Quality of life after transperineal rectosigmoidectomy

Recurrence Rates and Risk Factors in the Altemeier Procedure for Rectal Prolapse: A Multicenter Study

BACKGROUND

Perineal proctosigmoidectomy (Altemeier) is a surgical procedure that is commonly used for the treatment of rectal prolapse. However, there is a diverse range of recurrence rates after Altemeier procedure repair that has been reported in the literature.

OBJECTIVE

To identify primary and subsequent recurrence rates after perineal proctosigmoidectomy and to define potential risk factors for recurrence.

DESIGN

Cohort study.

SETTINGS

Conducted at 6 hospitals affiliated with the Cleveland Clinic.

PATIENTS

The study included patients who were older than 18 years and were treated with the Altemeier procedure for rectal prolapse between 2007 and 2022.

MAIN OUTCOME MEASURES

Primary outcomes were rates of primary and subsequent recurrences. Secondary outcomes included potential risk factors for recurrence previously mentioned in the literature.

RESULTS

We identified 182 patients, of whom 95.1% were women, with a mean age of 79 years (SD 11.4). Overall, procedures were elective in 92.1% of patients, and 14.3% had previously undergone prolapse repairs (Delorme, Thiersch, abdominal suture rectopexy, and abdominal mesh rectopexy). At a mean follow-up period of 27.5 months (SD 45.7), 37.9% of patients experienced recurrence, with 16.5% of patients having multiple recurrences. A subsequent Altemeier procedure was performed in 72.5% of instances. Other treatments included Delorme, abdominal suture rectopexy, abdominal mesh rectopexy, or conservative management. This study identified connective tissue disorders and time since surgery as significant risk factors for recurrence.

LIMITATIONS

Retrospective design and varying follow-up periods.

CONCLUSIONS

Perineal proctosigmoidectomy is associated with a significant risk of recurrence. The risk of recurrence increased with the presence of a connective tissue disorder and in proportion to the elapsed time since surgery. These discoveries assist health care professionals in counseling and managing patients who undergo perineal proctosigmoidectomy for rectal prolapse. See Video Abstract .

TASAS DE RECURRENCIA Y FACTORES DE RIESGO EN EL PROCEDIMIENTO DE ALTEMEIER PARA EL PROLAPSO RECTAL UN ESTUDIO MULTICNTRICO

ANTECEDENTES:La proctosigmoidectomía perineal (Altemeier) es un procedimiento quirúrgico que se utiliza comúnmente para el tratamiento del prolapso rectal. Sin embargo, existe una amplia gama de tasas de recurrencia después de la reparación con el procedimiento de Altemeier que se han informado en la literatura.OBJETIVO:Nuestro objetivo fue identificar las tasas de recurrencia primaria y posterior después de la proctosigmoidectomía perineal, así como definir los posibles factores de riesgo de recurrencia.DISEÑO:Estudio de cohorte.AJUSTES:Realizado en 6 hospitales afiliados a la Clínica Cleveland.PACIENTES:Se incluyeron pacientes mayores de 18 años que fueron tratados con procedimiento de Altemeier por prolapso rectal entre 2007 y 2022.PRINCIPALES MEDIDAS DE VALORACIÓN:Los resultados primarios fueron las tasas de recurrencias primarias y posteriores. Los resultados secundarios incluyeron factores de riesgo potenciales de recurrencia mencionados anteriormente en la literatura.RESULTADOS:Se identificaron 182 pacientes, de los cuales el 95,1% eran mujeres con una edad media de 79 años (DE 11,4). En general, el 92,1% fueron electivos y el 14,3% se habían sometido previamente a reparaciones de prolapso (Delorme, Thiersch, rectopexia con sutura abdominal y rectopexia con malla abdominal). En un período de seguimiento medio de 27,5 meses (DE 45,7), el 37,9% de los pacientes experimentó recurrencia, y el 16,5% de los pacientes tuvo recurrencias múltiples. En el 72,5% de los casos se realizó un procedimiento de Altemeier posterior. Otros tratamientos incluyeron Delorme, rectopexia con sutura abdominal, rectopexia con malla abdominal o manejo conservador. Este estudio identificó los trastornos del tejido conectivo y el tiempo transcurrido desde la cirugía como factores de riesgo importantes de recurrencia.LIMITACIONES:Diseño retrospectivo y períodos de seguimiento variables.CONCLUSIÓN:La proctosigmoidectomía perineal se asocia con un riesgo significativo de recurrencia. El riesgo de recurrencia aumentó con la presencia de un trastorno del tejido conectivo y en proporción al tiempo transcurrido desde la cirugía. Estos descubrimientos ayudan a los profesionales de la salud a asesorar y tratar a los pacientes que se someten a proctosigmoidectomía perineal por prolapso rectal. (Traducción-Dr. Ingrid Melo ).

