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Rincon-Cruz L, Staffa SJ, Dickie B, Nandivada P. Influence of Initial Treatment Strategy on Outcomes for Children With Rectal Prolapse. J Pediatr Gastroenterol Nutr 2023; 77:603-609. [PMID: 37889618 DOI: 10.1097/mpg.0000000000003924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/29/2023]
Abstract
OBJECTIVE Pediatric rectal prolapse is a common and often self-limited condition with multiple management options. Selecting the optimal approach requires personalization and remains a challenge for pediatricians and pediatric surgeons. METHODS A single-center retrospective review of 67 children with rectal prolapse undergoing surgical evaluation between 2010 and 2021. Patients with anorectal malformations, Hirschsprung disease, inflammatory bowel disease, and cystic fibrosis were excluded. We used multivariable logistic regression to compare medical management, sclerotherapy, and surgical correction (rectopexy or transanal resection) as initial treatment strategies, with a primary endpoint of prolapse resolution. RESULTS Younger patients (<5 years) were more likely to be initially treated with medical management alone (P < 0.001). Patients with a psychiatric diagnosis were more likely to be offered either sclerotherapy or surgery upfront (P = 0.009). The resolution rate with surgery as initial management was 79% (n = 11/14). The resolution rate with sclerotherapy as initial management was 54% (n = 13/24), with 33% (n = 8/24) resolving with sclerotherapy alone and 21% (n = 5/24) resolving after a subsequent surgical procedure (P = 0.011). Patients who underwent initial surgical management had an adjusted odds ratio of 8.0 (95% CI: 1.1-59.1; P = 0.042) for resolution of prolapse compared to patients who underwent sclerotherapy initially. Markers of severity (bleeding, need for manual reduction) were not associated with initial therapy offered (P = 0.064). CONCLUSIONS Surgical intervention (sclerotherapy, rectopexy, transanal resection) resolved rectal prolapse in most children (63%). Surgery as an initial management approach had a significantly higher success rate than sclerotherapy, even after controlling for severity of disease, psychiatric diagnosis, need for manual reduction, and age.
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Mustafa G, Asad A, tul Muntaha S. Comparison of 5% Phenol With Almond Oil Versus 15% Hypertonic Saline in Treatment of Pediatric Idiopathic Rectal Prolapse. Cureus 2022; 14:e23552. [PMID: 35399434 PMCID: PMC8986137 DOI: 10.7759/cureus.23552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2022] [Indexed: 12/01/2022] Open
Abstract
Objective: The objective of the study was to compare the frequency of recurrence with 5% phenol in almond oil versus 15% hypertonic saline for pediatric idiopathic rectal prolapse. Methodology: An open-label, randomized clinical trial was conducted at the Department of Paediatric Surgery, Services Hospital, Lahore, Pakistan, over a period of one year from May 1, 2018 to April 30, 2019. Altogether, 120 patients with idiopathic rectal prolapse were included in this study. After obtaining approval from the hospital ethical committee, all patients fulfilling the inclusion criteria were admitted to the pediatric surgery inpatient department of Services Hospital, Lahore. Patients were randomized into two groups with an equal number of candidates using the lottery method. Group A consisted of patients who were administered 5% phenol in almond oil and group B consisted of patients who were administered 15% hypertonic saline. All procedures were performed by a single surgical operating team to control bias. Patients were followed up for three months after surgery to note whether recurrence occurred or not. Results: The mean age of the patients was 3.97 ± 2.68 years in group A and 2.87 ± 1.84 years in group B. Gender distribution showed male dominance (71.7% in group A and 73.3% in group B). Statistically significant difference was observed in terms of recurrence (50% in group A and 23.3% in group B) (p=0.002), while statistically insignificant differences were found in terms of postoperative faecal incontinence (2% in each group, p=0.6478) and anal stenosis (8% in group A and 2% in group B with p=0.2426). Conclusion: Thus, 15% hypertonic saline was noted to be a more effective sclerosing agent than 5% phenol in almond oil in the management of idiopathic rectal prolapse in children. It was also found to have a statistically comparable rate of complications, including fecal incontinence and anal stenosis.
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Zhou W, Shi Y, Zhang M, Li L. The Remission Effects of First Injection of Sclerotherapy for Pediatric Rectal Prolapse: A Systematic Review and Meta-Analysis. Front Surg 2022; 9:835235. [PMID: 35284492 PMCID: PMC8907260 DOI: 10.3389/fsurg.2022.835235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 01/18/2022] [Indexed: 11/14/2022] Open
Abstract
Background Pediatric rectal prolapse is a common issue in clinical practice. Among various managements, sclerotherapy is an important method to successfully treat pediatric rectal prolapse, especially for the first injection. The knowledge of the first injection of sclerotherapy can be revealed by a systemic review and meta-analysis of randomized clinical trials. Methods We performed a systematic search and a meta-analysis for the retrospective clinical studies of sclerotherapy in pediatric rectal prolapse. The comparison between remission and recurrence after the first injection of sclerotherapy was performed to find if the first injection of sclerotherapy can treat rectal prolapse completely. After a restricted selection, 17 studies involving 1,091 pediatric rectal prolapse subjects with sclerotherapy were enrolled in a variety of classifications of injection agents. The focused outcome was to check whether the first injection of sclerotherapy can achieve a remission status. The meta-analysis was performed by Review Manager 5.4. Results Among the subjects receiving sclerotherapy, the meta-analysis favors the remission status after receiving the first injection of sclerotherapy. The meta-analysis results showed significant remission tests for the overall effect and significant heterogeneities in odds ratio and the fixed-effects model. The significant therapeutic effects remained, however, even after testing in the relative risk and the random-effects model. Conclusions Despite significant heterogeneity and relatively low quality of evidence, the first injection of sclerotherapy may conceivably demonstrate therapeutic effects to help the patients of pediatric rectal prolapse achieve a remission status.
