Same-Day Discharge and Quality of Life for Primary Laparoscopic Rectopexy for Rectal Prolapse in Children: A 10-Year Experience

Abstract

Introduction:

Rectal prolapse (RP) in pediatric patients may require surgical intervention. Varying surgical approaches and heterogenous patient populations have resulted in difficulty defining surgical outcomes and superiority of technique. We sought to review our surgical and self-reported outcomes of patients who underwent laparoscopic rectopexy for idiopathic RP.

Methods:

Records of children <18 years who underwent primary laparoscopic rectopexy between March 2009 and March 2019 were retrospectively reviewed. Patients with redo rectopexy were excluded. Demographics, pre- and postoperative treatment, and outcome data were collected and reported using descriptive statistics. Qualitative analysis of a quality of life (QoL) questionnaire administered to patients and parents 2–10 years postoperatively was performed.

Results:

Fifteen patients were included. Median age at surgery was 5 years (interquartile range [IQR] 3, 12.5); 60% were male and median weight was 22 kg (IQR 16.4, 39.2). Median length of stay was 6 hours (IQR 4, 22) with 9 (60%) discharged the same day. Perioperatively, 73% were on laxative for constipation, whereas only 33% were on laxative therapy at 6 months postrectopexy. Median follow-up was 19 months (IQR 8, 39). Three patients (20%) suffered recurrent RP (2 required redo rectopexy), and 2 patients self-limited urinary retention. Respondents to the QoL questionnaire indicated improvement in symptoms after surgery. No patient reported fecal incontinence, smearing, or leakage of stool.

Conclusion:

Laparoscopic rectopexy is a safe minimally invasive approach for children with idiopathic RP that offers high patient satisfaction with same-day discharge, early recovery, and low recurrence.

Introduction

Rectal prolapse (RP) is a common and often self-limiting problem in pediatric patients. It is primarily treated nonoperatively with a high-fiber diet, stool softeners, laxatives, and avoidance of prolonged straining, with a success rate of 28%–50%.^1–4 Patients who fail conservative management may require surgical treatment to control the recurrent or persistent RP.

Surgical treatment for RP varies based on age and surgeon preference with no clear practice patterns or consensus.⁵ Although there is no consensus on an optimal surgical approach and timing for RP, as the age of the child advances, more surgical therapy will be required to prevent recurrence.^4–6 Laparoscopic rectopexy for RP has demonstrated reduction in recurrence rate, reoperation rate, complication rates, hospital length of stay (LOS), and improvement in quality of life (QoL).^6,7–9 The LOS after laparoscopic rectopexy ranges from 1 to 8 days.^9–15 The population reported is often heterogenous for their underlying pathology. Although operative details have been documented, there are significant variations in follow-up in published literatures.^9,12,13,15 Therefore, there is limited evidence on long-term follow-ups after laparoscopic rectopexy.

Pediatric patients often present with concurrent constipation and additional vague bowel issues. Children who present with RP may suffer from decline in QoL, including problems with constipation and incontinence even after surgical correction. Therefore, the aim of this study is to review clinical and self-reported outcomes of patients who underwent outpatient laparoscopic rectopexy for idiopathic RP.

Materials and Methods

After approval by the Institutional Review Board (#00000644), a retrospective review of children between 0 and 17.9 years who underwent primary laparoscopic rectopexy between March 2009 and March 2019 was performed. All patients were initially managed medically and those who failed medical treatment underwent surgery for RP. Only patients who underwent primary laparoscopic rectopexy for RP were included. Patients were excluded from the study if they had an underlying pathology, which includes those with a redo laparoscopic rectopexy for recurrent RP, spina bifida/spinal differences, cloacal abnormalities, Hirschsprung's disease, and/or anorectal malformation. Redo rectopexies were excluded in an attempt to achieve a homogeneous study population and the majority of patients with redo rectopexy has underlying anorectal malformation, neurological problems, or Hirschsprung's disease with posterior sagittal rectopexy as a primary technique. Data collected included demographics, symptom characteristics, surgical procedures, pre- and postoperative treatments, and outcome variables.