Surgical Treatment of Rectal Prolapse in the Laparoscopic Era; A Review of the Literature

Rectal prolapse is associated with debilitating symptoms including the discomfort of prolapsing tissue, mucus discharge, hemorrhage, and defecation disorders of fecal incontinence, constipation, or both. The aim of treatment is to eliminate the prolapse, correct associated bowel function and prevent new onset of bowel dysfunction. Historically, abdominal procedures have been indicated for young fit patients, whereas perineal approaches have been preferred in older frail patients with significant comorbidity. Recently, the laparoscopic procedures with their advantages of less pain, early recovery, and lower morbidity have emerged as an effective tool for the treatment of rectal prolapse. This article aimed to review the current evidence base for laparoscopic procedures and perineal procedures, and to compare the results of various techniques. As a result, laparoscopic procedures showed a relatively low recurrence rate than the perineal procedures with comparable complication rates. Laparoscopic resection rectopexy and laparoscopic ventral mesh rectopexy had a small advantage in the improvement of constipation or the prevention of new-onset constipation compared with other laparoscopic procedures. However, the optimal surgical repair has not been clearly demonstrated because of the significant heterogeneity of available studies. An individualized approach is recommended for every patient, considering age, comorbidity, and the underlying anatomical and functional disorders.

Perineal Rectosigmoidectomy Revisited

Objective

The aim of this study was to evaluate the long-term results of perineal rectosigmoidectomy.

Background

Multiple surgical options are available for rectal prolapse perineal rectosigmoidectomy (Altemeier procedure) is the procedure of choice in elderly patients and those with multiple comorbidities.

Methods

Retrospective review was performed of all patients undergoing perineal rectosigmoidectomy from 1998 to 2008.

Results

Of 128 patients, 125 (98%) were women; with mean age 74 years. Mean operating time was 76 minutes. Hemostasis was achieved using ultrasonic scalpel or clamp and tie technique in equal numbers. Ultrasonic scalpel use resulted in shorter operative times (57.9 versus 94.7 minutes, respectively, P < 0.0001,) and estimated blood loss (18.8 versus 73 mL, respectively, P < 0.0001) compared to clamp-tie technique. Recurrence was seen in 23 (18%) patients. Recurrence was more after a handsewn anastomosis compared to a stapled anastomosis. Complications occurred in 3 patients (2%: 1 experienced major bleeding, 1 experienced perineal abscess, and 1 experienced postoperative ileus).

Conclusions

Perineal rectosigmoidectomy is associated with low morbidity and mortality. In addition, the minimal discomfort to patient, short length of stay and improvement in quality of life makes this a suitable operation for the elderly.

Perineal rectosigmoidectomy for rectal prolapse-the preferred procedure for the unfit elderly patient? 10 years experience from a UK tertiary centre

BACKGROUND

Rectal prolapse is a disease presentation with a prevalence of about 1%, mainly affecting older women. It usually presents with symptoms of rectal mass, rectal bleeding, fecal incontinence or constipation, with patients frequently feeling socially isolated as a result. Perineal rectosigmoidectomy is associated with lesser morbidity and mortality than the abdominal procedure, but with a much higher recurrence rate. Therefore, this technique is mainly suitable for the frail elderly patient. Specific outcomes in an elderly population have been described in only a few studies. We evaluated the morbidity, mortality, recurrence rate and functional results after this procedure related to age.

