Altemeier Procedure for Complete Rectal Prolapse: An Operation for all Ages and its Long-Term Functional Outcomes

Abstract

Objective The aim of this study is to evaluate the long-term functional outcomes in patients treated by Altemeier's procedure for complete rectal prolapse.

Methods Records of 40 patients who underwent Altemeier's procedure for complete rectal prolapse between January 2013 to June 2023 were analyzed. The median duration of post operative follow-up was 48 months (ranges- 6 months to 10 years). Postoperatively, fecal incontinence, constipation and recurrence were analyzed.

Results The median age was 45 (13-75) years. The male-to-female ratio was 1.4:1. Among forty patients, five patients had recurrent rectal prolapse. Out of forty, nine patients underwent emergency Altemeier's procedure. The median time taken for the procedure was 120 (80-155) minutes. The median postoperative length of hospital stay was 9 days. Three patients (7.5%) had Grade I anastomosis leak. All patients subsequently developed anastomotic stricture and were managed with periodic anal dilatation. There was no mortality. Postoperatively, constipation reduced from 25% to 7.5% and fecal incontinence reduced from 37.5% to 10%. There was no recurrence in our study.

Conclusion The Altemeier procedure is a safe and effective procedure in both elderly and young patients presenting with complete rectal prolapse. It was associated with minimal morbidity and good long-term functional outcomes.

Keywords

Altemeier procedure - complete rectal prolapse - perineal rectosigmoidectomy - levatorplasty - fecal incontinence - constipation

Introduction

Rectal prolapse is a clinically distressing condition that predominantly affects elderly patients. The estimated incidence of rectal prolapse is approximately 0.5% of the general population.[1] It occurs mostly in the fifth decade with female preponderance. The etiology is multifactorial and includes deep cul de sac, diastasis of pelvic floor muscles, redundant sigmoid colon, loss of anorectal angle, multiple pregnancies, deep pouch of Douglas and a patulous anus.[2] The various clinical presentations in complete rectal prolapse are mass descending per rectum, bleeding, mucus discharge, perianal discomfort, incontinence and constipation. At the time of diagnosis, approximately 25 to 50% of patients report constipation and 50 to 75% of patients report incontinence.[3] If left untreated, it may be associated with serious complications like ulceration, strangulation, and bowel necrosis.[4]

More than 100 procedures to repair rectal prolapse have been described with two major approaches in the form of abdominal and perineal.[5] Abdominal procedures include suture or mesh rectopexy with or without sigmoid resection done through either open, laparoscopic, or more recently, robotic approach. Perineal surgeries include the Altemeier procedure, the Delorme procedure and Thiersch wiring. Abdominal procedures are considered in young, fit patients. Perineal surgeries are frequently performed in elderly and high-risk patients with multiple comorbid conditions.

Materials and Methods

All patients who underwent the Altemeier procedure for complete rectal prolapse from January 2013 to June 2023 were reviewed retrospectively. Hospital inpatient records and operative reports were reviewed for data collection.

Preoperative clinical data including age, gender, comorbidities, duration of symptoms, bowel function including constipation and incontinence, details of previous abdominal or perineal surgery, colonoscopy and ASA (American Society of Anesthesiologists) gradings were obtained.

Bowel preparation was done on the day before surgery with laxatives for all patients except in emergency cases. Intravenous antibiotics were given one hour before the procedure and continued postoperatively for three days.

All patients underwent perineal rectosigmoidectomy with anterior levatorplasty after placing the patient in a lithotomy position under regional anesthesia. The coloanal anastomosis was done 2 cm above the dentate line in a single layer, interrupted sutures with 2-0 polyglactin suture material, and anterior levatorplasty was done using 2-0 polypropylene.

Perioperative data including operative time, blood loss, length of bowel resected, hospital stay, time of normal diet intake, morbidity and mortality were recorded. Perioperative constipation and incontinence were evaluated with the Cleveland Clinic Constipation as well as the Wexner Incontinence score.

Patients were followed up in the Outpatient department to evaluate long-term functional outcomes like fecal incontinence, constipation and recurrence.

