapse requires surgical management in certain situations. This review details the presentation of rectal prolapse, newly described clinical manifestations, and associated conditions, and up-to-date medical and surgical management.

Recurrent rectal prolapse following primary surgical treatment

PURPOSE

The management of recurrent rectal prolapse following initial surgical procedures remains unclear. We present a series of pediatric patients with rectal prolapse and describe their surgical management, and the subsequent care for those children developing recurrence.

METHODS

The records of 29 pediatric patients with rectal prolapse refractory to conservative medical management who were managed with primary modified Thiersch procedures over a 14-year period were reviewed. Initial surgical management consisted of a modified version of the Thiersch anal encirclement procedure, which involved a combination of injection sclerotherapy, linear cauterization, and placement of a Thiersch anal encirclement absorbable stitch. Age at initial procedure, predisposing conditions, complications, recurrence, time to recurrence, and subsequent procedures utilized were reviewed.

RESULTS

Of 29 patients, 22 (71%) were male with a mean age at time of first Thiersch procedure of 7.1 years (range 3 months to 19 years). Seven patients were lost to follow-up. Nineteen patients (90%) experienced resolution of their prolapse following one or two modified Thiersch procedures; 14 (67%) following an initial Thiersch and 5 (23%) following a subsequent Thiersch. One additional child experienced recurrence after an initial Thiersch procedure, and underwent a perineal resection of redundant rectum (modified Altemeier procedure). Two patients developed a recurrence after their second Thiersch. These cases both required a modified Altemeier procedure. Mean follow-up for all patients was 1.5 years.

CONCLUSION

For pediatric rectal prolapse refractory to conservative medical therapy, the modified Thiersch procedure appears reasonable. Initial recurrences are not uncommon, and their incidence increases with the age of the child. Recurrences should be initially managed by a repeat Thiersch procedure. However, subsequent recurrences should be treated with a modified Altemeier.