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Surgical Management of Rectal Prolapse in Children: Injection Sclerotherapy, Thiersch Procedure or Both

Kashif Chauhan, Omar Nasher, Richard WC Gan, Daniel W Colliver, Shailinder J Singh

Department of Paediatric Surgery, Nottingham University Hospitals NHS Trust, Queen’s Medical Centre, Nottingham, UK

 

Correspondence:

Kashif Chauhan

Paediatric Surgical Department

Nottingham University Hospital, Queen Mary Centre

Derby Road, Nottingham, UK

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Abstract

Aims: Rectal prolapse has two main first line surgical treatments: injection sclerotherapy and Thiersch suture. We have used a technique in which injection sclerotherapy is combined with Thiersch suture as first line treatment. This study compares results between two groups of patients: 1) injection treatment alone and 2) injection treatment combined with Thiersch suture.

Method: A retrospective single institution study on children diagnosed with full thickness rectal prolapse and managed surgically during a period of 5 years (October 2009 – July 2014) using known International Classification of Disease (ICD) code. Results are compiled using chi square test and p-value.

Results: A total of 26 patients (18 males, 8 females) were identified during the study period with a median age at diagnosis of 4 years (range 1-9). Clinical details of 25 patients were available. Two out of 25 had rectal mucosa prolapse so they are excluded. Rest of 23 patients had full thickness rectal prolapse and were analysed very carefully. Fourteen patients were treated with injection sclerotherapy alone, 8/14 (57.14 %) patients developed reoccurrence ranging from 1 month to 9 months post sclerotherapy injection. Among those 5/8 required further phenol injections, 1/8 required phenol and Thiersch suture, 1/7 required rectopexy and 1/8 required rectal mucosal excision. Nine patients were treated with injection sclerotherapy and Thiersch suture. One in 9 (11 %) had re-occurrence 3 months later and was successfully treated with repeated injection sclerotherapy and Thiersch suture. All the 23 patients were on laxatives post procedure and follow up was more than 18 months. The chi-square statistic is 4.1972 with p-value of 0.040491. This result is significant at p- value < 0.05.

Conclusion: Combination of injection sclerotherapy and Thiersch procedure is more effective than injection sclerotherapy alone in the treatment of full thickness rectal prolapse in children. A post-operative laxative regimen is required in these patients as they can develop de novo constipation in post-operative period.

Keywords: Thiersch procedure, rectal prolapse, injection sclerotherapy

 

Introduction

Rectal prolapse is a common condition in children. Most of them can be managed conservatively. A significant number do require surgical intervention. There are various surgical options available in treating rectal prolapse in children. There is no consensus on the most effective surgical treatment. The three main surgical modalities to treat rectal prolapse are: A) Injection sclerotherapy [1-3] B) Thiersch procedure [4] and C) Rectopexy [5]. Injection sclerotherapy is the least invasive option. The success rate following initial following injection sclerotherapy alone as 67% [6]. Thiersch procedure is a relatively more invasive procedure. The success following a Thiersch procedure alone been reported as 61% [7]. Injection therapy is usually a first line of treatment in majority of the centres and the recurrence following the sclerotherapy are treated with repeat injection or with a Thiersch procedure. Rectopexy is reserved for children who have recurrent rectal prolapse despite Injection treatment and Thiersch procedure. There is reported use of combination of injection sclerotherapy with Thiersch procedure at the same sitting as first line treatment for rectal prolapse. It has shown 100% success rate [8]. However, this study involved only two patients and does not provide follow-up period. We have been using two techniques as first line initial treatment for rectal prolapse: 1) injection sclerotherapy on its own and 2) injection sclerotherapy combined with Thiersch procedure at the same sitting. This retrospective study aims to compare the outcome of children with rectal prolapse managed with injection sclerotherapy alone and in combination with Thiersch procedure.

