Massive chronic irreducible rectal prolapse successfully treated with Altemeier's procedure

The utility of the Altemeier procedure in strangulated rectal procidentia secondary to rectal cancer. A case report

Introduction and importance

Altemeier rectosigmoidectomy has been cited in the literature as a suitable approach for incarcerated rectal prolapse when a large segment of bowel is involved. However, the literature is devoid of cases that employed the technique as an oncological procedure for rectal carcinoma. For this reason, this case report heralds a new perspective on an old technique.

Case presentation

We describe the case of a male in his 6th decade who presented with stage four rectal cancer. Computed tomography imaging showed a rectal mass at the rectosigmoid junction with pelvic lymphadenopathy and a solitary hepatic lesion in segment two of the liver. While admitted to the hospital a 16 cm segment of bowel containing the mass prolapsed and became incarcerated, eventually becoming necrotic. A modification of the Altemeier procedure was performed along with a diverting ileostomy and hepatic wedge resection of the solitary metastases. Histological assessment of the surgical specimens confirmed that adequate resection margins were obtained with one of twenty-one lymph nodes positive for malignancy. He is currently being followed up in the outpatient oncology clinic and has commenced adjuvant chemotherapy.

Clinical discussion

Synchronous excision of rectal carcinoma with hepatic metastasectomy is a feasible surgery even in the emergency setting and can offer improved patient survival.

Conclusion

The combination of both an abdominal and perineal approach was suitable for this patient given his improved quality of life and negative pathological margins.

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Rectal prolapse can be the first presentation of rectal cancer.

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Strangulated rectal procidentia should be addressed by the perineal route.

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Altemeier procedure can be utilized for oncological resection of rectal cancer.

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Low volume liver resection is feasible without adjustment of central venous pressure.

Anorectal emergencies: WSES-AAST guidelines

Anorectal emergencies comprise a wide variety of diseases that share common symptoms, i.e., anorectal pain or bleeding and might require immediate management. While most of the underlying conditions do not need inpatient management, some of them could be life-threatening and need prompt recognition and treatment. It is well known that an incorrect diagnosis is frequent for anorectal diseases and that a delayed diagnosis is related to an impaired outcome. This paper aims to improve the knowledge and the awareness on this specific topic and to provide a useful tool for every physician dealing with anorectal emergencies.The present guidelines have been developed according to the GRADE methodology. To create these guidelines, a panel of experts was designed and charged by the boards of the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) to perform a systematic review of the available literature and to provide evidence-based statements with immediate practical application. All the statements were presented and discussed during the WSES-AAST-WJES Consensus Conference on Anorectal Emergencies, and for each statement, a consensus among the WSES-AAST panel of experts was reached. We structured our work into seven main topics to cover the entire management of patients with anorectal emergencies and to provide an up-to-date, easy-to-use tool that can help physicians and surgeons during the decision-making process.

Incarcerated complete rectal prolapse managed by Altemeier's procedure

Rectal prolapse is a complete protrusion of the rectum through the anal canal, which usually occurs in elderly women. Incarceration is a rare event and can be the first presentation of a rectal prolapse. We present the case of a 54-year-old male patient who presented with incarceration and was managed successfully with Altemeier's procedure.

Case series: Incarcerated massive rectal prolapse successfully treated with Altemeier's procedure

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We review in the literature, and find out there are very few incarceration rectal prolapse. There is not clear indication of management for these cases.

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Our two cases, both were operated by Altemeier’s procedure, but creating the colostomy is performed only in one case.

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When do we need to create diverting colostomy? It depends on patient condition, anastomosis condition and surgeon’s skill. These two different cases give us the chance to show we should manage this uncommon condition individually.

Introduction

Incarceration and necrosis of rectal prolapse is rare but when it occurs it requires urgent management. Perineal rectosigmoidectomy (Altemeier’s procedure) may be a reasonable approach for the treatment of this condition. In some cases, a diverting stoma may be necessary.

Methods

We report two cases of incarcerated massive rectal prolapse, one of which also manifested tissue necrosis, that were successfully treated with perineal rectosigmoidectomy. In one case a diverting colostomy was required. Both patients recovered uneventfully.

Results

A literature review was performed to determine the optimal management of incarcerated and necrotic rectal prolapse, and to determine the indication for fecal diversion.

Conclusion

Perineal rectosigmoidectomy (Altemeier’s procedure) can be utilized in emergency circumstances and, in our experience, the procedure was both safe and effective. The need for fecal diversion depends on the condition of the patient and the experience and judgement of the surgeon.