Operative technique

Patient was prepped in the supine position. Umbilical access to the abdomen was gained using a 5 mm port. Pneumoperitoneum was obtained and the procedure was performed utilizing a 45° camera through 5 mm umbilical ports. Two 3-mm stab incisions in the lower lateral flanks were made under direct vision. Patient was placed in Trendelenburg position to move the bowel cephalad and free the pelvis. Sixty-seven percent of patients had a fourth instrument introduced through a 3-mm midabdominal stab incision used to mobilize the rectum cephalad during suturing. An important principle in this operation is to ensure low rectal mobilization up to the pelvic floor with careful dissection and preservation of blood vessels and nerves. Ensuring that mobilization was low was found to be the most helpful to be able to “hitch” up the redundant/prolapsing rectum. The peritoneal reflection was incised and the space posterior to the mesorectum was bluntly dissected up to where the rectum began to curve anteriorly (Fig. 1A). The redundant sigmoid was pulled up from the pelvis and the location of the sacral promontory was identified (Fig. 1B). While retracting the rectum cephalad, three silk sutures were placed through the seromuscular layer of the rectum and anchored to sacral promontory (Fig. 1C) to perform rectopexy (Fig. 1D). Variably, fibrin sealant (Tisseel by Baxter or Evicel by Ethicon) was injected posteriorly in the retrorectal area for hemostasis. The pneumoperitoneum was relieved, and the ports were removed.

FIG. 1.

Laparoscopic rectopexy. After laparoscopic port placement, the peritoneum is incised (arrow) (A). The dissection is continued to the pelvic floor (arrow) keeping the rectal mesentery intact (B). The colon is pulled to the sacral promontory (arrow) and sutures are placed (C). Completed laparoscopic rectopexy with sutures (D).

Quality of Life questionnaire

We administered 20-item QoL questionnaires to parents or legal guardians over the phone within 2–10 years after laparoscopic rectopexy. The survey QoL questionnaire (Appendix Table A1) was designed to allow parents/patient to express in detail some of the morbidities and QoL issues that patients suffer after laparoscopic rectopexy. The questionnaire was created to assess specific QoL measures for children with RP. To accomplish this, we utilized and incorporated many of the questions retrieved from validated tools such as Krickenbeck's pediatric fecal incontinence score.¹⁶ Two questions addressed how soon patient returned to normal school and normal activity after surgery. One question addressed any complication that required an emergency room visit, hospital, or another operation within 30 days of surgery. Three questions addressed RP recurrence and treatment for recurrence. Six questions addressed constipation after surgery, and its treatment. Six questions addressed fecal incontinence after surgery and its treatment, whereas three questions addressed patients/parents' satisfaction with laparoscopic rectopexy. The fecal incontinence questions in our QoL addressed presence of soiling in the underwear, which is one of the two major components of Krickenbeck's validated pediatric fecal incontinence score.¹⁶

Follow-up

Patients in our study were followed up in general surgery clinic between 2 and 10 years after primary surgery. During follow-up, patients and parents were interviewed for symptoms and patients were examined for recurrence.

Statistics

Data were analyzed using Stata Statistical Software: Release 15 (College Station, TX: StataCorp LLC). Results were reported using descriptive statistics. Continuous variables were reported in medians and interquartile range (IQR), whereas categorical variables were reported in percentages. QoL questionnaire responses were analyzed qualitatively and the responses in text forms grouped into categories.