Methods

This is a retrospective single institution study on children diagnosed with rectal prolapse and managed surgically during a period of 5 years (October 2009 – July 2014). We used the known International Classification of Disease (ICD-10) code for ‘Rectal prolapse’ (K623) to identify patients during the study period. We gathered clinical and operative details using our institution’s electronic database as well as clinical case notes. In particular, we looked at demographic information, symptoms, initial management outcome, type of surgical intervention and related complications. For injection sclerotherapy we use 5 ml of 5% phenol in almond oil. A park’s anal dilator or nasal speculum is used to open the Ano-rectal area for injection. The injection is administered in four equally divided doses around the four quadrants of lower rectum (above the anal canal). We use a spinal needle to inject in the submucosal plane. For injection sclerotherapy combined with Thiersch suture we used the same injection sclerotherapy as described above. The Thiersch stitch is then placed. Two small incisions (2-3 mm in length) are made through the skin with a Number 11 surgical blade, 1 cm from the mucocutaneous junction, at 12 o’clock and 6 o’clock position. We have utilized an absorbable suture in these procedures, as the need for the suture is only until the prolapsed rectal sub mucosa adheres to adjacent tissue. A 2/0 PDS stitch is paced circumferentially around the anal canal, utilizing the two incisions to insure its proper placement. The final tightening of the suture, before it’s tying, is made while the index finger of the operating surgeon in the anal canal. This maneuvered prevents over tightening. The PDS knot is then buried in the subcutaneous tissue in the incision at 6 o’clock or 12 o’clock position. Data on the patients who had undergone treatment with above two techniques was collected. Using the chi-square performed statistical analysis.

Results

A total of 26 patients (18 males, 8 females) with rectal prolapse were identified during the study period with a median age at diagnosis of 4 years (range 1-9 years).

Clinical details of 25 patients were available. Two out of 25 had rectal mucosal prolapse as presenting symptoms and was excluded from our study, as they do not have a full thickness rectal prolapse. Both had anorectal malformation for which a posterior sagittal ano-rectoplasty (PSARP) was done and then they had excision of rectal mucosa without any sclerotherapy or Thiersch procedure.

Rest of 23 patients who had full thickness rectal prolapse were analysed very carefully. Twenty patients had no underlying medical or surgical problems. One patient had cystic fibrosis (CF), one had spina bifida with neuropathic bladder and one had sacro-coccygeal teratoma excised. All had full thickness rectal prolapse. Sixteen patients had no history of constipation and were moving their bowel regularly with normal consistency having full thickness rectal prolapse on each occasion. The rest 7 patients had been constipated and were on laxatives with no relief of symptoms. All 23 patients were treated conservatively with or without laxatives and failed to improve clinically and subsequently required surgical intervention.

For data analysis we divided the 23 patients into two groups. First group had sclerotherapy (phenol) injections only and second group had phenol injection and Thiersch suture. Injection sclerotherapy alone was performed in 14/23 patients while 9/23 patients had a combination of injection sclerotherapy and Thiersch procedure. Out of 23 patients, pre-operatively 7 patients were constipated and were on laxative and had rectal prolapse. Five patients went for phenol injection only and 2 went for phenol and Thiersch suture.

Following treatment with injection sclerotherapy alone, 8/14 (57.1%) patients had reoccurrence of full thickness rectal prolapse ranging from 1 month to 9 months post sclerotherapy injection and all of them were on laxatives post injection. Among those 5/8 improved after another phenol injections, 1/8 improved after phenol and Thiersch suture, 1/8 required rectopexy and 1/8 required rectal mucosal excision. This group had 5 patients out of 14, who were constipated.

Following treatment with injection sclerotherapy and Thiersch suture 1/9(11%) had re-occurrence 3 months post-surgery and was successfully treated with repeated injection sclerotherapy (phenol) and Thiersch suture. This group had 2 patients out of 9 who were constipated were on laxatives and had rectal prolapse.

