Complete rectal prolapse, although relatively uncommon,

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1 ORIGINAL CONTRIBUTION Long-Term Outcome of Altemeier s Procedure for Rectal Prolapse Donato F. Altomare, M.D. 1 & GianAndrea Binda, M.D. 2 & Ezio Ganio, M.D. 3 Paola De Nardi, M.D. 4 & Paolo Giamundo, M.D. 5 & Mario Pescatori, M.D. 6 Rectal Prolapse Study Group 1 Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy 2 Galliera Hospital, Genoa, Italy 3 Colorectal Unit, S. Gaudenzio Hospital, Novara, Italy 4 Surgical Unit, S. Raffaele Hospital, Milan, Italy 5 Department of General Surgery, Hospital S. Spirito, Bra (CN), Italy 6 Coloproctology Unit, Ars Medica Hospital, Rome, Italy INTRODUCTION: Altemeier s procedure is infrequently applied in European countries and because of the small number of patients treated in each center, its long-term reliability is uncertain. METHODS: Medical records of 93 patients (median age, 77 years) undergoing perineal rectosigmoidectomy associated with levatorplasty in 72 patients (78 percent) were reviewed; 65 patients (70 percent) suffered from major fecal incontinence. RESULTS: There was no postoperative mortality. Eight (8.6 percent) major complications were observed (3 pelvic hematomas, 1 anastomotic dehiscence, 1 sigmoid perforation, 1 pararectal abscess, and 2 late anal strictures), and 13 (14 percent) minor complications. At a mean follow-up of 41 (range, 12Y112) months the complete recurrence rate was 18 percent (17 patients); these patients were treated with a repeat Altemeier s procedure (6 patients), Delorme s operation (1 patient), Wells rectopexy (1 patient), postanal repair (1 patient), anal bulking agents (2 patients), and sacral nerve stimulation (2 patients). Anal manometry significantly improved postoperatively. Incontinence improved postoperatively in 30 cases (28 percent), deteriorated in 2 patients, while 4 patients developed minor incontinence. CONCLUSIONS: Perineal rectosigmoidectomy for rectal prolapse is a relatively safe and effective treatment, in particular, for frail, older patients, with a low Address of correspondence: Donato F. Altomare, M.D., Dept. of Emergency and Organ Transplantation, University of Bari, Piazza G Cesare, Bari, Italy. altomare@clichiru.uniba.it Dis Colon Rectum 2009; 52: 698Y703 DOI: /DCR.0b013e31819ecffe BThe ASCRS 2009 postoperative morbidity, but the recurrence rate is not negligible and restoration of continence is unpredictable. KEY WORDS: Rectal prolapse; Altemeier s procedure; Functional results; Fecal incontinence. Complete rectal prolapse, although relatively uncommon, is one of the most disabling benign anal diseases and can severely affect the quality of life. It causes a number of problems including fecal incontinence, obstructed defecation, bleeding, ulceration of the mucosa, and, exceptionally, bowel necrosis as a result of strangulation. Despite having been first described three thousand years ago, management of this disease is still a daunting task for surgeons. The perineal approach to correct the prolapse was the first-born surgical option in view of the high risk of the abdominal approach before the introduction of antibiotics and improvements in anesthesiologic techniques. Mikulicz 1 was the first to describe perineal rectosigmoidectomy for rectal prolapse, in 1889, and Miles 2 popularized this technique in 1933, for all cases of procidentia recti. However, the name of this operation remains linked to Altemeier et al., 3 who fully described this technique, associated with anterior levatorplasty, in 1971, and reported a recurrence rate of only 2.8 percent. 4 Today, the most frequent approach to rectal prolapse in Europe is abdominal rectopexy, whereas a perineal approach is often preferred in the United States, in general, using Delorme s technique for minor rectal prolapse or Altemeier s procedure for more severe forms. The best way to repair a rectal prolapse is still a matter of debate and great uncertainty still surrounds the issue, 5 mainly because of the lack of reliable randomized trials. Although the abdominal approach seems to feature less recurrences than the perineal route, it is more 698 DISEASES OF THE COLON & RECTUM VOLUME 52: 4 (2009)

