Pelvic Floor Disorders: Surgical Approach

16. The Altemeier’s Procedure for External Rectal Prolapse

Simona Giuratrabocchetta1, Ivana Giannini1, Maria Di Lena1 and Donato F. Altomare 

(1)

Department of Emergency and Organ Transplantation, Aldo Moro University, Bari, Italy

Donato F. Altomare

Email: donatofrancesco.altomare@uniba.it

Abstract

During the 19th and 20th centuries, different perineal approaches were proposed for the treatment of external rectal prolapse, and despite the high recurrence rate of the prolapse they were preferred to the abdominal approach. In recent decades, the improvement in general anesthesia and perioperative care, and the widespread use of laparoscopic techniques, have enabled the abdominal approach to become more common, as it is believed to carry a lower recurrence rate and probably better functional results.

16.1 Introduction

During the 19th and 20th centuries, different perineal approaches were proposed for the treatment of external rectal prolapse, and despite the high recurrence rate of the prolapse they were preferred to the abdominal approach. In recent decades, the improvement in general anesthesia and perioperative care, and the widespread use of laparoscopic techniques, have enabled the abdominal approach to become more common, as it is believed to carry a lower recurrence rate and probably better functional results.

However, the perineal approach to rectal prolapse has not been abandoned altogether, and it is usually indicated in elderly, high-risk, frail patients for emergency incarcerated external prolapse [1] and gangrenous rectal prolapse [2], and it is often preferred to the abdominal approach in the USA because it is less invasive and results in a shorter length of hospital stay [3].

Perineal rectosigmoidectomy to treat external full-thickness rectal prolapse was first described by Altemeier in 1952 [4]. The procedure consists of a perianal rectosigmoidectomy, followed by a coloanal anastomosis, which is hand-sewn or stapled, and associated with a levatorplasty. It is indicated in symptomatic patients with an external prolapse exceeding 5 cm, which has an important impact on the quality of life because of bleeding, mucus discharge, and fecal incontinence.

16.2 Surgical Technique

Antibiotics and antithrombosis prophylaxis are indicated in the perioperative period. Preoperative bowel cleaning is also suggested. The anesthesia can be epidural (this is suggested because of fewer complications); general or local anesthesia have also been used by some surgeons. Patients can be placed in a lithotomy or jack-knife position; the latter is preferred because of its better and safer view of the operating field.

Using a Lone-Star self-retractor, the anal canal and the dentate line become more evident and the full-thickness rectal prolapse can be exteriorized with Babcock forceps. A mark is made with diathermy on the prolapsed mucosa to identify the dissection line; this line should be far enough away from the internal anal sphincter (5–6 cm from the anal verge) so that if a stapled anastomosis is planned it can be performed safely without the inclusion of the internal anal sphincter fibers.

The dissection is performed circumferentially by diathermy, including all the layers of the rectal wall, mobilizing all the extraperitoneal rectum, and sealing all the mesorectal vessels (with diathermy, ultrasound, or radiofrequency) close to the viscerum where they enter the posterior part of the rectum. When all the extraperitoneal rectum has been mobilized, the pouch of Douglas is opened and the peritoneal cavity can be explored. The dissection continues following the sigmoid wall, until the colon can be exteriorized without tension.

A posterior levatorplasty can be performed before resecting the colon, as this procedure is believed to decrease recurrence rate [5]. The levator ani muscle is exposed through the self retractor, and two or three nonabsorbable interrupted stitches (2-0 Prolene) are applied to its posterior plication. The sutures should allow a finger to be passed easily through the colon and the plicated muscle. Reclosure of the pouch of Douglas or the peritoneum is not strictly necessary.

The rectal wall is then cut anteriorly and a first absorbable stitch (3-0 Vicryl) is passed from the colonic wall to the anal canal, including both mucosa and muscle layers. The same action is repeated laterally, in the same way, leaving the posterior rectal wall as the last place to fix, after complete resection of the elongated colon. At least other two stitches are then apposed between each cardinal point in the same way. An excessive number of stitches or an uninterrupted suture could lead to stricture of the coloanal anastomosis.

During performance of the anastomosis, care should be taken to prevent contamination of the pouch of Douglas by stool. Once the hemostasis is controlled and the anastomosis is completed, the colon can be replaced inside the peritoneal cavity.

The coloanal anastomosis can be made by a circular stapler (31, 33, or 34 mm): a purse-string with nonabsorbable stitches (2-0 Prolene) is made on the proximal colonic wall where the head of the stapler is placed and another pursestring is fashioned on the anorectum around the stapler. After the introduction of the stapler into the anus, the sutures are narrowed and tied, and the device is activated and withdrawn. The resected sample should include about 1 cm of colon and anorectum. A hemostatic sponge can be left into the anus.

