Management of Rectal Prolapse in Children: Our Experience of Thiersch Stitch Procedure

Arshad Kamal, et al.
ORIGINAL ARTICLE
MANAGEMENT OF RECTAL PROLAPSE IN

CHILDREN: OUR EXPERIENCE
OF THIERSCH STITCH PROCEDURE
Arshad Kamal, Kifayat Khan, Mohammad Ayub Khan, Younis Khan,
Mohammad Uzair, Mohammad Tariq, Mamoon, Saddar Rahim
Mardan Medical Complex, Mardan, Pakistan
ABSTRACT
Background: Rectal prolapse is a common pediatric surgical problem with many treatment options. This
study was conducted to assess the outcome of Thiersch stitch in the management of rectal prolapse in
children.
Methodology: It was a descriptive study conducted at Department of Pediatric Surgery, Lady Reading
Hospital Peshawar from January 2003 to December 2008. Patients with complete rectal prolapse for more
than 3 months were included. Patients were admitted 24 hours before the procedure. Kleen enema was
given in the morning of operation. The procedure was performed under general anaesthesia. Vicryl size 1
was wrapped around the lower part of anal canal subcutaneously. Patients were discharged home on same
day on oral analgesics for a week and laxatives for a month. They were followed in outpatient department for
3 months and any complication was recorded.
Results: Sixty-five patients, 37 males and 28 females, with complete rectal prolapse were operated. Age
range was 2-8 years. No complication was seen during operation. Post-operatively painful defecation was
observed in all patients, wound infection in 36, scanty bleeding and diaper staining in 25, constipation in 20
and recurrent rectal prolapse in 6 patients.
Conclusion: Surgical treatment of rectal prolapse by Thiersch stitch is simple to perform and has less
complications.
KEY WORDS: Rectal prolapse, Thiersch stitch, Children.
INTRODUCTION
Rectal prolapse is defined as the herniation
of rectum through the anus.1 It is subdivided into
partial and complete prolapse. The term Procedentia refers to the complete variety.2 Rectal prolapse usually occurs at extremes of age. It is most
common at 3 to 5 years of age.3 Parents often
provide history of a dark red mass protruding
from the childs anus and the child usually is pain
free.4
Idiopathic rectal prolapse is seen in otherwise normal children.5 In our part of the world children with malnourishment and diarrhea frequently
present with rectal prolapse of various intensity.6
This sequel of events can be explained by the fact
that in early age the child tries to learn the balanced act of defecation. It is percieved that the
condition will improve over the period of time as
the child is taught how to defecate.7
Children with conditions such as rectal polyps, worm infestation, proctitis, ulcerative colitis,
Ehlers Danlos syndrome and cystic fibrosis may

also develop rectal prolapse.8,9 Rectal prolapse is
common in children with extrophy of bladder and
myelomenigocele, which are associated with
weakness of pelvic floor muscles or its innervations.10
Prolapse usually occurs during defecation or
crying. Failure to reduce the prolapse leads to
venous stasis, edema and ulceration. If it persists
for long time the bowel becomes edematous and
firm steady pressure for several minutes may be
necessary to reduce the swelling and allow reduction.11
If rectal prolapse recurs immediately reduction is again necessary and the buttocks strapped
together with a single band of adhesive tape for
several minutes.12
Most children with rectal prolapse do not
require any specific treatment. Treatment should
be directed at proper toilet training, treating constipation and eliminating any underlying cause
Gomal Journal of Medical Sciences July-December 2010, Vol. 8, No. 2
172
Thiersch stitch for rectal prolapse in children

such as gut worm infestation, diarrhea and rectal
polyp. Prolonged toilet sessions and straining at
stools should be discouraged.13,14
Historically, the correction of rectal prolapse
has evolved from simple perineal procedures like
Thiershs anal encirment to more complex perineal
procedures like Delorme, Altemer, perineal
rectosigmoidectomy with levatoplasty and abdominal aproaches ranging from suspension options with or without bowel resection and use of
slings and prosthetic material to restore rectal
anatomy and function. In the last decade,
laparoscopic repair has been successfully introduced and used in surgical treatment of rectal prolapse. Surgical intervention is reserved for children
in whom conservative measures fail. Children with
recurrence of rectal prolapse after injection sclerotherapy also require any other surgical treatment.15
This study was conducted to assess the outcome of Thiersch stitch in the management of rectal prolapse in children.
MATERIAL AND METHODS