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Affiliation(s)
- Weimo Zhou
- Department of Pediatric Surgery, Guigang City People's Hospital, Eighth Affiliated Hospital of Guangxi Medical University, Guigang, China
| | - Yingzuo Shi
- Department of Pediatric Surgery, Wuxi People's Hospital, Wuxi, China
| | - Ming Zhang
- Clinical Laboratory, Zhucheng Maternal and Child Health Hospital, Zhucheng, China
| | - Li Li
- The Department of Pediatrics, Ganzhou People's Hospital, Ganzhou, China
- *Correspondence: Li Li
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Saadai P, Trappey AF, Langer JL. Surgical Management of Rectal Prolapse in Infants and Children. Eur J Pediatr Surg 2020; 30:401-405. [PMID: 32920799 DOI: 10.1055/s-0040-1716725] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- Payam Saadai
- Department of Pediatric Surgery, UC Davis Children's Hospital, Sacramento, California, United States.,Department of Pediatric Surgery, Shriners Hospitals for Children Northern California, Sacramento, California, United States
| | - A Francois Trappey
- Department of Surgery, University of Texas McGovern Medical School, Houston, Texas, United States
| | - Jacob L Langer
- Department of Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
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Trappey AF, Galganski L, Saadai P, Stephenson J, Stark R, Farmer DL, Langer JC, Hirose S. Surgical management of pediatric rectal prolapse: A survey of the American Pediatric Surgical Association (APSA). J Pediatr Surg 2019; 54:2149-2154. [PMID: 30987759 DOI: 10.1016/j.jpedsurg.2019.02.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Revised: 01/19/2019] [Accepted: 02/17/2019] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Alfred Francois Trappey
- University of California at Davis Medical Center, Shriners Hospitals for Children, Northern California, David Grant Medical Center, Travis AFB, CA, 2425 Stockton Blvd., Sacramento, CA 25817.
| | - Laura Galganski
- University of California at Davis Medical Center, Shriners Hospitals for Children, Northern California, 2425 Stockton Blvd., Sacramento, CA 25817
| | - Payam Saadai
- University of California at Davis Medical Center, Shriners Hospitals for Children, Northern California, 2425 Stockton Blvd., Sacramento, CA 25817
| | - Jacob Stephenson
- University of California at Davis Medical Center, Shriners Hospitals for Children, Northern California, David Grant Medical Center, Travis AFB, CA, 2425 Stockton Blvd., Sacramento, CA 25817
| | - Rebecca Stark
- University of California at Davis Medical Center, Shriners Hospitals for Children, Northern California, 2425 Stockton Blvd., Sacramento, CA 25817
| | - Diana L Farmer
- University of California at Davis Medical Center, Shriners Hospitals for Children, Northern California, 2425 Stockton Blvd., Sacramento, CA 25817
| | - Jacob C Langer
- Shriners Hospitals for Children, Northern California, 2425 Stockton Blvd., Sacramento, CA 25817
| | - Shinjiro Hirose
- University of California at Davis Medical Center, Shriners Hospitals for Children, Northern California, 2425 Stockton Blvd., Sacramento, CA 25817
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Hintz GC, Zou VZ, Baird R. Sclerotherapy for rectal prolapse in children: A systematic review and meta-analysis. J Pediatr Surg 2019; 54:1083-1088. [PMID: 30782440 DOI: 10.1016/j.jpedsurg.2019.01.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 01/27/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Sclerotherapy is a commonly utilized treatment for rectal prolapse in children. This study systematically evaluates the effectiveness and complications of various sclerosing agents in treating pediatric rectal prolapse. METHODS After protocol registration (CRD-42018088980), multiple databases were searched. Studies describing injection sclerotherapy for treatment of pediatric rectal prolapse were included, with screening and data abstraction duplicated. The methodological quality of included papers was assessed using the Methodological Index for Non-Randomized Studies (MINORS) score. RESULTS Nineteen studies were identified, published between 1970 and 2017. Most studies were single institution case series, with median "N" 57+/-88.9 and mean MINORS score of 0.51+/-0.17 (perfect score = 1). 1510 patients with a mean age of 4.5 years were accounted for: 36.2% female, most without comorbidities. Mean follow up length was 30 months. The most common sclerosing agent described was ethanol (45%), followed by phenol (33%). The mean number of treatments per patient was 1.1+/-0.34. The overall success rate after a single sclerotherapy treatment was 76.9%+/-8.8%. The overall complication rate was 14.4%+/-2%. CONCLUSIONS Injection sclerotherapy appears effective and low-risk in the treatment of pediatric rectal prolapse and should be considered before more invasive surgical options. The available evidence is of relatively poor quality, and prospective comparative investigations are warranted. LEVEL OF EVIDENCE 3 (meta-analysis of level 3 studies).
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Affiliation(s)
- Graeme Charles Hintz
- Division of Pediatric Surgery, Department of Surgery, British Columbia Children's Hospital, Vancouver, BC, Canada; Division of General Surgery, Department of Surgery, University of British Columbia Faculty of Medicine, Vancouver, BC, Canada
| | - Vito Zhaoxin Zou
- MD Undergraduate Program, University of British Columbia Faculty of Medicine, Vancouver, BC, Canada
| | - Robert Baird
- Division of Pediatric Surgery, Department of Surgery, British Columbia Children's Hospital, Vancouver, BC, Canada.
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