METHODS

All patients who underwent a perineal rectosigmoidectomy over a 10-year period in two tertiary referral centers were included in the study. American Society of Anesthesiology (ASA) grade, pre- and postoperative symptoms, pathology-reported post-fixation specimen length, length of in-patient stay, 30-day morbidity/mortality, and recurrence were measured.

RESULTS

A total of 45 patients underwent a perineal rectosigmoidectomy. Forty-three (95%) were female, with a median age of 82.0 years (IQR 70.5-86.5), ASA grade III and median follow-up of 20 months (range 8.5-45.5 months). Half of the cohort was over 80 years old. Significant symptomatic relief was achieved, predominantly the resolution of rectal mass (8.9% vs. 60.0% preoperatively), fecal incontinence (15.6% vs. 46.7%) and constipation (4.4% vs. 26.7%). The median length of stay was 6 days, while morbidity occurred in 14 patients (31.1%) and recurrence occurred in 6 patients (13%). There were no deaths within 30 days of the procedure and outcomes were comparable in the < 80 and ≥ 80 age group.

CONCLUSIONS

Perineal rectosigmoidectomy is safe for older patients with greater comorbidities resulting in good functional results and is associated with low morbidity and mortality.

A Modification of the Stapled TransAnal Rectal Resection (STARR) Procedure for Rectal Prolapse

PURPOSE

This study was designed to assess the safety, efficacy, and postoperative outcomes of the modified Stapled TransAnal Rectal Resection (modified STARR) in patients presenting with cases of limited external rectal prolapse.

METHODS

A prospective cohort of patients with mild rectal prolapse undergoing rectal resection with the Tissue-Selecting Technique Stapled TransAnal Rectal Resection Plus (TSTStarr Plus) stapler between February 2014 and September 2016 was reviewed retrospectively.

RESULTS

Twenty-five eligible patients underwent rectal resection with the TSTStarr Plus stapler. The median vertical height of the resected specimen was 5.0 cm (range = 3.1-10 cm) with all cases being confirmed histologically as full-thickness resections. Over a follow-up of 33.6 ± 9.4 months, only 1 case (4%) was encountered with recurrence. The mean postoperative Wexner score was significantly improved when compared with the preoperative scores (preoperative: median = 3, range = 0-20, vs postoperative: median = 2, range = 0-20, respectively; P = .010). The median preoperative Symptom Severity Score and Obstructed Defecation Score were both decreased compared with the postoperative scores ( P = .001).

CONCLUSIONS

Modified STARR in management of mild rectal prolapse appear to be a safe and effective technique. The initial results would encourage a more formal prospective assessment of this technique as part of a randomized trial for the management of mild rectal prolapse.

Perineal resectional procedures for the treatment of complete rectal prolapse: A systematic review of the literature

BACKGROUND AND AIM

Several procedures for the treatment of complete rectal prolapse (CRP) exist. These procedures are performed via the abdominal or perineal approach. Perineal procedures for rectal prolapse involve either resection or suspension and fixation of the rectum. The present review aimed to assess the outcomes of the perineal resectional procedures including Altemeier procedure (AP), Delorme procedure (DP), and perineal stapled prolapse resection (PSR) in the treatment of CRP.

PATIENTS AND METHODS

A systematic search of the current literature for the outcomes of perineal resectional procedures for CRP was conducted. Databases queried included PubMed/MEDLINE, SCOPUS, and Cochrane library. The main outcomes of the review were the rates of recurrence of CRP, improvement in bowel function, and complications.

