Our Experience in Management of Complete Rectal Prolapse in Children by Delorme Procedure

Transcription

1 Med. J. Cairo Univ., Vol. 84, No. 1, December: , Our Experience in Management of Complete Rectal Prolapse in Children by Delorme Procedure MOHAMED E. ERAKI, M.D. The Department of Pediatric Surgery, Zagazig Faculty of Medicine, Zagazig University, Egypt Abstract Aim of the Work: The aim of the work is to study the functional and surgical outcome of Delorme procedure for the management of complete rectal prolapse in children at the Pediatric Surgery Department, Zagazig University Hospitals. Patients and Methods: This study was done on the records of 46 patients with complete rectal prolapse with a mean age of 7 to 15 years in Pediatric Surgery Unit, Faculty of medicine Zagazig University Hospitals in the period between 2010 to We used Fecal incontinence severity index (FISI) and Fecal Incontinence Quality of life (FIQL) questionnaires to evaluate the severity of the condition and impact on quality of life (QOL). The primary outcome was defined as complete recovery of continence, and partial recovery was defined as improvement in either type or frequency of incontinence or both. Recurrence was defined as recurrent incontinence after complete recovery. The secondary outcome was defined as change in the impact of incontinence on patients quality of life as assessed by the (FIQL). Results: The mean operative time was 50 to 70min, the mean time until the first oral intake was 8 to 12h, and the mean post operative hospital stay was 36 to 48h. Surgical repair of rectal prolapse by Delorme procedure showed a favorable outcome in the form of significantly higher postoperative scores of individual items of the (FIQL) questionnaire, with a significant higher post operative total (FIQL) compared with pre operative scores.throughout the follow-up duration of 2 years, 30 patients (65.2%) showed complete recovery, 10 patients (21.7%) showed only partial improvement and 6 patients (13.04%) developed recurrence of gas incontinence 6 months after the disappearance of his incontinence. Conclusion: The management of complete rectal prolapse by Delorme procedure is safe and effective with high rate of complete recovery and improvement of continence and fecal impaction with increase quality of life scores. Key Words: FIQL FISI Complete rectal prolapse in children Delorme procedure. Introduction RECTAL prolapse in childhood was first described in 1939 by Lockhart-Mummery [1] who attribute Correspondence to: Dr. Mohamed E. Eraki, The Department of Pediatric Surgery, Zagazig Faculty of Medicine, Egypt it to malnutrition and careless nursing of the child, but also diarrheal and wasting illnesses as a contributing factors. Rectal prolapse in children is a relatively common benign disorder. However, without proper management it can become a lifestyle-limiting, chronic condition [2]. Most cases are self-limiting, characterized by prompt resolution with institution of conservative measures and correcting the associated underlying problems. Rectal prolapse may be partial or complete, complete prolapse (full thickness) represents a protrusion of the entire layer of the rectum to outside of the anus and thus, shows concentric folds. Partial or incomplete rectal prolapsed is the one which the rectal mucosa only prolapsed and it should be differentiated from complete rectal prolapse and the management are different [3]. The classification of rectal prolapse was described by Altemeier et al., 1971 [4]. Type I: Protrusion of rectal mucosa termed false prolapse,its usually associated with haemorrhoids. Type II: Intussusception without sliding hernia, it occupies the rectal ampulla but does not continue through the anal canal; the most common symptom is fecal incontinence, but solitary ulcers in the anterior rectal mucosa can be seen. Type III: Complete rectal prolapse, including full thickness rectal wall prolapse and this the most frequent type. Management of complete rectal prolapse is still a matter of debate in terms of choice of the type of surgical approach. The perineal approach provided multiple advantages over the abdominal approach including the feasibility of using spinal anesthesia or even local anesthesia, early oral feeding, and patient comfort, with little or no postoperative pain, and thus short hospital stay 1357

