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.

Infected Haematoma Fistulating Through Adjacent Colorectal Anastomosis Mimicking an Anastomotic Leak

Anastomotic leakage is a well-understood major complication of colorectal surgery and carries significant implications for patient morbidity and mortality. However, an infected collection fistulating through an otherwise healthy colorectal anastomosis can mimic an anastomotic leak and warrants different management to a primary anastomotic leak. Such a presentation is undocumented in the current literature. A 42-year-old man underwent an elective perineal rectosigmoidectomy (Altemeier's procedure) for full-thickness rectal prolapse. Early postoperative computed tomography (CT) imaging demonstrated a large haematoma in the rectovesical pouch. He represented 13 days later with fevers and lower abdominal pain. CT revealed that the known haematoma had evolved into an infected collection. At this stage, there was an intact anastomosis on imaging with no evidence of fistula formation or an anastomotic leak. There was a four-day delay between diagnosis and drainage of the abscess. By then, the collection had developed gas and a subsequent CT fistulogram confirmed a fistula had formed between the colorectal anastomosis and abscess, resembling an anastomotic leak. The patient was treated successfully with a diverting ileostomy and percutaneous drainage. We present a unique case of an infected haematoma fistulating rapidly through an otherwise healthy colorectal anastomosis, mimicking an anastomotic leak 17 days after an Altemeier procedure.