It was a descriptive study conducted at Pediatric Surgery Unit, Lady Reading Hospital
Peshawar, from January 2003 to December 2008.
All patients having history of complete rectal
prolapse for more than 3 months were included
in this study. Patients with sphincter paralysis, cystic fibrosis and partial rectal prolapse were excluded.
Patients were admitted 24 hours before the
procedure. Patients underwent routine investigations like blood complete and screening for hepatitis. They were put on fluid oral diet 24 hours prior
to surgery. They received kleen enemas to mechanically washout the rectum.Vicryl size 1 was
the material used for applying Thiersch stich in all
patients.
RESULTS
A total of 65 patients with complete rectal
prolapse were operated during the study period.
Out of these 37 were males and 28 females. Age
range was 2 to 8 years.
Table 1: Age of patients at the time
of presentation.
S.
No
Age of patients
Number of patients
2-4 years
36
5-8 years
29
All the patients included in the study were

otherwise normal. Most of patients had history of
recurrent diarrhea or constipation. More than half
of the patients were malnourished.
All patients underwent surgery on elective list.
The hospital stay was one day. No anesthesia related complications occurred during this study.
All patients were followed periodically for 3 months
at outpatient department. No major complications
like myonecrosis were noted. However a few minor side effects like painful defecation was observed
in all patients, 36 patients had wound infection,
scanty bleeding and diaper staining was observed
in 25 patients. Twenty patients complained of constipation post-operatively while recurrent rectal
prolapse occurred in 6 patients.
Table 2: Complications encountered
during study.
S.
No.
Complication
Number of
patients
Painful defecation
65
Wound infection
36
Diaper staining
25
Constipation
20
Recurrence of rectal
prolapse
DICUSSION
Rectal prolapse is a common problem in children. It is usually self-limiting.16 Different options of
treatment are available but none of them are optimal or standard in pediatric age group.17 Management of rectal prolapse starts with conservative
measures like treating constipation, avoiding excessive straining at defecation, avoiding squatting position during defecation, proper toilet training and eliminating any precipitating factors like
malnourishment, diarrhea, rectal polyp, etc.18 There
is no consensus regarding the most effective surgical procedure for rectal prolapse.18,19 The ideal
surgical procedure for correction of rectal prolapse remain unknown despite more than a hundred procedures described so far.10-21 These procedures include abdominal procedures, trans-sacral fixation, injection sclerotherapy using different
substances and perennial procedures. The selection of surgical procedure depends upon many
factors like age, fitness for general anesthesia and
the presence of any other associated problem. In
adults the most commonly used procedures used
are trans-abdominal approach or resection and
or fixation of rectum to the sacrum.22 In chidren
173
Arshad Kamal, et al.

4.
Groff DB, Nagaraj HS. Rectal prolapse in infants

and children.Am J Colorectal Dis.2007; 22:
1561.
5.
Antao B, Bradly V, Roberts JP, Shawis R, Management of rectal prolapse in children. Dis colon Rectum 2005; 48: 1620-5.
6.
Saifekas C, Vottler TP, Anderson JM. Rectal prolapse in pediatric. Clin pediatr (phila) 1999; 38:
63-72.
7.
Ramachandran P, Vincent P, Prabhu S, Sridharan

S. Rectal prolapse of intussception: a single institution experience. Eur J Pediatrsurg 2006; 16:
420-2.
8.
Kabra SK, Kabra M, Lodha R, Shastri S, Ghosh

M, Panday RM, et al. Clinical profile and frequency of f508 mutation in Indian children with
cystic fibrosis. Indian Pediatr 2003; 40: 612-9.
9.
Van Heest, Jones S, Giacomantonio M. Rectal

prolapse in autistic children. J Pediatr Surg 2004;
39: 643-4.
Thiersch is a better option than sclerotherapy

as it is cost effective and the patient is exposed to
general anesthesia only once, unlike injection sclerotherapy which may need more than one session
to get the desired result. Secondly if recurrence of
rectal prolapsed occurs it can again be managed
by the same procedure.
10.
Lee Jl, Vogel AM, Sucher AM, Glynn L, Statter