Results

In our study, the median age was 45 (13 -75) years [ [Table 1] ]. The male-to-female ratio was 1.4: 1 with slightly male preponderance. Among them, 5 patients (12.5%) had undergone previous repair for rectal prolapse, 3 had abdominal suture rectopexy and 2 had Altemeier procedure in other tertiary health centers. Patients presented with preoperative constipation were 10 (25%). Preoperative incontinence was present in 15 patients (37.5%). Among forty patients, three patients had associated uterovaginal prolapse and underwent simultaneous total abdominal hysterectomy with the Altemeier procedure. Twenty-four patients (60%) had comorbidities. Most of the patients came under ASA grade II and III, one patient had ASA grade IV [ [Table 2] ]. The median operating time was 120 minutes (80–155). The median length of resected bowel was 20cm (10 -28). The median blood loss was 75 ml (0 - 150). The median time required to take a normal diet was 5 (3-7) days. The median duration of hospital stay was 9 (5–15) days. There were no intraoperative complications. Out of 40 patients, three (7.5%) had Grade I anastomosis leak and we managed them conservatively. During the follow-up, all three patients with anastomosis leak developed anastomotic stricture which was managed by periodic anal dilatation. There was no mortality.

Table 1 Preoperative data

1. Median Age	(13-75)	45 years
2. Sex  • Male  • Female	23 17	57.5% 42.5%
3. History of constipation  ● Present  ● No	10 30	25% 75%
4. History of Incontinence  ● None  ● Gas  ● Liquid  ● Solid	15 3 5 7	37.5% 7.5% 12.5% 17.5%
5. Previous surgery for Prolapse  • Perineal approach  • Abdominal approach	5 2 3	12.5% 5% 7.5%
6. Comorbidities  • Hypertension  • Diabetes mellitus  • Cardiac  • Pulmonary  • Chronic Kidney disease  • Hypothyroidism	24 9 6 3 3 2 1	60% 22.5% 15% 7.5% 7.5% 5% 2.5%

Table 2 PERIOPERATIVE DATA

1. ASA score  ASA 1  ASA 2  ASA 3  ASA 4	9 17 13 1	22.5% 42.5% 32.5% 2.5%
2. Elective surgery  Emergency Surgery	31 9	77.5% 22.5%
3. Median Operative time	120 min	80 - 155 min
4. Median Blood loss	75 ml	0-150 ml
5. Median Length of resected specimen	20 cm	12-28cm
6. Median Length of stay	9 days	5 - 18
7. Postoperative constipation  Present	3	7.5%
8. Postoperative incontinence  Gas  Liquid  Solid	4 0 1 3	10% 0 2.5% 7.5%
9. Anastomosis leak	3	7.5%

During follow-up, there was no recurrence of rectal prolapse. Postoperative constipation and incontinence rates were low with postoperative constipation being noted at 7.5% and postoperative incontinence at 10%.

Discussion

The perineal rectosigmoidectomy was first performed in the late 1800s.[6] Then in the late 1960s to early 1970s, Altemeier and Culbertson popularized this procedure, now bearing the name of Altemeier.[7]

Rectal prolapse is defined as the circumferential protrusion of all layers of the rectal wall through the external and internal anal sphincters. The male-to-female ratio is 1:9.[8] Rectal prolapse usually occurs in extreme of ages. Rectal prolapse is more common in children and elderly patients. It is rare in young adults less than 30 years old.[9]

Many different procedures are depicted for the surgical treatment of rectal prolapse. The choice of treatment is based on the age, comorbidities, assessment, stage, and workup of rectal prolapse. Transabdominal procedures are usually reserved for young, fit patients. Laparoscopic abdominal procedures have the potential benefits of a minimally invasive approach, including less postoperative pain, shorter hospital stays, earlier recovery, and fewer complications.[10] Based on these advantages, it is emphasized that laparoscopic surgery is a safe and feasible approach in patients with rectal prolapse. As per the results from the PROSPER trial, there were no significant differences in their analysis of bowel function, recurrence rate, and quality of life between any of the surgical treatment options.[11] More recently, robotic rectopexy is a well-described technique for the management of rectal prolapse.

