Hey there, listeners. Did you miss our annual pediatric surgery update course? It's a virtual conference that we put on every year to talk about groundbreaking research, practice changing articles, guidelines. Well, don't worry, because you can watch it on our website, or You can listen to this podcast where I'm gonna break down our favorite sessions from years past. And we've got a lot of content that we can bring to you. So, enjoy what we're gonna call our update course, rewind. If you listened to last week's episode, Doctor Megan Durham talked us through a couple of interesting cases of Hirschsprung disease. Well, for this week, we're gonna talk about something else, rectal prolapse. So, I'm gonna talk a little bit about rectal prolapse. This is a relatively unusual problem, but we recently had two systematic reviews that came out. That's Doctor Eunice Huang from Children's Hospital at Vanderbilt. 3.5 year old male presents with episodic rectal prolapse, has had Several episodes of circumferential prolapse, um, that spontaneously reduced, but then recently the prolapse required manual reduction in the emergency room, which was what prompted the mother to seek further evaluation. So, think to yourself, how would you manage this patient? I think this is like a nightmare in clinic, honestly, this is the patient that no one wants to see, right? I mean, rectal prolapses. I it's very distressing to the patient and the family, and we don't really have a lot of, of great options. That's Doctor Beth Remey from Cincinnati Children's Hospital. If it's a patient that I've never met before, I typically will address, you know, concerns about the constipation first and sort of prove or disprove whether or not this patient is significantly constipated. Um, I think if they are constipated, that's like the easier patient to deal with, but every once in a while, you get a kid who is well managed on whatever their regimen is, and they're still prolapsing, and then I think the question is, what do you do? Well, first, let's go back and review some basics about rectal prolapse. So remember that by and large, majority of these do not need surgery, and similar to adults. The most common reasons are going to be things like constipation or sitting on the potty too long or sitting on it incorrectly. But there is a difference with kids. It, it happens in kids because of the anatomy of children. They have a very weak pelvic floor and the rectum is very low and so it tends to pop out easily if you strain hard enough. Now the physical exam is key here because you really want to make sure you distinguish. A rectal prolapse versus an intestusoception versus polyps, versus rectal hemorrhoids. And then, for most of these patients, your treatment is probably gonna be about the same. If you treat their constipation and teach them how to sit appropriately in the potty, so sometimes that actually entails getting them a smaller seat, so they're not falling through the, the toilet, and then also giving them a step so that they're sitting properly upright, and that they don't spend a lot of time on it. They're not getting an iPad where they're sitting there for half an hour straining. So a lot of medical management as far as managing constipation in the pediatric patient. But then there's also some teachable moments for the parents, because you want to show them how to safely reduce a prolapse to avoid any incarceration that this patient may be at risk for. So what if you have a patient, as Beth was talking about, who has been appropriately managed, there's no other medical issues associated with them, and then they have persistent problems. So let's take a 10 year old female who presents with chronic recurrent rectal prolapse despite medical therapy for constipation. So what would be the next best option for management? I've got a low threshold for starting with sclerotherapy because it's, it's simple, it's innocuous, and then sometimes they just need that head start, particularly in that last case with a younger kid. They just need that window of a couple of months to not have a prolapse, and then they start seeing it less frequently. That's Dr. Sean St. Peter from Children's Mercy Hospital in Kansas City, and here's his sclerotherapy recipe 5 ccs of Sotradechol and inject it in 4 quadrants and then If there's a little left in between. Sclerotherapy was definitely very popular with our audience, but there are so many options as far as surgical approaches if the sclerotherapy isn't very successful. That's when Doctor Huang tried to break it down a little bit with a publication from the Journal of Pediatric Surgery that is linked in the description. So, if you want to open it up, you can read along while she talks you through it. So recently, there was a systematic review that came out that looked at um um a conglomeration of publications. And so a couple of things I wanted to point out, there are 27 publications included and um it spanned, uh, uh, you know, obviously across the whole world in terms of all these publications. Um, there was, um, out of these 900 patients. 