2 Diseases of the Colon & Rectum Volume 52: 4 (2009) 699 invasive and not free from potential morbidity, such as bleeding or pelvic nerve damage. Furthermore, full rectal prolapse is frequent in older persons when other coexisting morbidities are often present, contraindicating performance of the operation under general anesthesia. In such cases the less invasive perineal procedures can be performed under local or spinal anesthesia. However, the long-term outcome of Altemeier s procedure is still in doubt because few articles have yet reported on large series of patients, except in Europe. 6,7 The aim of this study was to evaluate the long-term outcome of a large European series of cases involving the use of Altemeier s procedure, looking for risk factors that might affect the recurrence rate. PATIENTS AND METHODS After obtaining approval from the Institutional Review Board, the clinical records of all patients with full thickness rectal prolapse who had undergone an Altemeier s procedure since 1998, in one of ten colorectal units belonging to the Italian Society of Colorectal Surgery (SICCR) participating in the study, were retrospectively reviewed. Only patients with at least one year of follow-up were included in this study. Preoperative workup consisted of a thorough clinical history, proctologic examination, full colonoscopy, and anorectal manometry. Videodefecography and colonic transit were carried out only in selected cases. Preoperative and postoperative fecal incontinence or constipation were evaluated according to the American Medical System (AMS) 8 score (range, 0-120), and Agachan s score 9 (range, 0Y30), respectively. The AMS score was the scoring system most commonly used in these patients (39/69), although other disease severity scoring systems were also used. Preoperative management was common to all the centers and consisted of bowel cleansing with laxatives the day before the operation, systemic antibiotics, together with antithrombotic prophylaxis, started just before the procedure and continued postoperatively for three to four days as for any other anorectal surgical procedures. All of the patients underwent a perineal rectosigmoidectomy according to Altemeier; levatorplasty was performed in cases of the intraoperative finding of an extremely thin levator ani. The choice of the jackknife or lithotomic position was left to the surgeon, as was the type of anastomosis. The anesthesiologist made all choices related to the anesthesia. Postoperative data were collected, including morbidity, length of hospital stay, and administration of analgesics. Patients were followed up at the set periods (one and six months postoperatively, and yearly thereafter) and results were retrospectively recorded on a standardized data sheet. Statistical Analysis The potential effect of some risk factors on the recurrence rate was statistically evaluated by univariate analysis by use of the 2 2 test or Wilcoxon s rank-sum tests where appropriate and by bivariate logistic regression analysis. The odds ratio and 95 percent confidence interval were also evaluated. A P value G 0.05 was considered statistically significant. Statistical analyses were carried out with MedCalc Software version 9 (Mariakerke, Belgium). RESULTS Ninety-three patients (female/male ratio, 7.45; median age, 77; 80 percent in American Society of Anesthesiologists [ASA] score III or IV) underwent an Altemeier s procedure between 1998 and All patients suffered from full thickness rectal prolapse exceeding 5 cm. Associated symptoms included severe fecal incontinence in 65 patients (70 percent) and soiling in 6 others (6.5 percent). Constipation was present in 20 patients (21 percent), whereas only 14 percent had a normal bowel habit with full continence. The median AMS score in patients with incontinence was 18 (interquartile range, 15Y87) and the median Agachan s score in constipated patients was 20 (interquartile range, 7Y25). Preoperative anal manometry showed a median resting tone of 25 mmhg (interquartile ranges, 19.4Y 34.3) and a median maximal squeezing pressure of 40 mmhg (interquartile range, 33.4Y60.3 mmhg). Rectoanal inhibitory reflex was elicited only in 40 patients because of the low anal pressure. Postoperative manometry data were available only in 23 patients because most of the patients did not undergo postoperative manometric evaluation. Although the limited number of