Influence of Initial Treatment Strategy on Outcomes for Children With Rectal Prolapse
Lorena Rincon-Cruz, Heather Riley, Nicole Wynne, Belinda Dickie, Prathima Nandivada
Surgery, Boston Children's Hospital, Boston, Massachusetts, United States
OBJECTIVE
Pediatric rectal prolapse is a common and often self-limited condition with multiple management options. The aim of this retrospective review was to analyze our center's practice patterns as well as evaluate the likelihood of success of the approach offered based on patient factors identified at initial surgical consultation.
DESIGN
Retrospective case series; duration of follow-up was from initial presentation for surgical evaluation (as early as 2010) to 2021, at the time of data collection. Multivariable logistic regression was used to compare initial treatment strategies
SETTING
Tertiary referral center for pediatric colorectal disease
PATIENTS
118 children with rectal prolapse underwent surgical evaluation at our institution from 2010-2021. Children with anorectal malformations and Hirschsprung disease were excluded. A total of 67 children were included in the study.
39% (n=26/67) were female and 61% (n=41/67) were male
Age distribution was from 1 to 22 years of age; 40.3% (n=27/67) were under the age of 5.
36% (n=24/67) had diagnosis of a comorbid psychiatric disease.
INTERVENTIONS
We compare medical management (n=29/67), sclerotherapy (n=24/67), and surgical correction (n=14/67) - either rectopexy or transanal resection - as initial treatment strategies.
MAIN OUTCOME MEASURE
Resolution of rectal prolapse
RESULTS
Younger patients (<5 years) were more likely to be treated initially with medical management alone (p <0.001), and none of those children ultimately required a procedure. Patients with a psychiatric diagnosis were more likely to be offered either sclerotherapy or surgery upfront (p=0.009).
The observed rate of resolution with surgery as initial management was 79% (n=11/14) and the rate of resolution 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 surgical procedure was performed (p=0.011). Patients who had 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 after controlling for severity, psych diagnosis, use of manual reduction, and age. 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) resulted in resolution of rectal prolapse in most children (63%). Additionally, surgery as an initial management approach had a significantly higher success rate compared to sclerotherapy, even after controlling for severity of disease, psychiatric diagnosis, need for manual reduction, and age.
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