What is the role of injection sclerotherapy in the treatment of pediatric rectal prolapse?

Updated: Nov 12, 2018
  • Author: Jaime Shalkow, MD, FACS; Chief Editor: Carmen Cuffari, MD  more...
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Answer

Injection sclerotherapy is a valuable initial procedure. Success rates range from 90-100%. Sclerotherapy is cheaper and less invasive than surgery. It might be a good alternative in the management of rectal prolapse in patients with HIV/AIDS [50] or other poor surgical candidates. [51]

In spite of this, some pediatric surgeons are reluctant to inject sclerosing agents into a child’s anorectum, out of concern for possible induction of fibrosis and the potential long-term risk for carcinogenesis.

Injection can be done with phenol in oil, isotonic sodium chloride, D50, or ethyl alcohol, as a sclerosant to promote adhesion formation, which stabilizes the rectum; each of these materials has its advantages and complications. It elicits an inflammatory reaction in the submucosal and perirectal tissues, resulting in fibrosis, with subsequent cessation of the prolapse. It can be performed in an outpatient setting, with no need for bowel preparation.

The patient is placed in the lithotomy or left lateral position under general anesthesia. A 20-gauge spinal needle is introduced through the anal mucosa via a proctoscope or is externally introduced 2-3 cm from the anal margin, with a guiding finger in the anal canal, to a point several centimeters above the dentate line. The sclerosant is circumferentially injected into the submucosal and perirectal space as the needle is withdrawn. To prevent, necrosis, bleeding, or stenosis, care should be taken to avoid injecting the sclerosing agent into the mucosa.

Patients undergoing sclerosant injection are discharged the same day with simple analgesics and stool softeners.

The success rates and complications of the treatment reported in the literature differ for each sclerosing agent. Possible complications include injury to nerves, injury to surrounding tissue, and possible carcinogenic effects.

In Spain, Ibanez et al used fibrin adhesive in patients aged 1 month to 8 years [52] ; they reported no postinjection complications and found that adequate sclerosis was achieved in less than 24 hours.

In Egypt, Fahmy and Ezzelarab treated 130 children with rectal prolapse aged 6 months to 12 years, who underwent injection with 98% ethyl alcohol (group 1), phenol in almond oil 5% (group 2), or dextranomer and hyaluronic acid injectable gel (Deflux; group 3); they found that submucosal injection resulted in no mortality and varying morbidity. [53] Deflux had the lowest complication rate. Phenol in almond oil 5% had a high complication rate and should not be used. Alcohol is inexpensive and should be considered an alternative to Deflux.

Follow-up in this study was 2 months to 3 years. [53] In group 1, the recurrence rate was 11%; 2 patients had mucosal sloughing, and 1 girl developed a rectovaginal fistula. In group 2, 18% had abscesses and mucosal sloughing and 2 developed perianal fistula. In group 3, 2 patients had immediate postoperative prolapse that spontaneously resolved. No patients had mucosal ulceration or abscess formation, and none had recurrence on follow-up.

In Turkey, Abes and Sarihan used 15% saline solution as sclerosing agent in 16 children with rectal prolapse [40] ; they found that prolapse ceased in 93.7% of the patients after the first injection, only 1 patient required a second injection, and no complications occurred. The investigators concluded that 15% saline is preferred over other sclerosing agents because of a high cure rate, the safety of the procedure, ease of injection, and lack of complications.

Zganger et al published their 30-year experience in Croatia, using cow milk as a sclerosing agent. Their study included 86 children with rectal prolapse treated with cow milk injection sclerotherapy. Treatment was successful in 95.3% (82 children) of patients. They reported recurrent rectal prolapse in 4 (4.7%) patients, which subsequently underwent surgical treatment. Seventy-two percent of patients were younger than 4 years (62 children), whereas the remaining 24 patients were older (28%). Up to 3 applications may be needed. For children who needed operative treatment, the Thiersch procedure was performed without complications. They conclude that injection sclerotherapy with cow milk is a simple and effective treatment method for rectal prolapse in children, with minimal complications. [54]


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