2 1358 Our Experience in Management of Complete Rectal Prolapse in Children [5,6]. Moreover, the perineal approach did not lead to risks of injury of pelvic or hypogastric nerves causing erection or ejaculatory problems in males [7], and the possibility of pelvic adhesions that may affect ovaries and tubes and cause secondary infertility in females patients [8]. The Delormethiersch procedure has a less risk of complications in patients of any age or risk category, especially for low-risk patients, patients with constipation or evacuation difficulties, young males, and in patients with symptomatic hemorrhoids or mucosal prolapse [9]. The current study evaluate our experience in management of complete rectal prolapse using Delorme procedure at the Pediatric Surgery Department, Zagazig University Hospitals. Patients and Methods This study was done on the records of 46 patients with complete rectal prolapse, the main age of the patients range from 7 to 15 years, at the Pediatric Surgery Department, Faculty of Medicine, Zagazig University Hospitals. From to 2013, and we allowed 6 months follow-up period for the last operated case. After approval of the study protocol and written fully informed parental consent, patients with complete rectal prolapse or recurrent after conservative management were included in this study. All patients in this study were subjected to, taking history of straining during defecation, history of constipation, fecal incontinence, and previous surgery, full laboratory investigations, proctoscopy and colonoscopy and radiological investigations including barium enema and defecation proctography. Parents of enrolled young children and patients who could answer the questions were asked to complete the fecal incontinence severity index (FISI), and the fecal incontinence quality of life (FIQL) questionnaires. The FISI questions evaluate the frequency of incontinence for bowel leakage and we divided the bowel leakage into four types, gas, mucus, liquid stool or solid stool. The severity of leakage was graded into six points, 0: never leakage, 1: 1-3 times leakage per month, 2: leakage once aweek, 3: more than 2 times leakage per week, 4: leakage once daily, 5: more than 2 times per day. Then we calculated the total FISI score, a higher score indicated greater severity, in which 1 means less severe condition, and 20 most severe condition [10]. The FIQL questionnaire included four items, life style (10 items), behavior (9 items), depression/self-perception (7 items), and embarrassment (3 items). Each item was graded on a four points scale: 1: most of the time, 2: some of the time, 3: a little of the time, and 4: never. For calculation of the total FIQL score, a higher score indicated lower severity of the impact of incontinence on patients quality of life [11]. All patients were subjected to preoperative bowel preparation, with intravenous prophylactic antibiotics and general anesthesia. Urinary catheterization was performed. With the patients in the lithotomy position, the prolapsed rectum was identified and pulled down with Babcock forceps so that the redundant rectal wall was taken into the prolapsed segment, adrenaline (1/200000) in normal saline was injected in to the sub mucosal layer above the dentate line to reduce bleeding and define the plane of dissection. A circumferential incision was performed in the rectal mucosa at 1-1.5cm proximal to dentate line to preserve the sensitive area of rectal mucosa and to simplify anastomosis. A plane of dissection between the mucosa and the internal sphincter and circular muscle of the rectum was developed, and a sleeve of mucosa was plicated longitudinally in the four quadrants with 2/0 absorbable sutures starting at the apex of the dissection and continuing down to the distal cut edge of the mucosa in the anal canal. Additional sutures were placed in between for a total 8 sutures to plicate rectal muscle on tightening the sutures. Excess mucosa was excised and an interrupted mucosa to mucosa anastomosis with 3/0 absorbable sutures was performed. Immediate postoperative care included an intramuscular injection of non steroidal anti inflammatory analgesia, intravenous antibiotic and intravenous fluid therapy until oral intake start. The urinary catheter was removed on the first post operative day. And oral antibiotics started once oral intake start. Mild laxative was administrated for 2 weeks post operative to avoid straining during defecation. Outcome: The primary outcome was defined as complete recovery of continence; partial improvement was defined as improvement in either the type or the frequency of incontinence, or both. Recurrence was defined as complaint of recurrent incontinence after complete recovery; the secondary outcome was defined as a change in the impact of incontinence on patients QOL as assessed by the FIQL questionnaire. Statistical analysis: The data were presented as mean ±SD, ranges, numbers, and ratio. Results were analyzed using the X2-test and the paired t-test. Statistical analysis was carried out using the SPSS for windows statistical package p-value less than 0.05 was considered statistically significant.