300 of them were vascular therapy and so you notice this there were 8 studies and only 3 sclerosclerosing agents involved. In the 600 patients that underwent operative management, there are 22 studies and 17 procedures. So anytime you see that large volume of procedures, you know that we're not exactly sure which is the best procedure for this, uh, for this pathology. So, um. Um, so if you look at in terms of actually operative procedures for this, um, there are many different options, but they do, um, have some, uh, fairly high success rate, um, and to Mark's point about the transabdominal procedures, what has been published have shown that they, they have pretty high success rate of being, um, um, correcting the, um, the, uh, prolapse. Now, if you are gonna use sclerotherapy, which sclerotherapy do you use? Doctor Huang had another JPS article for that. So there was a second publication also from JPS from 2019 that looked at just a uh a review of publications on skill therapy for rectal prolapse in children. I've linked that article as well, so you should be able to scroll down and open up the entire thing to read. When you do, you'll notice that the most popular slourishing agent is actually alcohol, and it's pretty effective too, if you continue to read through the article. Probably really easy to obtain in the hospital setting as well. But there's another reason that we should consider the sclerotherapy. And then the best part about using sclerotherapy as initial um procedure is that the complication rate is uh really mostly negligible and they're, they're acute and there's not really any, um, there's a very minimal risk of long-term problems with sclero therapy. Those two publications combined helped create a treatment algorithm that I've also attached to this podcast. So you can go ahead and open it up. So, if you have a patient with a rectal prolapse, you should rule out underlying diseases, especially cystic fibrosis, you should make sure that it is a rectal prolapse and not a polyp or a hemorrhoid or something else. If it's a small child that is in the potty training phase, certainly having appropriate management, medical management of, of how you'd, um, do potty training. Is appropriate, and, um, and then make sure they're not constipated and treat that appropriately. Now, if that fails, sclerotherapy is the recommended first option with ethyl alcohol. You can do that up to 3 times. There's an estimated cumulative success rate of a little bit over 80%, but if the patient fails that, then the next step is a laparoscopic rectopexy. That's the recommended operative approach, because it has the lowest complication rate. And the highest success rate. Now we're gonna change gears a little bit. Here is a new case presentation from Doctor Huang. 12 year old male presents with chronic recurrent rectal prolapse, refractory to medical therapy. He's seeing you for consideration of surgical treatment. He has also been diagnosed with depression and anxiety, which are being treated with medications. What should you inform his patient, his parents about this? The discussion with the parents. It can vary so much because there's so much that we want to talk to them about and inform them. Obviously, as surgeons, you know, the surgical expectations and the approach. But Doctor Huang was pointing at something else, behavioral therapy and physical therapy. And even addressing the psychology of rectal prolapse, because what you may find is these patients with rectal prolapse may necessitate a multidisciplinary team approach. Partially, it's, it's a feedback loop, so they are anxious, and they have uh rectal prolapse and it becomes this sort of um for one of my patients, it was sort of a an emotional release for her to actually prolapse herself and evacuate stool and so it was important that in addition to cleo therapy, I, I was able to help her, um, uh, support her through, through the, um, the, the anxiety component of that and the pelvic floor, um, Therapy was very useful in strengthening um the pelvic floor musculature such that once you perform the scope therapy, then uh they're likely to have a, a more durable outcome from that procedure. So there you have it, a condensed version of one of our favorite talks from the 2020 pediatric surgery update course. Did you find it useful? Or maybe this is a repeat for you because you were at our update course. Or maybe you missed it, you enjoyed this, and you wanna be a part of the 2021 update course. Well, mark your calendar, August 20th, there's gonna be more information on the event to come, and you can hear about it here, you can follow us on social media. But until next time, I'm Rod from Cincinnati Children's. Remember, knowledge should be free.
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