There is no need for postoperative medication, and postoperative analgesics can be delivered at the patient’s request; antibiotic prophylaxis is suggested for up to 2–3 days postoperatively, and oral feeding can be resumed after 1–2 days [4].

16.3 Complications

The overall complication rate ranges between 0% and 13% [6–96], and most complications are minor. Rare major complications reported include pelvic hematoma, anastomotic dehiscence and stricture, sigmoid perforation, pararectal abscess, and strangulated ileus trough transcoloanal anastomosis [10]. The mortality rate is relatively low (0–6%) [1113] despite the inclusion of elderly frail patients in the case series, probably because of the mini-invasive approach of the procedure, the shorter hospital stay, and early mobilization.

16.4 Recurrence

The major drawback of Altemeier’s procedure is the high recurrence rate; the medical literature reports a wide range of recurrence from 0% to 58% [1419], regardless of technical details and length of follow-up. Recurrence usually occurs in the first 2 years postoperatively, although the definition of recurrence is still not clear, because in some studies the presence of a minimal mucosal prolapse is also considered to be a recurrence. Most authors report a recurrence in about 10–20% of cases [121320]. A few authors [2122] have reported a lower recurrence rate (about 5–6%), but the sample size was too small (18 and 41 patients) and the follow-up period was too short (10 months) to produce meaningful results; in other studies with a larger sample of patients and longer follow-up, the reported recurrence rate was 14% and 18%, regardless of the length of the colon resected or the levatorplasty [723].

The association of levatorplasty with the technique was introduced as a means of reducing recurrence. Chun et al. [5] proved its efficacy in a study that was not randomized or controlled, showing that after a mean follow-up of 28 months, recurrence rate was 20.6% in patients without levatorplasty compared with 7.7% in the levatorplasty group, with no significant changes in functional outcomes between the two groups. These results were confirmed by Habr-Gama et al. [9], who reported a 7% recurrence rate after 24 months, irrespective of the coloanal anastomosis produced.

Another critical point for prolapse recurrence could be the length of the resected specimen, although no studies have confirmed this hypothesis. However, if there is residual mobile colon and weakness of the connective tissue in the pelvic diaphragm, then this might contribute to recurrence of the prolapse.

Recurrent prolapse can be safely re-treated by using the perineal route: among the treatments proposed, another Altemeier procedure or Delorme procedure can be performed, however an abdominal rectopexy is sometimes considered in patients fit to have an abdominal operation. Other procedures, such as postanal repair, anal bulking agent injection, or sacral nerve stimulation [18] are often required to help the patient with associated fecal incontinence.

16.5 Functional Outcome

The functional outcome in this operation is of paramount importance; nevertheless, this information is lacking in most studies, and a validated questionnaire on the quality of life has been reported in only a few recent papers.

About 80% of patients who undergo to the Altemeier procedure have fecal incontinence associated with external rectal prolapse [12151823], and this has been reported to be improved in about 70–100% of patients after the operation [5917]; on the other hand, however, some patients complain of new-onset minor fecal incontinence (soiling, liquid stool) after treatment.

The reasons for fecal incontinence include inhibition of the internal anal sphincter by the prolapse itself or impairment of pelvic autonomic nerves. However, it has been shown that pudendal neuropathy is not related to the incontinence, because even patients with severe pudendal neuropathy show continence improvement after the Altemeier procedure [24]. It is thought that removal of the rectal ampulla, with the loss of its function of reservoir and compliance, could account for worsening of incontinence.

16.6 Comparison with Other Procedures

The old debate as to whether the abdominal or the perineal approach for full-thickness rectal prolapse is best was recently investigated by a multicenter European randomized controlled trial (the Prosper Trial), in which nearly 300 patients with full-thickness rectal prolapse were randomly treated with different approaches (abdominal versus perineal, suture versus resection rectopexy, Delorme versus Altemeier). Although not all the patients recruited in the trial were randomized for the treatment, the results showed no statistically significant differences in the abdominal versus perineal group, in terms of recurrence and quality of life [25].

References

1.

Altemeier WA, Giuseffi J, Hoxworth P (1952) Treatment of extensive prolapse of the rectum in aged or debilitated patients. AMA Arch Surg 65:72–80PubMedCrossRef

2.

Zuo ZG, Song HY, Xu C et al (2010) Application of Altemeier procedure in the emergent management of acute incarcerated rectal prolapse. Zhonghua Wei Chang Wai Ke Za Zhi 13:427–429PubMed

3.

Voulimeneas I, Antonopoulos C, Alifierakis E et al (2010) Perineal rectosigmoidectomy for gangrenous rectal prolapse. World J Gastroenterol 16:2689–2691PubMedCrossRef

4.