3 Mohamed E. Eraki 1359 Results Our study done included 46 patients with complete rectal prolapse, 30 males and 16 females, mean age at presentation from 7 to 15 years. In which the number of patients from 7-10 years was 20 (43.5%) with mean 6.2 (7-9) years. And the number of patients from years was 26 (56.5%) with mean 13.6 (12-14) years. The weight of the studied group range from 10-40kg with mean (25±5), all patients subjected to conservative management before surgery in which all the studied group not responding to conservative management, 10 patients (21%) had a previous history of surgical interference for the same problem (Table 1). Table (1): Patients characteristics. Data Sex: Males 30 Females 16 Findings Age: (43.5%) 6.2 (7=9) (56.5%) 13.6 (12-14) Total (7-15) 8.5 (7-15) Weight (kg) 25 ±5 (10-40) Conservative management 46 (100%) Previous surgical interference 10 (21%) All studied patients had intra operative course without excessive bleeding or injury to the rectal muscle layer. The mean operative time in all groups was (70±5) and range from (40-90) minutes, the operative time was less than 60 minutes in 21 (45.6%) patients with mean (45 ±5) and range from minutes, and operative time was more than 60 minutes in 25 (54.4%) patients, with mean 65 ±5 and range minutes. The mean length of excised mucosal sleeve was 13 ±3cm and range from (12-19) cm, the length of excised mucosa was less than 15cm in 30 (65.2%) patients with mean 13±2 and range from (12-15) cm, and the length of excised mucosa was more than 15cm in 16 (34.8%) patients with mean 16 ±2 and range (16-19) cm. The mean time for first oral intake post operative was 9 ± 1h, with range from (4-18) hours, and the first oral intake started in 16 (34.8%) patients in less than 6h with mean 5 ± 1 and ranged from (4-6) h and was 6-11h in 20 (43.5%) patients with mean 8±2 and ranged from (7-11) h, and the oral intake started after 12 hours in 10 (21.7%) patients with mean 13 ± 1h and ranged from (12-18) hours. The mean hospital stay in all studied groups was 30±5 hours and ranged from (24-48) hours. Hospital stay was 24 hours in 36 (78.3%) patients and was 48 hours in 10 (21.7%) patients (Table 2). Table (2): Operative and postoperative data. Data Start of oral intake (h): Less than 6: From 6-11: Findings Operative time (minutes): Less than 60: 21 (45.6%) 45±5 (40-55) More than 60: 25 (54.4%) 65±5 (60-90) Total 70±5 (40-90) Length of excised segment (cm): Less than 15: 30 (65.2%) 13±2 (12-15) More than 15: 16 (34.8%) 16±2 (16-19) Total 16±3 (12-19) 16 (34.8%) 5± 1 (4-6) 20 (43.5%) 8±2 (7-11) More than 12h: 10 (21.7%) 13±2 (12-18) Total 9± 1 (4-18h) Hospital stay: 24h 36 (78.3%) 28h 10 (21.7%) Total 30±5 (24-48) Data are presented as mean ± SD and numbers: Ranges and percentage are in parentheses. Functional evaluation was performed using FISI questionnaire, and all patients showed improvement in their complaints; however 2 patients still had gas incontinence, 4 had mucous incontinence, and 8 patients had mucus and liquid stool incontinence, with the persistence of incontinence in 19%. 3 patients developed recurrence of gas incontinence 6 months after the disappearance of his incontinence, with recurrence rate of 6.5% we compared pre operative and post operative fecal incontinence severity index, in which we found that there is a significant improvement in post operative fecal incontinence severity index. In the mean pre operative total fecal incontinence severity

4 1360 Our Experience in Management of Complete Rectal Prolapse in Children index was 15 ±2.1 compared to mean post operative total fecal incontinence severity index 0.3 ±0.5 with p-value (Table 3). Rectal incontinence had an adverse impact on patient quality of life, in which when rectal incontinence score decrease the score of quality of life increase, in our study we compared pre operative and post operative quality of life score, we found that there was significant difference between the pre operative and post operative quality of life score, the mean total post operative score was 96.2±6.8, and the mean total pre operative score was 60±8.7, with p-value (Table 4). Follow-up was done post operative, in which follow-up was less than 12 months in 2 (4.3%) patients, and was from 12 to 24 months in 25 (54.3%) with mean 20±2 (14-24), and follow-up was from 24 to 36 months in 15 (32.6%) patients with mean 26±2 (25-35), and was more than 36 months in 4 (8.7%) patients with mean 38 ± 1 (36-40). In our study complete recovery was observed in 30 (65.2%) patients in which there was no incontinence, partial recovery was observed in 10 (21.7%) patients in which the patients has incontinence to mucus and liquid stool, and recurrence was observed in 6 (13.04) patients, in which the patients developed incontinence to gases after period of complete recovery (Table 5). Table (3): Fecal incontinence severity index, pre operative and operative score. Pre-operative Post-operative p-value Gases 8± ± Mucus 6.9± ± Liquid stool 5± ± Solid stool 4.2± Total 15± ± Data are presented as mean ± SD. Table (4): pre operative and post operative score of quality of life. Pre-operative Post-operative p-value Life style 26± ± Coping/behavior 16± ± Depression/self perception 12± ± Embarrassment 5.5± ± Total 60± ± Data are presented as mean ± SD. Table (5): Follow-up data. Follow-up data (month) Findings Less than 12m: 2 (4.3%) 6m 12-24m: 24-36m: More than 36m: Total Complete recovery Partial