| Abstract|| |
A handmade snare is designed from easily available materials to treat bleeding per rectum in children due to rectosigmoid polyps. A total of 29 polypectomies were done in 24 patients. It is simple, effective, safe and economic.
Keywords: Bleeding per rectum, children, juvenile polyp, snare polypectomy
|How to cite this article:|
Saha M. Recto-sigmoid polypectomy by a handmade snare: Experience of 24 children with bleeding per rectum. Afr J Paediatr Surg 2014;11:91-2
| Introduction|| |
Most common cause of bleeding per rectum in children is colorectal polyps. Literature review and our own experience suggest that most of these polyps are solitary and usually located at rectosigmoid region. I designed a simple device to remove these rectosigmoid polyps.
| Materials and Methods|| |
Twenty-four patients with rectosigmoid polyps were treated. Diagnosis was made by history and digital rectal examination. Rectum was evacuated by enema 2 hours before the procedure. Procedure was performed under short acting intravenous anaesthesia (Propofol). A handmade snare was designed from the left over sheath of an Ethicon-endoloop ® or similar non-conducting synthetic tube. Copper wire is retrieved from household flexible electrical wiring system. The copper wire is inserted into the plastic tube with a loop protruding out on one side and the free ends on the other side. The loop end is used to snare the polyp and the free end is used for delivering the diathermy current. The copper wire is malleable and it can be put in a desired curvature [Figure 1]. Procedure: The polyps are located by conventional proctoscope of appropriate size for age and body size of the patient, which reaches up to the lower sigmoid colon. Polyp usually prolapses into the lumen of the proctoscope. Assistant nurse is instructed to fix the scope in that position. The snare is then passed within the proctoscope and the copper wire loop is passed around the polyp to its pedicle. The free of the copper loop on the other side of the plastic tube is then pulled out till the loop snugly fits at the pedicle. Monopolar diathermy is set at low voltage. Short pulses of monopolar diathermy current are delivered at the free end of the copper wire till the polyp is detached. The snare is kept in slight traction to keep the polyp at the centre of the scope and care is taken to avoid contact of diathermy with the proctoscope. The procedure is shown schematically in [Figure 2]. Wait and watch is done for few minutes for bleeding from the stump and the procedure is completed. All polyps were sent for histological examination. Patients were allowed orally after 2 hours and sent home.
|Figure 1: Picture showing two type handmade snares and the disposable copper wire and proctoscopes|
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| Results|| |
From January 2008 to June 2013, 29 polypectomy were performed in 24 children. Age of the patients ranged from 3 to 12 years. There were 12 female and 12 males patients. Bleeding per rectum was the main complaints in all the patients. Duration of the bleeding ranged from 3 months to 2.5 years. Additional symptoms were pain in abdomen in 14 cases (58%), mucous diarrhoea in 8 cases (33%), tenesmus in 5 cases (20%) and constipation in 4 cases (16.6%). Five patients gave history of red mass protruding outside anus during defecation and two patients presented with persistent prolapsed polyp and acute pain. Twenty (83%) cases were diagnosed by first digital examination and in four patients the polyps were evident by re-examination after rectal evacuation by enema (N.B. length of author's index finger is 7.5 cm). Finger was stained by blood in 75% (n =18) of the cases. Additional finding during examination was fissure-in-ano in two cases. In two patients with obvious bleeding per rectum, no polyp was felt by digital examination. Subsequent colonoscopy detected polyp in high sigmoid colon and snare polypectomy was done. These two cases are not included in the study group.
Twenty-one patients had solitary polyp and one had three polyps and two other patients has two polyps each. In 20 patients polyps were located in rectum and rectosigmoid region and in 4 patients polyps were located in lower sigmoid colon. All the multiple polyps were located in rectum. There was no case of bleeding during the procedure. Minor bleeding was reported in two cases 24 hours after polypectomy. There was no case of perforation. Histopathology revealed juvenile polyp in 22 cases, inflammatory polyp in 1 case and adenomatous polyp in 1 case. Recurrent bleeding was not encountered in any case.
| Discussion|| |
Common cause of rectal bleeding in children is colorectal polyps. Most of these polyps are juvenile polyps and very rarely adenomatous or inflammatory or sometimes associated with polyposis syndromes. The most common locations of these polyps are rectum and rectosigmoid region. ,,,,
Conventionally, these polyps are removed by proctoscopic visualization and excision of the polyp after transfixing the pedicle. With the development of fibreoptic colonoscope, these polyps are now routinely removed by colonoscopic snaring. ,,,, But in the developing countries these facilities are not readily available in all the centres. In contrast, when the polyp is located in the rectosigmoid region or at lower sigmoid colon, it is technically difficult to ligate the pedicle manually. In these situations this innovative snare is a simple and versatile alternative. It can reach the lower sigmoid colon easily and can get good control of the pedicle. This device is almost without cost. It can be cleaned and reused with or without changing the wire till it is in good condition. Efficacy is similar to that of colonoscopic snare. Minor bleeding after 24 hours was reported in two cases, but resolved spontaneously without any intervention.
We conclude that snare polypectomy by convensional proctoscopy is simple, safe and cheap and can treat more than 90% of the cases of bleeding per rectum due to polyps in children.
| References|| |
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R T Medicos, B K Kakoti Road, Ulubati, Gauhati, Assam
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2]