Altomare DF, Rinaldi M (2008) Perineal approach to external rectal prolapse: The Altemeier Procedure. In: Altomare DF, Pucciani F (eds) Rectal prolapse, diagnosis and clinical management. Springer-Verlag Italia, Milan, pp 97–102CrossRef

5.

Chun SW, Pikarsky AJ, You SY et al (2004) Perineal rectosigmoidectomy for rectal prolapse: role of levatorplasty. Tech Coloproctol 8:3–8PubMedCrossRef

6.

Pescatori M, Zbar AP (2009) Tailored surgery for internal and external rectal prolapse: functional results of 268 patients operated upon by a single surgeon over a 21-year period. Colorectal Dis 11:410–419PubMedCrossRef

7.

Altomare DF, Binda G, Ganio E et al (2009) Long-term outcome of Altemeier’s procedure for rectal prolapse. Dis Colon Rectum 52:698–703PubMedCrossRef

8.

Hammond K, Beck DE, Margolin DA et al (2007) Rectal prolapse: a 10-year experience. Ochsner J 7:24–32PubMed

9.

Habr-Gama A, Jacob CE, Jorge JM et al (2006) Rectal procidentia treatment by perineal rectosigmoidectomy combined with levator ani repair. Hepatogastroenterology 53:213–217PubMed

10.

Di Lena M, Angarano E, Giannini I et al (2013) Strangulated ileal trans-coloanal-anastomotic hernia: A complication of Altemeier’s procedure previously never reported. World J Gastroenterol 19:776–777PubMedCrossRef

11.

Finlay IG, Aitchison M (1991) Perineal excision of the rectum for prolapse in the elderly. Br J Surg 78:687–689PubMedCrossRef

12.

Williams JG, Rothenberger DA, Madoff RD et al (1992) Treatment of rectal prolapse in the elderly by perineal rectosigmoidectomy. Dis Colon Rectum 35:830–834PubMedCrossRef

13.

Kim DS, Tsang CB, Wong WD et al (1999) Complete rectal prolapse: evolution of management and results. Dis Colon Rectum 42:460–466PubMedCrossRef

14.

Prasad ML, Pearl RK, Abcarian H et al (1986) Perineal proctectomy, posterior rectopexy, and postanal levator repair for the treatment of rectal prolapse. Dis Colon Rectum 29:547–552PubMedCrossRef

15.

Porter NH (1971) Surgery for rectal prolapse. Br Med J 3:113PubMedCrossRef

16.

Friedman R, Muggia-Sulam M, Freund HR (1983) Experience with the one-stage perineal repair of rectal prolapse. Dis Colon Rectum 26:789–791PubMedCrossRef

17.

Zbar AP, Takashima S, Hasegawa T et al (2002) Perineal rectosigmoidectomy (Altemeier’s procedure): a review of physiology, technique and outcome. Tech Coloproctol 6:109–116PubMedCrossRef

18.

Marino F, Binda G, Ganio E (2007) Long-term outcome of Altemeier procedure for full thickness rectal prolapse. A survey of 6 colorectal units. Tech Coloproctol 11:172–173

19.

Cirocco WC (2010) The Altemeier procedure for rectal prolapse: an operation for all ages. Dis Colon Rectum 53:1618–1623PubMedCrossRef

20.

Takesue Y, Yokoyama T, Murakami Y et al (1999) The effectiveness of perineal rectosigmoidectomy for the treatment of rectal prolapse in elderly and high-risk patients. Surg Today 29:290–293PubMedCrossRef

21.

Gopal KA, Amshel AL, Shonberg IL et al (1984) Rectal procidentia in elderly and debilitated patients. Experience with the Altemeier procedure. Dis Colon Rectum 27:376–381PubMedCrossRef

22.

Ramanujam PS, Venkatesh KS (1988) Perineal excision of rectal prolapse with posterior levator ani repair in elderly high-risk patients. Dis Colon Rectum 31:704–706PubMedCrossRef

23.

Ris F, Colin JF, Chilcott M et al (2012) Altemeier’s procedure for rectal prolapse: analysis of long-term outcome in 60 patients. Colorectal Dis 14:1106–1111PubMedCrossRef

24.

Steele SR, Goetz LH, Minami S et al (2006) Management of recurrent rectal prolapse: surgical approach influences outcome. Dis Colon Rectum 49:440–445PubMedCrossRef

25.

Senapati A, Gray RG, Middleton LJ et al (2013) PROSPER: a randomised comparison of surgical treatments for rectal prolapse. Colorectal Dis. doi:10.1111/codi.12177