MB, Liu DC. Sequential linear stapling technique
for perineal resection of intractable pediatric rectal prolapse. Am Surg 2006; 72: 1212-5.
11.
Batool T, Akhter J, Ahmad S. Management of

idiopathic rectal prolapse in children. J Coll Physicians Surg Pak 2005; 15: 628-30.
In our study the rate of recurrence of rectal

prolapsed was 6/65.In comparison to other studies done by Daulat Khan18 and Bashlr Ahmad27 regarding surgical management of rectal prolapse
through injection scletherapy the reccurence rate
had nearly same ratio.In another study done by
Sobaro CW regarding treatment of rectal prolapse
performing sacral rectopexy as the surgical procedure had recurrence rate of 2/28 and also creating a rectovaginal fistula in 1/28 patints during the
study
12.
Azeemuddink, Khubchandani TT, Rosen L,

Stasik JJ, Riether RD, Reed JF. Rectal prolapse:
A search for the best operation.Am Surg 2001;
67: 622-7.
13.
Brown AJ, Anderson JH, Mckee RF, Finlay IG.

Strategy for selection of type of operation for
rectal prolapse based on clinical criteria. Dis
Colon Rectum 2004; 47: 103-7.
14.
Khainga SO. Graciloplasty in treatment of recurrent complete rectal prolapse. East Afr Med
J 2007; 84: 398-400.
CONCLUSION
15.
Candela G, Grillo M, Compione M, Casaburi V,

Mashio A, Sciano D, et al. Complete rectal prolapse in patient with Hirschprung disease: a clinical case. G Chir 2003; 24: 289-94.
16.
Saunder S, Vural O, Unal M. Management of

rectal prolapse in children. Ekehorn rectopexy.
Pediatr Surg Int 1999; 15: 111-4.
17.
Hayashi S, Masuda H, Hayashi I, Sato H,

Takayama T. Simple technique for complete rectal prolapse using a circular stapler with Thiersch
procedure. Eur J Surg 2002; 168: 124-7.
18.
Khan D. An experience of management of rectal

prolapse in children. J Surg Pak 2008; 13:
33-5.
19.
Steele SR, Goetz LH, Minami S, Madoff RD,

Mellgren AF, Parker SC. Management of recurrent rectal prolapse outcome.Dis Colon Rectum
2006; 49: 440-5.
injection sclerotherapy is commonly employed

besides fixation of rectum to the sacrum,
laproscopic fixation of rectum and perineal procedure like Thiersch stitch procedure.23
In our study we used Thiersch stitch as the
surgical procedure for rectal prolapse in children.
This procedure was selected due to the fact that
rectal prolapse is common in our part of the world.
Thiersch procedure was described for the first time
in 1912. This study was conducted to emphasize
that this procedure is still effective in the management of rectal prolapse in children. No study has
been conducted in this part of the world to assess
its effectiveness regarding the management of rectal prolapse.
Thiersch stitch is recommended as a better
surgical option because it is technically simple to
perform, hospital stay is short, rapid healing and
less side effects. In our study there were no major
side effects like myonecrosis, etc.24
In conclusion Thiersch stitch is still a valid

and effective surgical option for the management
of rectal prolapse in children. It is simple to perform, inexpensive and safe in children.
REFERENCES
1.
lbanaz V, Gutierrez C, Garcia-sala C, Lluna J,

Barrious JE, Roca A, et al. The prolapse of rectum: treatment with fibrin adhesive. Cir
Pediattr1997; 10: 21-4.
2.
Gourgiotis S, Baratsis S, Buhr HJ. Rectal prolapse. Int J colorectal Dis.2007; 22: 1561.
3.
Shah A, Parikh D, Jawaheer G, Gomaal P.

Persistant rectal prolapse in children: sclerotherapy and surgical treatment. Pediatr Surg Int
2005; 21: 270-3.
174
Thiersch stitch for rectal prolapse in children

20.
Madiba TE, Baig MK, Wexner SD. Surgical management of rectal prolapse. Arch Surg 2005;
140: 63-73.
21.
Hachiro Y, Kunimoto M, Abe T, Kitada M, Ebisawa

Y. Aluminium potassium sulfate and tannic acid
injection in treatment of total rectal prolapse:
early outcomes. Dis Colon Rectum 2007; 50:
1996-2000.
22.
Raftopolous Y, Senafore AJ, DiGuro G,

Bergamaschi and rectal prolapse recurrence
group. Surgical options for complete rectal prolapse: a multicenter pooled anaylsis of 643 individual patient data. Dis Colon Rectum 2005;
48: 271-5.
23.
Koivu salo A, Parkernan M, Rintala R.

