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Stapled anopexy in the treatment of rectal prolapse

 

Christina Tinghus, Niels Qvist
Surgical Department A, Odense University Hospital
Odense, Denmark

 

Correspondence

Niels Qvist, Professor, Surgical Department A
Odense University Hospital, DK-5000 Odense C, Denmark
Tel: +45 6541 2236 / Fax: +45 65 91 9872
E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

 

Abstract

Aim: To evaluate the stapled anopexy in the surgical treatment of rectal prolapse in children.

Material and Methods: Prospective analyses of 24 patients with a follow-up varying from 2 years to 9 years and 10 months. Results: The success rate after primary stapling was 50 % and after secondary stapling procedure the value was 83,3%. There were no early postoperative complications. Late complications were seen in one patient with a relative stenosis of the anastomotic line treated with a single dilatation procedure.
Conclusions: The method seems to be a promising and safe alternative in the surgical treatment of persistent rectal prolapse in children. Future studies should focus upon the long term functional results.

K ey words: rectal prolapse, stapled anopexy, postoperative complications

 

 

Introduction

Rectal prolapse is often seen in children with a history of long-standing constipation or diarrhoea. Several other conditions such as cystic fibrosis and neurological conditions may be predisposing, but in a significant number of children there is no obvious cause. Most cases respond to treatment of the underlying condition or are otherwise self-limiting. However, the prolapse may persist indefinitely in some children requiring surgical intervention.

A wide variety of operative methods have been described throughout the years, including injection sclerotherapy with different kinds of solvents [1, 2], rectosacropexy [3, 4], abdominal rectopexy, mucosal plication [5], modified Thiersch suture [6] and several others. None of them seems to be the ideal one in respect to recurrence and complications. The success rate varies between 20-100 % depending upon the duration of the observation period. Stapled anopexy has become a recognized method in the treatment of mucosal prolapse and prolapsing haemorrhoidal disease in the adults. The procedure includes a 2-4 centimetres high mucosal resection and anastomosis 1-2 centimetres above the dentate line.

To our knowledge, there are no studies on the stapled anopexy used as a routine treatment for rectal prolapse in children. There exists only one case report describing a sequential linear stapling method in a boy weighing 5 kg [7]. The present study describes the results and experiences from a prospective and consecutive series of 24 children with refractory rectal prolapse of less than 5 cm in length that underwent anopexy with the circular stapling method.

Materials and methods

Prospective analyses of all patients in the age from 0-15 years referred for surgical treatment of full- thickness rectal prolapse in the period between February 1999 and December 2006. The department serves as a tertiary referral centre for paediatric surgery covering a population of 2.1 million inhabitants.

During the inclusion period 34 children were referred. In all cases a photo documentation of the prolapse was available. Photos were taken at home by the parents with the child in a position making it possible to judge the length of the rectal prolapse. Ten patients were excluded. Three children had an abdominal rectopexy due to a long rectal prolapse (>5 cm). Three patients were treated with sclerotherapy due to parent preference. One patient had only one episode of rectal prolapse, one patient turned out to have a rectal polyp and another patient had a rectal duplication cyst. Thus, the study included a total 24 patients (5 girls and 19 boys). The girls presented with symptoms at an average age of 3 years and 9 months (range 2 years and 2 months – 5 years and 9 months) and were operated at an average age of 4 years and 2 months (range 2 years and 10 months – 6 years and 2 months). The boys presented with symptoms at an average age of 4 years and 10 months (range from newborn – 10 years and 7 months) and were operated at an average age of 6 years and 4 months (range 2 years and 10 months – 10 years and 11 months). Thus, the duration of symptoms prior to surgery varied from 6-34 months. Prolapse at defecation was the only symptom in 16 children, two patients had recurrent rectal bleeding and in 6 patients digital repositioning was necessary.

Preoperative preparation included a phosphate enema one hour prior to surgery. For the anopexy a purse string suture was placed 3-4 centimetres above the dentate line with the intention to include only the mucosa. The anvil of a circular stapler (Ethicon Endo-Surgery, USA, CDH 29-33 or PPH) was introduced into the rectum and the purse string suture was tied over the anvil. A mucosal resection was performed under maximal tissue compression (fig. 1). The anastomotic line was inspected and any bleeding spot was secured with bipolar electrocoagulation. No antibiotics were used. The operation was performed under general anaesthesia and all patients were treated in the outpatient clinic. A regular follow up was performed three months after surgery and all patients were contacted (September, 2008) by phone for an interview on any complications including incontinence and recurrence.

3 JPSS 8 1 2010-3

Figure 1: Resected mucosa using the PPH 03 stapler

Results

Recurrence of the rectal prolapse was seen in 12 of the 24 patients during the follow up period after primary surgery ranging from minimum 2 years to maximum 9 years and 10 months. Recurrence was seen on average 9 months (range 1 week - 22 months) after primary surgery. In 9 of the patients with recurrence of the rectal prolapse a secondary stapled anopexy was performed with success and no further recurrence in 8 patients. One patient underwent submucosal sclerotherapy as the second procedure due to parent decision. The last two patients with recurrence underwent an abdominal rectopexia because the rectal prolapse was > 5 cm long.