In total 23 patients with full thickness rectal prolapse were treated. Fourteen were treated with Phenol injection alone and 8 (57.1%) of them had a re-occurrence of rectal prolapse. As compared to 9 patients treated with phenol and Thiersch suture with only one patient (11%) had a re-occurrence of rectal prolapse. Follow up period in all 23 patients are more than 18 months (Table 1) and all of them were on laxatives post-surgery, which were weaned off slowly. Patients with cystic fibrosis and spina bifida had injection sclerotherapy and Thiersch suture in first instant with no postoperative complications or rectal prolapse where as one patient who had sacro-coccygeal teratoma excised and presented with full thickness rectal prolapse had injection sclerotherapy only (phenol) with re-occurrence of prolapse requiring excision of rectal mucosa.

Table 1

Total Patients

 

23

Re-Occurrence

Re-do Phenol

Re-do Phenol and Thiersch

Rectopexy

Rectal Mucosa Excision

Outcome

Phenol Injection

14

8 (57.1%)

5

1

1

1

Good

Phenol Injection and Thiersch Suture

 

09

1 (11%)

0

1

0

0

Good

We analyse our results and data using the chi-square statistic p-value. Our results are significant.

The chi-square statistic is 4.8735. The p-value is 0.0272. This result is significant at p value < 0.05. The chi-square statistic is 4.8735. The p-value is 0.02722. This result is significant at p value < 0.05. The chi-square statistic is 4.8735. The p-value is 0.02722.

Discussion

Rectal prolapse is a common condition in children. It affects both genders equally and normally manifests before the age of 4 years with the highest incidence in the first year of life [9]. In our cohort, the mean age at diagnosis was 4 years and there were more males than females affected by this condition. Predisposing conditions includes increased intraabdominal pressure as a result of chronic constipation and straining, infectious diarrhoea, parasitic and neoplastic disease of the rectum, malnutrition, pelvic floor weakness (Siafakas et al.)[10] and cystic fibrosis (Stern et al.)[11]. Other conditions are Ehlers Danlos syndrome (Douglas and Douglas et al.)[12] and Hirschsprung’s disease (Traisman et al.)[13]. In our series, only one patient had cystic fibrosis, two had previous Posterior sagittal Anorectoplasty (PSARP) for anorectal malformation, one had a previously excised sacrococcygeal teratoma and another had spinal bifida with neuropathic bowel. The condition can be self-limiting in some children.

There are conservative measures, which could be used if the rectal prolapse persists. These include manual reduction and modification of the position during defecation [1]. In addition, laxatives for constipation and anti-diarrhoeal medications to control loose stools may be useful in this condition. Following failure to manage rectal prolapse conservatively, different surgical options may be implemented depending on the clinical case.

Injection sclerotherapy is a common minimally invasive procedure used to treat rectal prolapse. There are several different sclerosing agents which include ethyl alcohol, 5% phenol, hypertonic saline solution, cow milk and dextranomer/hyaluronic acid copolymer (Deflux®) and have shown different outcomes [1-3]. This procedure has been reported having a 67% success rate following first injection of 5% phenol in almond oil [6].

In our series, we only used 5% phenol in almond oil with 57% recurrence following one injection treatment. Thus our recurrence rate following treatment with injection of 5% phenol in almond oils is similar to the one reported in literature.

Surgical option is anal encirclement (Thiersch’s procedure) which consisted of placing a suture internally around the anus with the aim of providing mechanical support and preventing the rectal prolapse [4]. This procedure is advocated to be the possible management option when the prolapse is due to an anatomical defect or in case of persistence (Oeconomopoulos and Swenson, 1960). In their study, Flum et al. showed a success rate of 61% when performing initial Thiersch procedure [7]. It is crucial that the Thiersch suture is not placed too tight or too loose. In the first instance, the child might experience difficulty in passing stool whereas in the second case rectal prolapse could occur followed by ischemia as the portion of bowel is unable to reduce due to the anal suture [14].

In our series we only had one case in which the Thiersch suture was too tight leading to extreme constipation necessitating its removal under general anaesthesia. However, in this child spontaneous rectal prolapse resolution occurred without the need of further surgical intervention. Thiersch procedure combined with injection sclerotherapy has also been reported successful in two patients in a retrospective study [8]. In our series, the combination of these two procedures lead to effective results in 89% of the patients compared to 52.9% achieved following injection sclerotherapy alone. These differences in the results are statistically significant. None of our patients underwent isolated Thiersch procedure. Laparoscopic rectopexy is another technique to treat recurrent rectal prolapse where the rectum is sutured to the sacral promontory fascia [5]. This procedure had been shown to have a very low recurrence rate (5%) [5]. In our study, rectopexy was only required in one case as patient developed multiple recurrences following phenol injection.

