Perineal Rectosigmoidectomy Associated with Low Colorectal Anastomosis for Complete Rectal Prolapse Correction – Altemeier’s Procedure

Introduction: Rectal prolapse constitutes in rectal protrusion through anal orifice. It’s more frequent in elderly women and the correction is exclusively surgical and fundamental, given the condition’s social relevance. We intend to describe a perineal rectosigmoidectomy (Altemeier) for correction of prolapse in multi-morbidity elder patient. Case Report: Female patient, 78 years old, evaluated by proctology ward of CHSBC. She Came in with complaint of anal region bulge for past 2 years. Proctological examination showed 15 cm rectal procidentia Rectal prolapse’s diagnosis came from colonoscopy. A perineal rectosigmoidectomy associated with colorectal anastomosis was done (Altemeier’s Procedure). There was appropriate postoperative evolution, discharge with good wound healing and ambulatorial follow up with good general healing. Discussion: Rectal prolapse is a result of anatomical alterations due to factors such as age and multiparity. Clinical presentation: abdominal discomfort, constipation, feces and gases release. It leads to life quality loss, thus surgical interventions become essential. Corrective surgeries seek to give back fecal continence. Currently, procedures branch out into abdominal and perineal. Altemeier consists in complete rectal removal via perineum. It’s appropriate for high surgical risk elders, since it has the lowest complications rate.

The Altemeier Procedure for Strangulated Rectal Prolapse: A Case Report

Rectal prolapse is the complete protrusion of the rectum through the anal canal. It is most common in elderly people, but can rarely occur at any age, the strangulated rectal prolapse is a rare complication. We report the case of a 78-year old men who underwent emergency surgery for strangulated rectal prolapse. Emergency perineal rectosigmoidectomy (Altemeier repair) was performed with simple outcome. This case highlights the importance of Altemeier’s procedure in the face of a strangulated rectal prolapse in an emergency situation.

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's 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 1998-2008. Results: Of 128 patients, 125(98%) were women; with mean age 74 yrs. 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 vs. 94.7 minutes, respectively, p< 0.0001,) and estimated blood loss (18.8 vs. 73 ml, respectively, p <0.0001,) compared to clamp-tie technique. Recurrence was seen in 23(18%) patients. Recurrence was more after a hand-sewn anastomosis compared to a stapled anastomosis. Complications occurred in 3 patients (2%)(1-major bleeding, 1-perineal abscess, and 1-post-operative 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.

Rectal prolapse surgeries using perineal, trans-anal and extra-anal approach

Rectal prolapse is a rare condition. Epidemiological data estimate that 4/1,000 adults are affected. Although rectal prolapse in most often seen in older women, it may develop in both men and women at any age. In the last century, perineal access was the primary surgical approach in patients with rectal prolapse. Currently, a number of transabdominal (laparotomy, laparoscopy) and transperineal techniques are used. Proper preoperative qualification is of key importance for therapeutic success in a patient with rectal prolapse. Indications for perineal rectal prolapse surgery include advanced age, general comorbidities, short-segment prolapse, incarceration and necrotic rectal prolapse. Advantages of the perineal approach include prolapse repair by resection, simultaneous repair of pelvic prolapse, and, in the case of overlapping anal sphincter insufficiency (which is common), the possibility of simultaneous anterior and posterior levator ani repair. Perineal rectosigmoidectomy (Altemeier’s procedure) and Delorme’s procedure are the most common perineal surgical procedures performed in patients with full-thickness rectal prolapse. Anal encirclement (Thiersch wire) is a historical method, which is used in rare cases of patients not eligible for other procedures. STARR (stapler transanal rectal resection), wedge resection of the rectal mucosa, mucosal plication (Gant-Miwa procedure) may be used in patients with partial-thickness rectal prolapse. The paper presents the above mentioned surgical methods, along with their indications, uses, advantages, disadvantages, and possible complications.

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.