RESULTS

Thirty-nine studies involving 2647 (2390 females) patients were included in the review. The mean age of patients was 69.1 years. Recurrence of CRP occurred in 16.6% of patients. The median incidences of recurrence were 11.4% for AP, 14.4% for DP, and 13.9% for PSR. Improvement in fecal incontinence occurred in 61.4% of patients after AP, 69% after DP, and 23.5% after PSR. Complications occurred in 13.2% of patients. The median complication rates after AP, DP and PSR were 11.1%, 8.7%, and 11.7%, respectively.

CONCLUSION

Perineal resectional procedures were followed by a relatively high incidence of recurrence, yet an acceptably low complication rate. Definitive conclusions on the superiority of any procedure cannot be reached due to the significant heterogeneity of the studies.

Quality of life after laparoscopic ventral rectopexy

AIM

This study evaluated continence, constipation and quality of life (QOL) before and after laparoscopic ventral rectopexy (LVR) METHOD: Between February 2012 and July 2014, patients who underwent LVR for external rectal prolapse (ERP) and/or rectoanal intussusception (RAI) were prospectively included. A standard questionnaire including the Fecal Incontinence Severity Index (FISI), the Constipation Scoring System (CSS) and QOL instruments (Short-Form 36 Health Survey, Fecal Incontinence QOL scale, Patient Assessment of Constipation-QOL) were administered before and after operation. Psychiatric patients and those with dementia were excluded from the study. Defaecography was performed 6 months postoperatively.

RESULTS

Fifty-nine patients were included in the study period and 44 (19 with ERP, 25 with RAI) completed the follow-up questionnaire and were reviewed after a median of 26 (range 12-42) months. There was no recurrent ERP. Postoperative defaecography showed new-onset RAI in 6 and persistent RAI in 1. One year after surgery, incontinence was improved in 30/39 patients (77%) and constipation in 19/32 (59%). The FISI scores reduced between preoperative status and 1 year after surgery [32 (13-61) vs 11 (0-33), P < 0.0001]. The CSS scores also reduced [preoperative 12 (5-18) vs 1 year 5 (1-12), P < 0.0001]. Compared with the preoperative scores, almost all of the scale scores on the three kinds of QOL instruments significantly improved over time. The presence of new-onset or persistent RAI did not have an adverse effect on the improvement of QOL.

CONCLUSION

LVR improves both generic and symptom-specific QOL with good functional results.

Clinical outcomes of perineal proctectomy among patients of advanced age

BACKGROUND

Rectal prolapse occurs primarily in older patients who often have significant comorbidities. With the aging population, increasing numbers of elderly patients are presenting with rectal prolapse. The perineal approach is preferred for these patients because it involves less perioperative risk than an abdominal procedure, but the outcomes of this procedure in elderly patients are unknown.

OBJECTIVE

The aim of this study was to examine whether clinical outcomes after perineal proctectomy are similar among elderly patients versus patients of younger age.

DESIGN

This study was a retrospective review.

SETTING

This study was conducted in mixed academic and private practice; the operations were performed at 16 hospitals.

PATIENTS

Patients who had perineal proctectomy for rectal prolapse from 1994 to 2012 were grouped according to age: <70 (group A), 70 to 79 (group B), 80 to 89 (group C), and ≥90 years (group D).

INTERVENTIONS

Perineal proctectomy with or without concurrent levatorplasty was performed.

MAIN OUTCOME MEASURES

The primary outcomes measured were postoperative complications, recurrence, and survival after perineal proctectomy.

RESULTS

Four hundred patients underwent 518 perineal proctectomies: group A, N = 113; group B, N = 113; group C, N = 208; and group D, N = 84. The immediate and late complication rates were 5.6% and 3.5% and did not vary by age. Recurrence was 22.6% and was significantly different between groups, with the lowest recurrence in group D, 14.3% (p = 0.007). Reoperation after recurrence was less likely in group D. The main type of reoperation was perineal proctectomy (41.5%), but, for group D, recurrence was usually managed nonoperatively (58.3%). Median survival after operation was more than 4 years in the advanced age group.