Thus, the success rate after primary stapling was 50 % and after secondary stapling procedure the value was 83,3%. There were no early postoperative complications. Late complications were seen in one patient with a relative stenosis of the anastomotic line treated with a single dilatation procedure. Otherwise, there were no complications and no complaints on incontinence.

Discussion

The recurrence rate in our study did not differ significantly from other studies using other treatment modalities. Antoa et al. [8] found an overall success rate of 63 % using a variety of different methods including Thiersch procedure, anal stretch, banding of prolapse and rectopexy. Several children underwent 2 procedures. Using sclerotherapy with hypertonic saline (15%) a success rate on 71% after one injection increasing to 83% after two injections has been reported in a group of children in the age from 2-4,5 years [2]. In the group of children in the age of 5-13 years all 5 children needed surgical correction after 1-3 injection procedures without success. Sclerotherapy with the injection of cow milk [1] has been described with a success rate of 95,3% after up to 3 injections procedures. With other methods like the closed rectosacropexy and the Ekehorn´s rectosacropexy [3,4], a success rate on 100% has been reported. However, these procedures are much more invasive and caries a higher risk of major complications, discomfort and longer hospital stay. The mucosal plication [5] has been described as a method easy to perform with no complications and a 100% success. This technique may to some degree mimic the method with stapled anopexy used in our study.

The prognosis for success is dependent upon follow-up period and is worse when presentation of prolapse occurs after the age of 4 years [9]. The majority of patients in our study were above the age of 4 years, and the follow-up period in our study was considerably longer than in many other comparable studies. The initial rate of success was only 50%, but it improved considerable after a secondary procedure to 83,3%. There were no complaints on serious postoperative pain that was treated with paracetamol if needed. The secondary procedure was not more difficult to perform compared to the primary procedure.

There were no early postoperative complications or serious late complications and all patients were treated in the outpatient clinic. In adults several serious complications to anopexy has been described including rectovaginal fistula, perforation to the peritoneal cavity, sphincter damage and severe postoperative pain. The deep peritoneal reflection and rectocele in the elderly may be predisposing factors. An important factor is the correct placement of the purse string suture. A too high placed suture increases the risk of perforation to the peritoneum and a too low placed suture increases the risk of damaging the sphincter complex and of severe postoperative pain if the transitorial zone is included in the resection. I order to avoid vaginal or urethral lesion only mucosa should be included in the purse sting suture. Furthermore, the vagina should be checked before the stapler is released and urethra may be catheterized is case of doubt.

We choose to include only prolapse less than 5 centimetres in length from the idea that only a length 2-4 cm of the mucosa could be resected using the circular stapler. However, it might be possible to increase the amount of resected tissue by an additional stapling procedure made during the same general anaesthesia. This has been documented in the adults, but has not been performed in the present study.

In the judgement of the length of the prolapse we have found the photo documentation of great value. Rectal prolapse in children may be difficult to prove in the clinical setting, and history alone is often inaccurate. In several cases where the parents reported a rectal prolapse it turned out to be perianal venous complexes, which need a much different treatment.

Conclusions

The stapled anopexy seems to be a promising and safe alternative in the surgical treatment of persistent rectal prolapse in children. The initial recurrence rate is relative high and comparable with other methods. However, the success rate improves considerable after a second procedure. Future studies should focus upon the long term functional results.

 

 

 

References

  1. Zganjer M, Cizmic A, Cigit I, Zupancic B, Bumci I, Popovic L, Kljenak A. Treatment of rectal prolapse in children with cow milk injection sclerotherapy: 30-years experience. World J Gastroenterol 2008;14:737-40
  2. Shah A, Parikh D, Jawaheer G, Gornall P. Persistent rectal prolapse in children. Sclerotherapy and surgical management. Pediatr Surg Int 2005;21:270-3
  3. Lasheen AE. Closed rectosacropexy for rectal prolapse in children. Surg Today 2003;33:642-4
  4. Sander S, Vural O, Unal M. Management of rectal prolapse in children. Ekehorn’s rectopexy. Pediatr Surg Int 1999;15:111-4
  5. Shafik A. Mucosal plication in the treatment of rectal prolapse. Pediatr Surg Int 1997;12:386-8
  6. Groff DB, Nagaraj HS. Rectal prolapse in Infants and Children. Am J of Surg 1990;160:531-2
  7. Lee JI, Vogel AM, Suchar AM, Glynn L, Statter MB, Liu DC. Sequential linear stapling technique for perineal resection of intractable pediatric rectal prolapse. Am Surg 2006;72: 1212-5
  8. Antao B, Bradley V, Roberts JP, Shawis R. Management of rectal prolapse in children. Dis Colon Rectum 2005;48:1620-5
  9. Siafakas C, Vottler TP, Andersen JM. Rectal prolapse in pediatrics. Clin Pediatr 1999;38:63-72