recovery Recurrence 25 (54.3%) 20±2 (14-24) 15 (32.6%) 26±2 (25-35) 4 (8.7%) 38± 1 (36-40) 25.7± (6-40) 30 (65.2%) 10 (21.7%) 6 (13.04%) Data presented as mean ± SD and number, ranges and percentages are in parentheses Discussion In our study we evaluated surgical and functional outcome of the studied patients with complete rectal prolapse, treated with Delorme procedure. All patients had uneventful intra operative course without excessive bleeding during mucosal dissection or injury to the rectal muscle, so there was no additional morbidities. There is multiple advantage of Delorme procedure including short operative time (70±5min), early resumption of oral feeding (9± 1h), and little post operative analgesia which provided more patients and parents comfort, and short duration of post operative stay (30 ±5h), these advantages of Delorme procedure make the procedure a safe perineal approach for correction of complete rectal prolapse in children. Riansuwan et al. [12] retrospectively studied 177 patients who underwent abdominal or perineal repair for complete rectal prolaspe and found that patients undergoing perinael repair had less procedural blood loss, operative time, hospital stay, and dietary restriction. Another study by Lee et al. [13], retrospectively studied 104 patients with complete rectal prolapse who underwent abdominal or perineal repair, found that the abdominal group had significantly longer operative times and post operative hospital stay than perineal repair group. Our results with Delorme procedure are in agreement with those of Pascual Montero et al. [14] who documented that Dlerome procedure for the repair of complete rectal prolapse is associated with low morbidity, improve rectal incontinence, gives rise to no post operative constipation, and has an acceptable relapse rate with high patients satisfaction because of it is intradural anesthesia, short hospital stay and little post operative pain and optimal

5 Mohamed E. Eraki 1361 results, and this study agree with our study. Leiebeth et al. [15] reported that most pre operative evaculatory symptoms resolve with repair of rectal prolapse in children and serious complications are uncommon after Delorme operation, and the recurrence rate and complication rate were lower in medically fit children and he suggested that Delorme procedure is more convenient for younger and fit children than for adult patients. Another study was done by Mahmoud et al. [16], in which 37 patients with complete rectal prolapse were operated by Delorme procedure and reported a mean operative time of min, no mortality, and minimal blood loss, with a mean hospital stay of 3.5 days, and this study matches with our study, but in our study the mean operative time was longer than this study but the total hospital stay in our study was 1 to 2 days. Functionally, all studied patients showed improvement in their quality of life, as they had significantly higher Fecal incontinence quality of life score determined 6 months post operative compared with their pre operative scores, these data show the adverse impact of rectal incontinence on patients Quality of life and psychological status and this means that, surgical correction can alleviate the adverse effects of rectal prolapse. Surgical correction of complete rectal prolapse improves quality of patient s life irrespective to the type of surgical procedures. Kairaluoma M.V. et al. [17] reported significantly improved of quality of life after laparoscopic sacrocolporectopexy procedure D Hoore A. et al. [18] reported that if rectal prolapsed was left untreated this pathology markedly alter the patient Quality of life for the worse; in which surgical correction is necessary for each patients. In our study complete recovery was observed in 30 (65.2%) patients in which there is no incontinence, partial recovery was observed in 10 (21.7%) patients in which the patients has incontinence to mucus and liquid stool, and recurrence was observed in 6 (13.04) patients, in which the patients developed incontinence to gases after period of complete recovery. The reported improvement rates are in agreement with previous studies that evaluate the outcome of Delorme s procedure. Joshi et al. [19] reported that of 11 patients who were incontinent pre operatively and underwent Delorme procedure, seven patients became fully continent (63/6%), two patients (18.2%) showed partial improvement, and two patients (18.2%) showed no response. Hill S.R. et al. [20] studied 19 patients who had undergone Delorme s procedure for complete rectal prolapse correction and found that three patients (15.8%) reported rectal prolapse recurrence and functional outcome eval- uated in 16 patients indicated that 5 (31.3%) of these 16 patients reported improved continence, seven patients (43/7%) recovered completely from incontinence, and in 4 patients, incontinence remained unchanged. Conclusion: From our study, Delorme procedure is safe and effective methods for treatment of complete rectal prolapse in children with high complete recovery rate with improvement of patients Quality of life and incontinence. References 1- LOCKHART-MUMMEY J.P.: Surgical procedures in general practice. Br. Med. J., 1: 345-7, YOON S.G.: Rectal prolapsed: Review according to the personal experience. J. Korean Soc. Coloproctol., 27: , FOX A., TIETZE P.H. and RAMAKRISHNAN K.: Anorectal conditions: Rectal prolapse. 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