Results

Demographics

Fifteen patients were included in the study. Sixty percent were male and the median age at surgery was 5 years (IQR 3, 12.5). Median weight at surgery was 22 (IQR 16.4, 39.2). Three patients (20%) had neuropsychiatric diagnosis (autism spectrum disorder in 2 and attention-deficit/hyperactivity disorder in 1). Eight patients (53%) reported chronic constipation requiring the use of laxatives, whereas 3 patients (20%) had chronic diarrhea presurgery. Preoperative workup included screening for cystic fibrosis with sweat chloride testing in 8 patients (53%), diagnostic colonoscopy in 7 patients (47%), sweat chloride testing and colonoscopy in 5 patients (33%), and consultation with a gastroenterologist in 13 patients (87%) (Table 1). The decisions for diagnostic workups in all the patients were made based on the clinical judgment of surgeons and gastroenterologists. All the diagnostic workups were negative before surgical intervention. Fifteen patients underwent laparoscopic rectopexy (2 patients (13%) underwent an additional procedure; excision of an ingrown toenail in 1 and excision of benign lymphangioma in the other). No patient underwent sigmoidopexy, resection, mesh placement, or levatorplasty.

Table 1.

Demographics, Comorbidities, and Preoperative Workup

Characteristic	n (%) or median (IQR)
Age (years)	5 (3, 12.5)
Gender
Male	11 (60)
Female	6 (40)
Weight (kg)	22 (16.4, 39.2)
Neuropsychiatric problems
Autism spectrum disorder	2 (13.3)
Attention-deficit/hyperactivity disorder	1 (7)
Preoperative symptom
Constipation	8 (53)
Diarrhea	3 (20)
Preoperative workup
Sweat chloride testing	8 (53)
Diagnostic colonoscopy	7 (47)
Gastroenterologist consultation	13 (87)

IQR, interquartile range; n, number.

Perioperative and long-term outcome

The median operative time was 64 minutes (IQR 52, 79). The median hospital LOS was 6 hours (IQR 4, 22), with 9 patients (60%) discharged the same day and 6 (40%) requiring an overnight stay. The median follow-up time was 19 months postoperatively (IQR 8, 39). Compared with 8 patients (53%) who took laxative preoperatively and 11 patients (73%) who were on laxative in the perioperative period, only 33% (5) patients were still on laxative therapy at 6 months after surgery; the other patients (10) 67% were either off laxatives or had no record of laxative use at 6 months follow-up.

The recurrence rate after laparoscopic rectopexy was 20% (n = 3). Of those with recurrence 2 had behavioral disorders, whereas the third patient was found to have a poor pelvic muscular tone and weak anal tone at operation. Recurrence occurred between 0.5 and 22.7 months after surgery. Two patients underwent redo laparoscopic rectopexy, whereas the third patient refused further procedures. Other complications observed postoperatively within our cohort include acute urinary retention in 2 patients that resolved without treatment.

QoL questionnaire

Five patients (33%) responded to the QoL questionnaire administered at a median 5 years (IQR 2, 8) after surgery. Four of the 5 patients reported fast recovering and quick return to school within 2 days and the 1 patient who returned to school later had unrelated medical problem. There was no complication that required return to the emergency room among all the respondents. Only 1 among the respondents reported constipation as a problem after laparoscopic rectopexy for RP with the rest and was using laxative as needed. No patients reported fecal incontinence, smearing, or leakage of stool. All respondents acknowledged improvement in previous symptoms and high satisfaction after surgery, including the 2 patients who had redo operations for recurrent RP (Table 2).

Table 2.

Summary of Responses to the Quality of Life Questionnaires

Questions	N = 5
Time from surgery to QoL survey (years)	5 (2–8)
Time to return to school
2 days	4 (80%)
>2 days	1 (20%)
Problem with constipation after first surgery
Utilizing further laxatives	1 (20%)
No further laxatives	2 (40%)
PRN stool softener	2 (40%)
Additional operations for with recurrent rectal prolapse or constipation?
Yes	2 (40%)
No	3 (60%)
Problems with rectal incontinence, smearing, or leakage?
Yes	0 (0%)
No	5 (100%)
Additional operation to deal with rectal incontinence, smearing, or leakage?
Yes	0 (0%)
No	5 (100%)
Overall, are you glad the first operation was done?	5 (100%)
Why? (qualitative comments)	“felt like it was definitely needed”
	“seemed to help”
	“doing better without RP”
	“fixed the problem and now back in school”
	“good experience”

Continuous variables are represented in median (IQR), whereas categorical variables are represented in frequency.