Other invasive procedures described in the literature include the Thiersch anal encirclement [4], linear cauterization [16], and packing of the pre sacral space with various materials [17]. More invasive options described include: trans sacral rectopexy [18,19], trans-coccygeal rectopexy [20], posterior sagittal ano-rectoplasty [21], and perineal procto-sigmoidectomy (Altemeier procedure) [22]. If little is known about the optimal initial operative management for rectal prolapse, far less is known about the best management approach following failure of the primary operative procedure, with only cases of recurrence following failure of injection sclerotherapy [23] and linear cauterization [16] being reported.

Following failure to manage rectal prolapse conservatively, different surgical options may be implemented depending on the clinical case. Injection sclerotherapy is a common minimally invasive procedure used to treat rectal prolapse. Widely used surgical option is Thiersch’s procedure, which consisted of placing a suture internally around the anus with the aim of providing mechanical support and preventing the rectal prolapse [4]. It is a minimally invasive procedure and is used in the treatment of rectal prolapse and faecal incontinence [24]. It was first described in 1891 by the German surgeon, Karl Thiersch [25]. He surrounded the anus with a ring of silver wire. Since the first description of this method, numerous modifications have been made. In 1896 making four small incisions through the skin with a knife, 1 cm from the muco-cutaneous junction laterally, and using a Nylon No. 1 stitch to pass around the perianal space cutaneously modify the procedure. This aims to narrow the relaxed anal sphincter and cause proliferation to form adhesions with the surrounding tissues. The success of the operation is probably due to the fact that placed suture ringbring the sphincter and pelvic floor higher, giving the sphincter a chance to contract normally. This procedure is advocated to be the possible management option when the prolapse is due to an anatomical defect or in case of persistence rectal prolapse [4].

Flum et al. showed a success rate of 61% when performing initial Thiersch procedure [7]. It is crucial that the Thiersch suture is not placed too tight or too loose. In the first instance, the child might experience difficulty in passing stool whereas in the second case rectal prolapse could occur followed by ischemia as the portion of bowel is unable to reduce due to the anal suture [14]. There is little agreement about the best management of rectal prolapse recurrence following initial surgical procedure [7]. Repeated sclerotherapy injections or Thiersch procedures may show to eventually succeed in some cases. Furthermore, modified Thiersch procedure has also been demonstrated to manage cases of recurrence with good outcomes [7]. Injection sclerotherapy is said to yield a success rate between 67%. The Thiersch procedure has a reported outcome of 61% success rate.The two procedures combined have a higher success rate than when performed separately [26]. In our series one patient out of eleven (11%) developed recurrence following combined treatment. This child had the combined procedure repeated twice and on the second occasion he had 5% phenol injection with a modified Thiersch procedure which consisted of three concentric sutures: two sutures placed above the dentate line and one suture below it. This patient was followed up for two and a half years and did not develop any adverse outcome. To best of our knowledge this type of modified Thiersch procedure has never been previously reported in the paediatric literature.

When the surgical management of rectal prolapse failed after phenol injection and Thiersch suture most of the surgeons recommend doing rectopexy. It is a major surgical procedure to treat recurrent rectal prolapse where the rectum is sutured to the sacral promontory fascia [5]. This procedure had been shown to have a very low recurrence rate (5%) [5]. In our study, rectopexy was only required in one case as patient developed multiple recurrences following phenol injection, but there is new technique and surgical procedure just been introduced to do modified 3 suture Thiersch technique. One PDS 1/0 (absorbable) Thiersch suture was placed just above the anal canal and below the dentate line, a second 1/0 Prolene (non-absorbable) Thiersch suture was inserted above the dentate line and a third 1/0PDS (absorbable) Thiersch suture was placed about 3 cm above the dentate line. At the end of the procedure, a soft jelonet dressing was left in the rectum, which self-ejects. This technique showed an excellent outcome results [27]. One can use this technique instead of major surgical procedures like Altemeier or Delorme procedures, or rectopexy.