LIMITATIONS

Retrospective data, which did not allow analysis of patients with rectal prolapse who did not undergo surgery, were used in this study.

CONCLUSIONS

When selected appropriately, patients 90 years of age or older have outcomes similar to younger patients; therefore, age alone should not be a contraindication to surgery. In addition, elderly patients have a median survival of more than 4 years after surgery, so the operative risk can be worth the benefit accrued.

Recurrence after perineal rectosigmoidectomy: when and why?

AIM

Reported recurrence rates after perineal rectosigmoidectomy (Altemeier's procedure) in patients with full-thickness rectal prolapse vary from 0% to 60%. The object of this study was to analyse risk factors for recurrence after this procedure.

METHOD

From May 2004 to December 2012, 63 consecutive patients suffering from full-thickness rectal prolapse undergoing perineal rectosigmoidectomy were included. Of these 46 were female and the median age of the whole group was 79 (30-90) years. The median follow-up was 53 (3-99) months. Patient characteristics and operative parameters were compared between patients with and without recurrence.

RESULTS

One patient died and another patient needed re-operation. Eight full-thickness recurrences occurred in eight patients after a median of 18 (6-48) months. Stapled compared with handsewn anastomosis (hazard ratio 7.96, 95% confidence interval 1.90-33.47; P = 0.001) and shorter specimen length (hazard ratio 4.06, 95% confidence interval 0.97-16.99; P = 0.03) increased the risk of recurrence in Cox regression analysis.

CONCLUSION

The operative technique including stapled anastomosis and length of the resected specimen seems to be associated with a high recurrence rate after perineal rectosigmoidectomy.

[Pelvic floor disorders from the surgeon's viewpoint]

Pelvic floor disorders present very differently with regard to symptoms and manifestation. Both diagnostic and treatment options require specific experience and an interdisciplinary approach. Diagnostic work-up is primarily based on medical history, physical examination and procto-rectoscopy. Furthermore, endosonography and perineal sonography have also gained importance. In almost all cases following these basic examinations conservative therapy options should be considered. As the interdisciplinary concept is very important, for careful diagnosis of pelvic floor disorders it became crucial to find an adequate form of treatment. Every decision for surgical therapy should not only focus on the results of previous examinations but should also consider the individual situation of each patient. In pelvic floor disorders a large variety of symptoms are confronted with a vast number of different and often highly specific procedures. The decisions on who to treat and how to treat are not only based on individual patient requests and desires but also on the experience and preference of the surgeon.

Colonic transit before and after resection rectopexy for full-thickness rectal prolapse

BACKGROUND

The objective of this study was to measure the change in colonic transit time after resection rectopexy for complete rectal prolapse.

METHODS

We prospectively carried out isotope colonic transit studies before resection rectopexy in 38 patients with full-thickness complete rectal prolapse and invited them to attend for a postoperative transit study at least 1 year after resection rectopexy.

RESULTS

Preoperatively, 27 (70 %) patients had abnormally prolonged colonic transit times, while 11 had normal colonic transit. Twenty-two (61 %) patients agreed to attend for a three-day colonic transit study. Resection rectopexy failed to correct delayed colonic transit in all patients with abnormal preoperative tests, while 4 patients developed new delayed transit and 2 with normal transit were unchanged.

CONCLUSIONS

The study suggests that most prolapse patients have a pan-colonic motility disorder that is not corrected by rectopexy and resection of most of the left colon. If resection rectopexy fails to correct abnormal transit, this study questions the rationale for continuing to offer resection and supports less invasive surgical procedures such as ventral rectopexy.

Perineal rectosigmoidectomy: quality of life

AIM

For any surgical treatment of full-thickness rectal prolapse, little attention has been given to quality of life (QoL). This study prospectively evaluated continence, constipation and QoL after perineal rectosigmoidectomy for full-thickness rectal prolapse in young and elderly patients in the long term.