PRN, pro re nata/as needed; QoL, quality of life; RP, rectal prolapse.

Discussion

In this study, we describe a homogenous patient population who underwent primary laparoscopic rectopexy for idiopathic RP as an ambulatory procedure without prior bowel preparation. The majority of patients were discharged the same day with a median LOS after surgery of 6 hours. Patients who struggled with constipation preoperatively reported significant improvement in symptoms after surgery. Recurrence of RP while low was present in 20% (n = 3) patients. QoL questionnaires in pediatric patients were collected demonstrating overall improvement in symptoms after surgery with a high level of satisfaction among parents and no reported fecal incontinence, smearing, or leakage of stool.

Surgeons approach to repair of RP varies based on the age of the patient. The differences in surgical management of RP were further highlighted by a recent survey of active members of American Pediatric Surgical Association (APSA). Fifty-eight percent of APSA members who responded to the survey would treat a 2-year-old and 6-year-old differently compared with 40% who would treat both similarly.⁵ Invasive procedures and surgical repairs as an initial invasive treatment for RP are more likely to be offered to 6-year-old than to 2-year-old by APSA members.⁵ The median age at surgery in our series was 5.5 years (1QR 3, 12.5), consistent with the median age reported by many published articles.^6,7–9 These differences in practice pattern are not supported by strong evidence and, consequently, there is no consensus on surgical approaches to RP based on the age of patient. Transabdominal rectopexy was the most common technique utilized after failed medical therapies among surveyed APSA members. Although the survey did not clarify if the transabdominal rectopexy was open or laparoscopic, if bowel was resected or if mesh versus suture was used for the rectopexy but judging from current trend in literature, many centers are reporting laparoscopic rectopexy for RP.⁶ Furthermore, within the past decades, several retrospective studies had reported excellent results with laparoscopic suture rectopexy in the pediatric population.^6,8,9

The short LOS, low recurrence rate, and minor complications observed are consistent with a recent systemic review and several other retrospective studies where laparoscopic rectopexy was shown to be safe and efficacious.^6,9–11 The median LOS after surgery in our series was 6 hours (IQR 2, 22) with 60% of patients discharged the same day. Compared with postoperative LOS between 2 and 5 days in majority of published studies, our series demonstrated a shorter LOS.^9,10,14,15 Our recurrence rate in this homogenous population was 20% (3 patients), which is consistent with previously published recurrence rate for laparoscopic rectopexy, which ranges between 0% and 15%.^9–11,13 Higher recurrence rate (35%–70%) has been reported for other surgical techniques, specifically for the posterior sagittal rectopexy technique that was the predominant technique in our institution before laparoscopic rectopexy.^4,8 Two of the patients who had redo rectopexy had complete resolution of the RP, whereas the third patient refused further surgical intervention and opted for conservative management.

Long-term follow-up and QoL tracking is difficult for children with acute issues that do not require long-term follow-up but are at risk for recurrence. The patients in our series were followed up in surgery clinic for a median duration of 19 months (IQR, 8, 39). Our series had a longer phone follow-up with median duration of 5.5 years (IQR 1, 10).^8,9,13–15 The phone follow-up is an attempt to reach patients who might have been lost to follow-up after a move, receiving care in a different local hospital system or transitioned into adult clinic.

Same-day discharge after laparoscopic rectopexy is a paradigm shift from lengthy postoperative inpatient stays awaiting bowel function. In our series, 60% of patients were discharged the same day without readmission for surgery-related complications, demonstrating that same-day discharge after laparoscopic rectopexy is feasible and safe. In addition, there is an implication of cost reduction benefit in the overall hospital charge for patients who were discharged the same day. In a single institution study, 19 pediatric patients who underwent laparoscopic suture rectopexy for RP were retrospectively reviewed, 9 patients (47%), of the total patients reviewed, were discharged the same day after surgery.¹³ This study appears to be in the minority as most literatures on laparoscopic rectopexy report a postoperative LOS ranging from 2 to 5 days.^10,14,15