Traditionally, perineal procedures are recommended in elderly with multiple comorbidities, debility, and unfit, young patients. Advantages of perineal rectosigmoidectomy include lower morbidity rates, shorter hospital stays, and less postoperative pain. An additional advantage of perineal procedures includes the prevention of erectile dysfunction in males and infertility in females by avoiding the risk of pelvic nerve injury. The incidence of sexual dysfunction in males is seen in 17 -20% in open abdominal procedures, up to 50% in laparoscopic procedures, and minimal to no risk in perineal procedures.[12]

The morbidity rates reported in various literature ranges from 0 - 25% in perineal procedures and 5 - 10% in abdominal approaches.[13] The most significant postoperative complication was an anastomotic leak. In our study, the anastomosis leak rate was 7.5%. Three out of forty patients developed Grade I anastomosis leak eventually followed by anastomotic stricture. All were successfully managed by periodic anal dilatation. The technical factors that help in reducing the anastomosis leak are not resecting more bowel and avoiding ligating the mesentery more proximally. This ensures a well-vascularized and tension-free coloanal anastomosis.

The median postoperative length of hospital stay in our study was 9 days. Early discharge after Altemeier repair can be done in 60% of patients on the day of surgery and 80% on postoperative day 1.[14]

Long-term functional outcomes after the Altemeier procedure show different results in the literature. The reduction of resting anal pressure and neorectal compliance after perineal rectosigmoidectomy results in a higher incidence of urgency, frequency of defecation, and fecal incontinence. The lower rectal compliance is mainly caused by the loss of anorectal reservoir function.

Levatorplasty was first described by Cohn et al. in 1942 [15] and was routinely performed by Altemeier beginning with his first published series. The addition of levatorplasty recreates this anorectal angle, which improves anal continence. The improvement in fecal incontinence rate after the Altemeier procedure was around 60%.[16] The significant advantage of adding levatorplasty is that simultaneously corrects the fecal incontinence associated with rectal prolapse.[17] In our study, incontinence rate in postoperative follow-up was reduced to 10%.

Improvement in constipation rates documented in resection rectopexy was 18 to 80%. In contrast, suture rectopexy with posterior rectal mobilization can produce or worsen constipation in at least 50% of patients postoperatively. New onset of constipation was experienced in 15% of patients.[18] Perineal procedures improve postoperative constipation by 13 to 100%.[19] Constipation rate in our study preoperatively was seen in 10 of 40 (25%) patients. In the postoperative period, it was reduced to 7.5%. The mortality rate in the Altemeier procedure for rectal prolapse is very low. In our study, there was no mortality.

The major disadvantage of the perineal procedure is the high risk of recurrence. Reported recurrence rates after the Altemeier procedure are 0 to 16%, the Delorme procedure is 0 to 38% and laparoscopic rectopexy is 3 to 4%.[20] [21] Recurrent prolapse in perineal rectosigmoidectomy with or without levatorplasty may be due to inadequate mobilization and resection of the redundant colon. Comparing recurrence rates in patients with complete rectal prolapse showed that perineal rectosigmoidectomy with levatorplasty had fewer recurrence rates.[22] The recurrence rate was significantly higher about 38% for redo perineal rectosigmoidectomy. The recurrence rate after primary perineal rectosigmoidectomy was 18%.[23] In our study, 5 patients who underwent previous rectal prolapse repair in other centers had recurrence. Previous surgical procedures include abdominal procedure (suture rectopexy) in 3 patients and perineal procedure (Altemeier procedure) in 2 patients. All five patients underwent the Redo Altemeier procedure in our center and had no recurrence during the follow-up period.

Limitations of our study include that it is a retrospective study. Anorectal manometry to assess rectal compliance was not performed. The measurement of quality of life was not assessed.

Conclusion

Altemeier procedure for complete rectal prolapse is generally considered a safe procedure in elderly and frail patients resulting in significantly better long-term outcomes. It is also an effective procedure in young, healthy patients with low morbidity, good functional outcomes, and a low recurrence rate. Altemeier procedure for rectal prolapse is an available minimally invasive perineal approach that can be performed under regional anesthesia with no or least recurrence and better long-term functional outcomes.

Conflict of Interest

The authors declare that they have no conflict of interest.

Author's Contributions

All authors contributed to the study's conception and design. Padmanabhan S proposed the study. Thamarai Kannan M and Karthikeyan S performed research and wrote the first draft. Thamarai Kannan M, Venkkatesh S, and Krishna Prasad Chowdary Mikkilineni Bharani collected and analyzed the data. Sastha A and Villalan R contributed to the design and interpretation of the study. Sastha A, Padmanabhan S, and Karthikeyan S contributed to further drafts. All authors read and approved the final manuscript.

Data Availability Statement

There is no data availability statement.

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Publication History

Received: 11 August 2024

Accepted: 24 October 2024

Article published online:
18 December 2024