Abdominal versus Perineal Approach for Treatment of Rectal Prolapse: Comparable Safety in a Propensity-matched Cohort

Abstract

Abdominal operations for rectal prolapse are associated with lower recurrence rates than perineal procedures but presumed higher morbidity. Therefore, perineal procedures are recommended for patients deemed unfit for abdominal repair. Consequently, bias confounds retrospective comparisons of the two approaches. To clarify the impact of operative approach on outcomes, we analyzed abdominal and perineal procedures in a propensity score-matched analysis. We selected patients undergoing surgery for rectal prolapse from the American College of Surgeons National Surgical Quality Improvement Program data set from 2005 to 2010. We grouped procedures as abdominal or perineal. We identified preoperative variables predictive of complications and regressed against operative approach. The resulting propensity score was used to select a matched cohort with similar clinical risk. We identified 2188 patients (848 abdominal [38.8%]; 1340 perineal [61.2%]). Patients undergoing the perineal approach had higher rates of most risk variables. Propensity matching resulted in 563 matched pairs (1126 patients) with similar clinical risk. In this matched cohort, no significant difference was found in the rate of any complication between the operative approaches; mortality was 0.9 per cent in each group ( P = 1.0). Relative risk for major morbidity after abdominal approach was 1.39 (95% confidence interval, 0.92 to 2.10; P = 0.15). Although many patients with rectal prolapse are high risk for abdominal surgery, our study indicates that many patients treated by perineal repair could be safely treated with a more durable operation.

I want to go home: should we abandon open surgery for treatment of rectal prolapse? Consideration of discharge destination following surgery for rectal prolapse

“…However, morbidity was as high as 14.83% for open abdominal procedures. These findings are consistent with other NSQIP studies examining the safety of these surgical approaches [6–10]. This study demonstrates that overall morbidity is lowest with a perineal approach and that discharge to a higher level of care is required most often with open surgery.…”

“…Perineal approaches have traditionally been reserved for poor surgical candidates due to the assumption that perineal approaches harbour lower morbidity, although this has also been challenged with the increased utilization of MIS techniques. Multiple American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) studies have demonstrated that MIS abdominal operations are safe when compared with perineal operations in regard to the 30-day outcomes for these procedures [6][7][8][9][10]. A recent NSQIP study assessed the safety of available surgical approaches specifically for elderly patients, and recommended individualization of surgical decision-making for patients with rectal prolapse [10].…”

What is the recommended procedure for recurrent rectal prolapse? A retrospective cohort study in a single Japanese institution

“…Recently, some reports have suggested that a laparoscopic procedure could be an alternative to conventional abdominal procedures. Mustain et al [ 17 ] reported no significant differences in the complication rates between the abdominal approach and perineal approach groups in a propensity-matched cohort. Additionally, de Bruijn et al [ 7 ] evaluated the long-term outcomes of 80 patients with full-thickness RP, including 35 patients with recurrent RP, and stated that lap-rectopexy is a safe surgery for full-thickness RP.…”

Challenges in the Surgical Treatment of Rectal Prolapse

“…All the abdominal procedures carry a slightly higher morbidity and mortality with respect to perineal operations, thus selection criteria are of utmost importance, considering the benign nature of the disease. In a propensity matched cohort of patients with comparable surgical risk status, no differences were found in terms of morbidity and mortality between perineal and abdominal operations [33], thus the progresses in anesthesiology, surgical techniques and technology and postoperative care make abdominal approach rather safe even in risky patients [34,35].…”