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

Abstract

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

Sigmoido-rectal intussusception anastomosis in the Altemeier procedure for complete rectal prolapse: preliminary results of a new technique

“…This condition typically follows a protracted course, and affected individuals often present with comorbidities. The Altemeier procedure, a representative transperineal surgical approach, is applicable to a broad spectrum of patients but is challenged by recurrence rates and complications, such as anastomotic issues ( 12 , 13 ).…”

A modified perineal approach for the management of strangulated rectal prolapse: A case report

“…Fecal diversion is one way reduce the chance of leak, however, leaks are still possible [ 17 ]. Two recent studies revealed partial anastomotic dehiscence and leak in a small number of patients with prolapse who underwent perineal rectosigmoidectomy with and without diversion, respectively [ 14 , 18 ]. A case series from 2018 also reported two patients who underwent perineal rectosigmoidectomy for incarcerated prolapse, one of whom was diverted due to concerns for mucosal necrosis; the post-operative course was uneventful for both patients [ 19 ].…”

A case report of largest rectal prolapse in the literature successfully treated with Altemeier's procedure

“…Since the abdominal approach is difficult to adopt, we had no choice but to select the perineal approach in this case. Perineal proctosigmoidectomy, also known as Altemeier's procedure is one of the popular techniques in the emergency setting for almost all patients with acceptable outcomes [ 4 , 12 , 13 ]. Also, a temporary diversional loop such as ileostomy or colostomy can be considered for patients to ensure the excellence of anastomosis healing due to the surgeon's judgments [ 14 ].…”