Laparoscopic suture rectopexy in the treatment
of persisting rectal prolapse in children; a preliminary report. Surg Endosc 2006; 20: 960-3.
24.
Saleem MM, AI-Momani H. Acute scroum as a

complication of Thiersch operation for rectal prolapse in a child. BMC Surg 2006, 28: 19.
25.
Gupta PJ.Combined Thiersch procedure

and subandromal coagulation for complete rec-
tal prolapse in elderly. Dig Surg 2006; 23:

146-49.
26.
Shoab SS, Saravanan B, Neminathan S, Garsaa

T. Thiersch repair of a spontaneous rupture of
rectal prolapse with eviceration of small bowl
through anus: a case report. Ann R Coll Surg
Engl 2007; 89: w6-w8.
27.
Bashir A, Roshan A. Management of rectal prolapse in children.. J Surg Pak 2009; 14: 116-9.
28.
Crlos WS, Desiderio RK, Sergio Cguilme C. Surgical treatment of rectal prolapse: experience
and late results with 51 patients. Med S Paulo
2004; 59: 168-71.
Coresponding author:
Dr. Arshad Kamal
District Pediatric Surgeon
Mardan Medical Complex
Mardan, KPK, Pakistan
E-mail: [email protected]
175

Management of Rectal Prolapse in Children: Our Experience of Thiersch Stitch Procedure

Uploaded by

Copyright:

Available Formats

Management of Rectal Prolapse in Children: Our Experience of Thiersch Stitch Procedure

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Management of Rectal Prolapse in Children: Our Experience of Thiersch Stitch Procedure

Uploaded by

Copyright:

Available Formats

Arshad Kamal, et al.

MANAGEMENT OF RECTAL PROLAPSE IN

Ehlers Danlos syndrome and cystic fibrosis may

Gomal Journal of Medical Sciences July-December 2010, Vol. 8, No. 2

Thiersch stitch for rectal prolapse in children

MATERIAL AND METHODS

All the patients included in the study were

Gomal Journal of Medical Sciences July-December 2010, Vol. 8, No. 2

Arshad Kamal, et al.

Groff DB, Nagaraj HS. Rectal prolapse in infants

Ramachandran P, Vincent P, Prabhu S, Sridharan

Kabra SK, Kabra M, Lodha R, Shastri S, Ghosh

Van Heest, Jones S, Giacomantonio M. Rectal

Thiersch is a better option than sclerotherapy

Lee Jl, Vogel AM, Sucher AM, Glynn L, Statter

Batool T, Akhter J, Ahmad S. Management of

In our study the rate of recurrence of rectal

Azeemuddink, Khubchandani TT, Rosen L,

Brown AJ, Anderson JH, Mckee RF, Finlay IG.

Candela G, Grillo M, Compione M, Casaburi V,

Saunder S, Vural O, Unal M. Management of

Hayashi S, Masuda H, Hayashi I, Sato H,

Khan D. An experience of management of rectal

Steele SR, Goetz LH, Minami S, Madoff RD,

injection sclerotherapy is commonly employed

In conclusion Thiersch stitch is still a valid

lbanaz V, Gutierrez C, Garcia-sala C, Lluna J,

Shah A, Parikh D, Jawaheer G, Gomaal P.

Gomal Journal of Medical Sciences July-December 2010, Vol. 8, No. 2

Thiersch stitch for rectal prolapse in children

Hachiro Y, Kunimoto M, Abe T, Kitada M, Ebisawa

Raftopolous Y, Senafore AJ, DiGuro G,

Koivu salo A, Parkernan M, Rintala R.

Saleem MM, AI-Momani H. Acute scroum as a

Gupta PJ.Combined Thiersch procedure

tal prolapse in elderly. Dig Surg 2006; 23:

Shoab SS, Saravanan B, Neminathan S, Garsaa

Gomal Journal of Medical Sciences July-December 2010, Vol. 8, No. 2

You might also like