Treatment of rectal prolapse in children with cow milk injection sclerotherapy: 30-year experience

Most children experience resolution of idiopathic pediatric rectal prolapse with bowel management alone

BACKGROUND

Recent studies in children with idiopathic rectal prolapse report up to 48% require surgical intervention to manage refractory disease. We sought to examine outcomes of our non-surgical approach to managing rectal prolapse using a bowel management program.

METHODS

A retrospective review was performed for all children with the diagnosis of rectal prolapse between 2011 and 2020. Children with a rectal polyp or hemorrhoid were excluded.

RESULTS

47 children with rectal prolapse were identified (median age at diagnosis of 4 years (IQR 3,7.75); age ≤ 4 years n = 30; age > 4 years n = 17). Associated diagnoses included constipation (n = 45, 96%) and psychiatric diagnoses (n = 7, 14%). Children underwent a bowel management program including stimulant laxatives in 44 (94%) and osmotic laxatives in 2 (4%). Median follow-up time was 181 days (IQR 77, 238). Median time to resolution of rectal prolapse was 9 months (IQR 4, 13) with a maximum time to resolution of 31 months. We compared children ≤ 4 years old (Group A) to those > 4 years old (Group B). Psychiatric diagnoses were less common in Group A (3.5 vs. 38.9%, p = 0.003). Median time to spontaneous resolution was 6.5 months (IQR 3.5, 9.5) in Group A versus 13.5 (IQR 4, 16) months in Group B, p = 0.13. No differences in surgical intervention were identified. Three (6.4%) patients required surgery for prolapse.

CONCLUSIONS

A bowel management program is an effective treatment for most children with rectal prolapse. This data suggests that surgical intervention is unnecessary in most children.

LEVEL OF EVIDENCE

III.

Comparison of 5% Phenol With Almond Oil Versus 15% Hypertonic Saline in Treatment of Pediatric Idiopathic Rectal Prolapse

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.

The Remission Effects of First Injection of Sclerotherapy for Pediatric Rectal Prolapse: A Systematic Review and Meta-Analysis

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.

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.

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.

Sclerotherapy for rectal prolapse in children: A systematic review and meta-analysis

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).

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.

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.

Sclerotherapy for the management of rectal prolapse in children

PURPOSE

Rectal prolapse is a commonly occurring and usually self-limited process in children. Surgical management is indicated for failures of conservative management. However, the optimal approach is unknown. The purpose of this study is to determine the efficacy of sclerotherapy for the management of rectal prolapse.

METHODS

This was a retrospective review of children <18years with rectal prolapse who underwent sclerotherapy, predominantly with peanut oil (91%), between 1998 and 2015. Patients with imperforate anus or cloaca abnormalities, Hirschprung disease, or prior pull-through procedures were excluded.

RESULTS

Fifty-seven patients were included with a median age of 4.9years (interquartile range (IQR) 3.2-9.2) and median follow-up of 52months (IQR 8-91). Twenty patients (n=20/57; 35%) recurred at a median of 1.6months (IQR 0.8-3.6). Only 3 patients experienced recurrence after 4months. Nine of the patients who recurred (n=9/20; 45%) were re-treated with sclerotherapy. This was successful in 5 patients (n=5/9; 56%). Two patients (n=2/20; 10%) experienced a mucosal recurrence which resolved with conservative management. Forty-four patients were thus cured with sclerotherapy alone (n=44/57; 77%). No patients undergoing sclerotherapy had an adverse event. Thirteen patients (n=13/20; 65%) underwent rectopexy after failing at least one treatment of sclerotherapy. Three of these patients (n=3/13; 23%) recurred following rectopexy and required an additional operation.

CONCLUSIONS

Injection sclerotherapy for children with rectal prolapse resulted in a durable cure of prolapse in most children. Patients who recur following sclerotherapy tend to recur within 4months. Another attempt at sclerotherapy following recurrence is reasonable and was successful half of the time. Sclerotherapy should be the preferred initial treatment for rectal prolapse in children and for the initial treatment of recurrence.

LEVEL OF EVIDENCE

Level IV.

TYPE OF STUDY

Treatment Study.

Outcomes following sclerotherapy for mucosal rectal prolapse with oily phenol injection: single-centre review

AIM OF THE STUDY

To review the outcomes of injection sclerotherapy with oily phenol for mucosal rectal prolapse.

METHODS

Retrospective case note review of all children who underwent sclerotherapy with oily phenol injection as primary surgical intervention for mucosal rectal prolapse, from January 2007 to December 2015.

MAIN RESULTS

A total of 31 patients were identified. Mean age at presentation was 4.8 years (range 5 months-12 years). 23 patients with mucosal rectal prolapse underwent injection sclerotherapy with oily phenol as primary procedure. Patients with full-thickness rectal prolapse (n = 6) and 2 with mucosal prolapse who had Thiersch stitch were excluded from the study. The cause for mucosal rectal prolapse was considered to be due to constipation (n = 15), idiopathic (n = 7), spina bifida (n = 1). Follow-up was for minimum 6 months (median = 4 years; range 6 months-17 years). Recurrence following injection sclerotherapy with oily phenol requiring further procedures was 30.4% (7/23).

CONCLUSIONS

Injection sclerotherapy with oily phenol is a safe, effective and minimally invasive primary treatment option for mucosal rectal prolapse not responding to conservative management. In case of recurrence, a cautious re-examination under anaesthesia should be undertaken to exclude a missed full-thickness rectal prolapse before reinjecting.

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.