In the paediatric population, rectal prolapse is most commonly encountered before 4 years of age, with the highest incidence found in the first year of life. In our cohort, the median age at diagnosis was 4 years and there were more males than females affected by this condition. The decision to perform surgery for prolapse is generally based on the duration of conservative management, recurrence of symptoms and the overall severity of symptoms, including pain, rectal bleeding and perianal excoriation.

We studied the retrospective data of the patients having full thickness rectal prolapse over the last 5 years. In our series, we divided patients into two groups one having phenol injection only and other group had phenol and Thiersch suture for full thickness rectal prolapse. We have excluded two patients who had mucosal prolapse and required excision of mucosa in the first instant.Our patient population was affected with conditions associated with rectal prolapse, including constipation, which was most common, as well as, ano-rectal malformation, spina bifida, sacro-coccygeal teratoma and CF. These conditions have all been described in the literature to be associated with rectal prolapse in addition to diarrheal diseases, imperforate anus (post-repair), rectal polyps, and Ehlers–Danlos syndrome [28-29]. It is interesting to note that only one of the patients included in our study group carried a diagnosis of CF. A prevalence of 11.1% has been reported for CF in children with rectal prolapse, and the prevalence of rectal prolapse in CF patients has been estimated to be 18.5– 22.6% [30-31]. The observation that only one of our patients had an established diagnosis of CF, suggests that CF in more recent years is better managed, allowing successful treatment with medical therapy alone.

We analysed the data using Chi Square and p-value and got significant result supporting our conclusion and outcome. The patients with full thickness rectal prolapse having phenol injection only had higher incidence of re-occurrence rate as compared to our other group who had phenol as well as Thiersch suture done at the same time. Patients with phenol injection only had a re-occurrence rate of 57% as compared to our Thiersch group with re-occurrence rate of 11%. In our series we found that the children with failed medical management of rectal prolapse will be treated better with phenol injection and Thiersch suture at the same time. It will give better outcome results, less traumatic to the children and chances of having another surgical intervention involving general anaesthesia and traumatising the child and family will be avoided. In our series, the combination of these two procedures lead to effective success rate of 89% in the patients compared to 42.8% achieved following injection sclerotherapy alone. None of our patients underwent isolated Thiersch procedure. Finally, laxative regime post-surgery is important in order to avoid developing new onset of constipation and hence possible recurrence [15]. We always start laxatives post operatively for our patients treated with full thickness rectal prolapse and then slowly wean them off. There are other studies advocating the use of laxatives for post-operative constipation following rectal prolapse [32-33]. This could be explained by the fact that post-operative pain might prevent the child from passing stools leading to constipation. In addition, post-operative constipation, may also potentially lead to recurrence of the rectal prolapse due to excessive straining.

Finally, laxative regime post-surgery is important in order to avoid developing new onset of constipation and hence possible recurrence [15]. This could be explained by the fact that post-operative pain might prevent the child from passing stools leading to constipation. In addition, post-operative constipation, may also potentially lead to recurrence of the rectal prolapse due to excessive straining. In this series, 33% of those patients who received the combination of injection sclerotherapy and Thiersch suture, developed complications post-operatively and required management with laxatives.

Conclusion

In conclusion, combination of injection sclerotherapy and Thiersch procedure for the treatment of rectal prolapse in children demonstrated much lower recurrence rate in our study when compared to injection sclerotherapy alone. Post-operative laxative management is important in these patients as they can develop de novo constipation.

 

 

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Total Patients

 

23

Re-Occurrence

Re-do Phenol

Re-do Phenol and Thiersch

Rectopexy

Rectal Mucosa Excision

Outcome

Phenol Injection

14

8 (57.1%)

5

1

1

1

Good

Phenol Injection and Thiersch Suture

 

09

1 (11%)

0

1

0

0

Good