Laparoscopic rectopexy survey response rates are consistent with previously reported proportion of survey response rates. Although our response rate was low, the response rate is consistent with previously reported adult QoL for RP of 42% response rate.¹⁷ Our QoL survey yielded self-reported outcomes and provided the parents/patients the freedom to explain in their own words their satisfaction with the procedure, the ability to return to school, and identify any issues with constipation or incontinence. Of surveyed patient, all but 1 respondent reported resolution of chronic constipation with no need for routine laxative, although four patients reported occasional use of laxatives as needed. Our positive reported results are in contrast with an adult retrospective study reporting nonsignificant increased fecal incontinence through the Cleveland Clinic Incontinence Score (CCIS) in patient assessment of constipation-quality of life scores both pre- and postlaparoscopic rectopexy.^18,19 The lack of fecal incontinence in our series is consistent with other single institutional retrospective review that reported improved continence after transabdominal rectopexy.¹⁷

Our study recorded high satisfaction with the surgery among respondents, including the 2 respondents whose children underwent redo laparoscopic rectopexy for recurrent RP. Parents were happy and reported quick recovery with return to school 2–3 days after surgery except for 1 patient who did not return to school until the next school next year because of other unrelated health problems. Thus, our patients reported improved QoL and quick recovery after laparoscopic rectopexy for RP.

Limitations of this study include those inherent with a retrospective design. The long-term follow-up was variable, with only 33% of patients able to be contacted for the phone questionnaire. With a small sample size, it is difficult to identify if any difference that is statistically significant. Our survey was created to incorporate QoL and qualitative metrics but lacked the traditional validated scoring of the fecal incontinence or PedQoL.

Conclusion

We have demonstrated that laparoscopic rectopexy has a low recurrence rate and complication profile, and can be performed as a primary surgical procedure with same-day discharge for pediatric patients with idiopathic RP. Furthermore, patients report high satisfaction and resolution of symptoms postoperatively.

Footnotes

Authors' Contributions

O.O., R.M.D., and R.M.R. equally contributed to the conception and design of the study. O.O., R.M.D., C.D., W.J.S., and R.M.R. contributed to acquisition of data. O.O., R.M.D., C.D., W.J.S., R.M.R., J.D.F., P.A., T.A.O., and . contributed to analysis and interpretation of data and O.O. drafted the article. All authors critically revised the article, agree to be fully accountable for ensuring the integrity and accuracy of study, and read and approved the final article.

Disclosure Statement

No competing financial interests exist.

Funding Information

The authors have no sources of funding or funding agencies to disclose.

Appendix Table A1.

Quality of Life Questionnaires

1. Study ID

2. Date and time of phone survey

3. Are you willing to participate in this survey? Yes/no

4. Do you remember how soon you/[patient name] were able to return to school or work? Specify_

5. Did you/[patient name] have any complications that required an ER visit, a hospital stay, or another operation?

6. Did your/[patient name]'s rectal prolapse come back again?

7. If yes to #6 question, how was it treated?

8. Did you/[patient name] have problems with constipation soon after the operation?

9. If yes to #8 question, how was it treated?

10. Do you [patient name] still have problems with constipation now?

11. If yes to #8 question, how was it being treated?

12. Did you/[patient name] require any additional operations to deal with rectal prolapse or constipation?

13. If yes to #12 question, when and where?

14. Did you/[patient name] have problems with rectal incontinence, smearing, or leakage soon after the operation?

15. If yes to #14 question, how was it treated?

16. Do you [patient name] now have problems with rectal incontinence, smearing, or leakage now?

17. If yes to #16 question, how was it treated?

18. Did you/[patient name] require any additional operations to deal with rectal incontinence, smearing, or leakage?

19. If yes to #18, where and when?

20. Overall, are you glad the first operation was done? (yes/no/unsure)

21. Explain why to #20 question response

22. Do you have any other comments about the operation or its results you would like to share?

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