postoperative controls makes any conclusive evaluation unreliable, the median resting pressure increased significantly to 34 mmhg (interquartile range, 24.8Y41.2; P value = ) and the median squeezing pressure increased to 54 mmhg (interquartile ranges, 42.7Y62.2; P value = 0.004). One rectocele, one cystocele, and one vaginal prolapse were repaired during the performance of an Altemeier s procedure. Comorbid conditions are listed in Table 1. Fourteen patients had previously undergone surgery (eight Delorme s operations, one stapled transanal rectal resection (STARR), one stapled hemorrhoidopexy, two hemorrhoidectomies, one abdominal rectopexy with mesh, one artificial anal sphincter (ABS) in the attempt to correct the prolapse, and three to correct a vaginal or bladder prolapse). Most patients had spinal anesthesia (53 patients, 57 percent), whereas 30 (32.3 percent) and 10 (10.8 percent) patients had general or regional anesthesia, respectively. The mean duration of the operation was 125 (range, 55Y200) minutes and the median length of the resected rectocolonic specimen was 15 (range, 5Y60) cm. The coloanal anastomosis was fashioned manually in 90

3 700 ALTOMARE ET AL: ALTEMEIER FOR RECTAL PROLAPSE patients, while in 3 cases a 31mm circular stapler was used. Levatorplasty was performed in 78 percent of the cases. Outcomes No deaths occurred postoperatively. Blood loss ranged between 20 and 200 ml. Early complications occurred in 6 patients (6.5 percent): 3 pelvic hematomas, 1 anastomotic dehiscence, 1 sigmoid perforation, and 1 pararectal abscess. Surgical revision was needed in three patients: one patient with anastomotic leakage and sigmoid perforation had a fecal diversion, and one patient with a pelvic hematoma required reoperation by an abdominal route; one patient with pelvic abscess required CT scanguided drainage placement. Minor complications occurred in 13 patients (14 percent): 5 had transient anal pain and burning, 2 had a transient high temperature, 2 urinary retention, 2 had cystitis, and 2 had rectal bleeding. Late complications included 2 anal strictures, both after hand suture, that were managed successfully by anal dilation. Postoperative analgesics were needed by only 43 patients (45 percent) and just for the first 2 postoperative days. The median hospital stay was 6 (range, 1Y25) days. The minimum follow-up period was 12 months, with an average of 41 (range, 12Y112) months; two patients were lost to follow-up and 3 patients older than 90 years died of unrelated disease. A recurrence of full thickness rectal prolapse occurred in 17 patients (18 percent), and a recurrence of mucosal prolapse occurred in 6. Complete recurrences were managed by further surgery, including a repeat Altemeier s procedure in six patients (6.5 percent), a Delorme s procedure in one, and a Wells rectopexy in one. The remaining patients refused further operations. Mucosal prolapse was managed conservatively or with rubber band ligation in all cases. Three of the retreated patients had a further prolapse, two after the second Altemeier s procedure, one after postanal repair. Functional Results Postoperatively, fecal incontinence worsened in 2 patients, remained unchanged in 33 (52 percent), but TABLE 1. Comorbidities associated with full rectal prolapse and previous surgery in 93 patients Comorbidities No. of patients % Cardiopulmonary diseases Neurologic diseases Polymyositis 1 1 Multiple sclerosis 1 1 Myeloma 1 1 Diabetes Liver cirrhosis Hypothyroidism Chronic bronchitis 1 1 Previous surgery for prolapse improved in 10 (16 percent) and completely resolved in 20 patients (31 percent). Five patients with persisting fecal incontinence were further treated by postanal repair in one patient, injection of anal bulking agents in two patients, and sacral nerve stimulation in the other two. Overall, 47 percent of the patients had some improvement in continence after the operation. The AMS score decreased significantly postoperatively, from a median score of 18 (interquartile range, 15Y87) to 11 (interquartile range, 6Y62) (P G ). Four of the patients with normal preoperative continence had postoperative soiling; in one, the complaint was transient. The constipation score showed a nonsignificant decrease (from a median of 20 to 14, P value = 0.54) in the 16 patients with