METHOD

From May 2003 to May 2010, consecutive patients suffering from full-thickness rectal prolapse and treated with perineal rectosigmoidectomy were prospectively studied. A standardized questionnaire, including the Cleveland Clinic Constipation Score (CCCS), the Cleveland Clinic Incontinence Score (CCIS) and generic [EuroQol five-dimension (EQ-5D)] and constipation-specific [Patient Assessment of Constipation-Quality of Life (PAC-QOL)] QoL scores, was administered pre- and postoperatively. The Wilcoxon test (for EQ-5D data) and two-sample Student's t-test [for EuroQol visual analogue scale (EQ-VAS), CCCS, CCIS and PAC-QOL data) were used for statistical analyses.

RESULTS

Fifty-three patients (47 women), 72.7 (range 30-89) years of age, underwent perineal rectosigmoidectomy. One patient died and one patient needed reoperation. Five full-thickness recurrences occurred. Thirty-seven patients completed the follow-up questionnaire at a median of 49 (range, 6-89) months. Postoperative incontinence and constipation improved significantly (CCIS from 13 ± 7.28 to 8.7 ± 6.96 and CCCS from 8.32 ± 6.96 to 3.49 ± 4.17). Furthermore, QoL, in terms of mobility, usual activity, pain/discomfort and anxiety/depression and subjective state of health, were significantly better at follow-up (P < 0.001). All dimensions of constipation-related QoL improved (P < 0.001). The results did not differ significantly between patients under or over 69 years of age.

CONCLUSION

Patients' experience improved general and constipation-related QoL after perineal rectosigmoidectomy, and this was independent of age.

Impact of prolapse mass on Contour Transtar technique for third-degree rectal prolapse

PURPOSE

Contour Transtar procedure for rectal prolapse is a promising technique according to safety and efficacy. One potential surgical problem is failure of the stapler due to the thick rectal wall. In order to evaluate the practicability and the impending limitations of the Contour Transtar technique, we reviewed our data with special respect to the necessity of additional anastomosis suturing.

METHODS

A prospective analysis of 25 consecutive patients, which underwent Contour Transtar procedure from January 2009 to July 2012, was performed. For statistic analysis, the groups with and without additional suturing of the anastomosis were evaluated according to patient characteristics and surgical outcome.

RESULTS

Twenty-five patients, three men and 22 women, underwent transanal Contour Transtar stapling procedure for rectal prolapse. Due to stapling failure, additional suturing of the anastomosis was necessary in 4 of 25 procedures (16%). Age (74.1 vs. 83.1 years) and body mass index (30.8 vs. 22.7 kg/m(2)) were significantly different with and without additional suturing. Operative time was longer (62 vs. 31 min), more cartridges were used (12 vs. 6), and the specimen weight was higher (220 vs. 107 g) in patients with additional suturing. Early postoperative complications were observed in two patients without anastomosis suturing including one patient with bleeding and systemic inflammatory reaction in one case. Postoperative stay did not differ between both groups.

CONCLUSION

Patients with extensive obesity, which present with a substantial rectal prolapse, may need additional suturing of the rectal anastomosis after Contour Transtar stapling. This causes prolonged operative time. However, this does not correlate with complications and it is not related to significant longer hospital stay.

Trans-obturator colonic suspension during Altemeier's operation for full-thickness rectal prolapse: preliminary results with a new technique

AIM

With the aim of reducing recurrence after perineal surgery for full-thickness rectal prolapse, a new operation consisting of a trans-obturator colonic suspension during Altemeier's operation has been developed.

METHOD

Eighteen women with full-thickness rectal prolapse were examined clinically, with validated quality of life and continence scores, colonoscopy, anorectal manometry, anal EMG and sacral reflex latency. Ten had a newly diagnosed and eight a recurrent prolapse. The Altemeier operation was combined with a levatorplasty in all cases using two porcine collagen prostheses sutured to the descending colon and passed through the trans-obturator space bilaterally. The operation was completed by a manual or stapled colo-anal anastomosis. Clinical examination, with quality of life and continence scores, anorectal manometry, EMG and sacral reflex latency, was scheduled during follow up, with the recurrence of prolapse as the primary outcome measure.