Rectal prolapse in children: a study of 71 cases

Introduction

Prolapse of the rectum is the herniation of the rectum through the anus, which may be categorised as mucosal or complete.

Aim

To evaluate the clinical manifestation, treatment, and surgical complications of children with rectal prolapse over a 6-year period.

Material and methods

This study was carried out on children aged < 14 years who were admitted or referred for rectal prolapse that failed to respond after medical treatment in Imam Khomeini and Abouzar Children's Hospital. Duration of the study was 6 years starting in March 2002. These cases were referred after failure of medical and conservative treatment. Age, sex, clinical manifestation, and type of procedure were recorded. Analysis was done using SPSS version 11.0 (SPSS Inc, Chicago, IL, USA). The χ² test was used for comparison.

Results

Seventy-one cases were included in this study. Of these cases, 50 (70.4%) were male and 21 (29.6%) were female (p < 0.0001). Mean age of cases was 4.97 ±3.42 years (range: 2 days to 13 years). Of the male cases, 38% were in the age range of 3–6 years. In female cases, 57.1% were in the range of 1.5–3 years. Of all 71 cases, injection sclerotherapy was done for 50 (70.43%) for the first time. Twenty-one cases had history of injection sclerotherapy and 16 (22.53%) were treated by perineal surgery, and 5 (7.04%) had abdominal surgery. One case experienced recurrent rectal prolapse (1.40%) following injection sclerotherapy.

Conclusions

In girls, more than half of the cases were in the age range 1.5–3 years. Among male cases, 38% were in the age range of 1.5–3 years. The results of treatment of rectal prolapse in our hospitals was similar to that seen in developed countries.

Comparative effects of different sclerosing agents used to treat rectal prolapse: an experimental study in rats

BACKGROUND/PURPOSE

Sclerosing agents injected into the rectal submucosal area produce an inflammatory response and scar that prevent rectal prolapse. This study aimed to investigate the histopathological changes following submucosal injection of different sclerosing agents in rats.

METHODS

Rats (n=35) were divided into control, sham, and five experimental groups, each treated with a different sclerosing agent: cow's milk, 30% saline solution, 30% dextrose solution, 70% ethyl alcohol, and 5% phenol in almond oil (PAO). All agents were injected into the submucosal area. After 4 weeks, all animals were sacrificed. Histopathological evaluation was performed according to a semi-quantitative fibrosis scoring system (grades 0 to 3), by using Masson trichrome and hematoxylin and eosin staining.

RESULTS

Histopathological changes in the 5% phenol in almond oil group were significantly different from other groups (p=0.0001). Prominent submucosal fibrosis (grade 3), lymphatic vascular dilation, foreign body reaction, and lipogranuloma were observed in the 5% PAO group (p=0.007). No significant histopathological differences were seen between the 30% saline, 30% dextrose, and 70% ethyl alcohol groups. Significantly increased mucosal fibroblast proliferation (grade 2) was seen in 60% rats of the 30% dextrose group (p=0.026). The cow's milk and ethyl alcohol groups had mucosal erosions and congestion (grade 1) which were significantly different from the control group (p=0.024). No statically significant difference was observed between the 30% saline group and the control group.

CONCLUSIONS

In this study we showed that 5% PAO can induce some histopathological changes in the submucosal area that increase the mucosal tightness of the mucosa, which are necessary for the treatment of rectal prolapse.

Critical procedures in pediatric emergency medicine

Children comprise approximately one-quarter of all visits to most emergency departments. Children are generally healthier than adults, yet there are similar priorities in assessment and management of pediatric patients. The initial approach to airway, breathing, and circulation still applies and is first and foremost in the evaluation of young infants and children. There are certain anatomic, physiologic, developmental, and social considerations that are unique to this population and must be taken into account during their evaluation and treatment. In this review, we present and discuss an evidence-based approach to high-yield procedures necessary for all emergency physicians taking care of children.

Injection treatment of rectal prolapsed: current research status

Injection therapy is currently an important treatment choice for rectal prolapse. Frequently used drugs include alcohol, 50% glucose, phenol-almond oil, 5% sodium morrhuate, alum injection, peony-gallnut injection, and Xiaozhiling injection. Injection methods include rectal submucosal injection, perirectal injection, double-layer four-step injection, punctiform injection, columnar injection, and sector injection. Foreign scholars usually treat infants and patients with incomplete rectal prolapse by injection therapy, while domestic scholars often use this method to treat various kinds of rectal prolapse. Xiaozhiling injection is the most commonly used drug for rectal prolapse in China and is associated with a satisfactory short-term curative effect despite a low level of recurrence. Injection therapy has many advantages such as minimal invasiveness, low cost, good safety and efficacy, and simpleness, and is therefore a preferred treatment for rectal prolapse.

Common transperineal surgical options for rectal prolapse

Rectal prolapse is a troublesome anorectal disorder. Surgical procedures for rectal prolapse contain transabdominal and transperineal approaches. There are hundreds of transabdominal approaches currently available for treatment of rectal prolapse. In contrast, only tens of transperineal approaches available for the disease, such as Delorme procedure, Altemeier prodecure, Thiersch prodecure and Gant-Miwa prodecure. Procedure for prolapse and hemorrhoids (PPH) represents the latest advance in transperineal treatment of rectal prolapse. Injection treatment is applied widely in China and has remarkable superiority. As each procedure has its strength and weakness, selection of appropriate procedure based on individual difference can greatly improve surgical outcome. Individualized diagnosis and treatment plan may represent a new direction for transperineal surgical treatment of rectal prolapse.