RESULTS

There were no recurrences at 30 months. There was no mortality and no complications. All patients experienced significant improvement in quality of life and faecal continence scores (P<0.01). Surgery did not affect anorectal pressures or sacral reflex latencies.

CONCLUSION

The new technique appears to be relatively easy to perform and is complication free with no recurrence after a short period of follow up. A larger study with appropriate controls and longer follow up is now needed to assess its real effectiveness in reducing the risk of recurrence.

Quality of life after laparoscopic resection rectopexy

PURPOSE

This study evaluated continence, constipation, and quality of life (QoL) after laparoscopic resection rectopexy (LRR) for full-thickness rectal prolapse. Results were compared with existing data after perineal rectosigmoidectomy (PRS).

METHODS

From May 2003 to February 2008, consecutive patients suffering from full-thickness rectal prolapse undergoing LRR were retrospectively studied. A standardized questionnaire including the Cleveland Clinic Constipation and Incontinence Scores (CCCS and CCIS) as well as general and constipation-related QoL scores (EQ-5D and PAC-QOL) was administered. Results were compared with those after PRS. For statistic analysis, the Wilcoxon test (EQ-5D and EQ-VAS) and two-sample Student's t test (CCCS, CCIS, and PAC-QOL) were used for LRR, for the comparison of both procedures Mann-Whitney test (EQ-5D) and two-sample Student's t test (EQ-VAS, CCCS, CCIS, and PAC-QOL).

RESULTS

Eighteen patients, 15 female, aged 58.1 (±20.2) years underwent LRR. Eleven patients completed follow-up. Postoperatively, neither functional outcome nor QoL improved. Two recurrences occurred, morbidity was n = 2, and mortality n = 1. In comparison, patients after PRS benefit from improved constipation, general QoL measures, status of health, and all dimensions of constipation-related QoL.

CONCLUSIONS

Patients after LRR do not benefit from improved general nor constipation-related QoL nor improved functional results compared to PRS.

The Altemeier procedure for rectal prolapse: an operation for all ages

PURPOSE

Perineal rectosigmoidectomy was the most popular operation performed for rectal prolapse in the first half of the 20th century. However, high recurrence rates relegated it to a back-up role for elderly or other high-risk patients who were not candidates for an abdominal operation. Recent series (combined with levatorplasty = Altemeier procedure) revealed excellent results across a broader spectrum of patients and inspired this ongoing consecutive series of cases.

METHODS

This is a review of 103 (99 women) consecutive patients (mean age, 68.9 y; range, 20-97 y) who underwent the Altemeier procedure between 2000 and 2009. Patients were placed in the prone jackknife position: 93 patients (90%) with the use of general anesthesia and 10 patients (10%) with the use of spinal anesthesia. The mean follow-up was 43 months (range, 3 mo to 10 y).

RESULTS

The mean time for the operation was 97.7 minutes (range, 50-180 min) with a mean 7.2 cm of rectum resected (range, 2.5-26.7 cm). The mean blood loss was 66.9 mL (range, 0-350 mL). The mean time to tolerating a diet was 2.3 days (100% within 4 d) and mean postoperative length of hospital stay was 4.2 days (93% within 6 d). There was no mortality, minimal morbidity (14%), and no recurrence. Preoperative constipation (61% of patients) improved in 94% and preoperative fecal incontinence (47% of patients) improved in 85%, whereas 15% developed new onset of seepage or incontinence to flatus.

CONCLUSIONS

The Altemeier procedure for rectal prolapse provided excellent results across all age groups with minimal morbidity, allowing for short hospital stays and periods of convalescence. To this point, there has been no evidence of recurrence in this group of patients, pending longer periods of follow-up, especially among patients from the younger age groups.