preoperative constipation. Univariate analysis did not show any significant relationship between recurrence of full thickness prolapse and the duration of follow-up, length of the resected specimen, levatorplasty, age, sex, and the severity of fecal incontinence, whereas patients already treated unsuccessfully for the prolapse had a significantly higher recurrence rate (odds ratio, 3.8; 95 percent confidence interval, 1.1Y 13.6; P value = 0.042) (Table 2). Levatorplasty was not related to the continence outcome. DISCUSSION The best treatment for full thickness rectal prolapse remains controversial 5 because both the perineal and the abdominal approach feature advantages and drawbacks. A full overview of the modern surgical choices has recently been published. 10 An important prospective, randomized trial, the PROSPER (PROlapse Surgery PErineal Rectopexy), has been designed and is still ongoing to answer this difficult question. The right answer probably does not lie in a single operation but in tailoring the most appropriate treatment to each individual patient. Rectal prolapse is frequent in advanced age when other comorbidities are very common, increasing the risks of general anesthesia and of an abdominal approach. In our series, 40 percent of patients were older than 80 years and 7 patients were older than 90; more than half of these patients had severe, multiple comorbidities. In these situations, a perineal approach, with the possibility of performing the operation under spinal or locoregional anesthesia, could be a true advantage. Despite the high anesthesiologic risk and the lack of a protective ileostomy before removal of the rectum and sigmoid colon with a coloanal anastomosis, these patients had no mortality and just 8.6 percent had major complications, which is less than the complication rate observed after surgery in some colorectal cancer series. 11 The choice between Delorme s and Altemeier s procedures should be based on the extent of the prolapse. In all our cases the length of the prolapse exceeded 5 cm and a perineal rectosigmoid resection was preferred to a Delorme s procedure because of the

4 Diseases of the Colon & Rectum Volume 52: 4 (2009) 701 TABLE 2. Factors potentially affecting the recurrence rate Recurrence (17 patients) Nonrecurrence (75* patients) P OR (95% CI) Female 14 (82%) 68 (87%) (0.2Y17.4) Median age (0.9Y1.1) Levatorplasty 12 (80%) 61 (79%) (0.3Y4.5) Preoperative incontinence 11 (73%) 53 (68%) NS Median length of resected specimen 15 cm 18 cm (0.9Y1.1) Previous surgery for prolapse 5 (33%) 9 (12%) (1.1Y13.6) Median length of follow-up NS OR = odds ratio; CI = confidence interval. *One patient not evaluable because of abdominal stoma. possibility of resecting more tissue and the lower expected recurrence rate. 12 Actually, the most recent experiences with this technique report a reassuring recurrence rate, ranging between 5 and 22 percent, 13 similar to the rate after Altemeier s procedure, although it is much higher in elderly patients (Q80 years old). 13 Furthermore, a very poor anal sphincter tone might predispose to failure of this operation and early recurrence. Delorme s procedure is generally better suited to smaller prolapses, and does not result in an improvement of the anal pressure, unless it is associated with other procedures like postanal repair. 14 Several of our patients had already experienced some kind of surgery to repair the prolapse, like Delorme s procedure, stapled hemorrhoidopexy, or STARR, but without success. In this subgroup the risk of recurrence was higher, especially after Altemeier s procedure. When a perineal approach is indicated, another technical issue that should be considered is the possibility of performing a levatorplasty and even a sphincteroplasty during Altemeier s procedure. 15,16 This technical step, together with the reduction of the prolapse, could contribute to an improvement of continence, but we were unable to confirm this. However, continence improved in about half of our series, despite the potential damage secondary to the removal of the rectal ampulla. The role of this effect on continence has never been investigated appropriately and is probably less important than expected, because patients who have undergone anterior rectal resection for cancer rarely complain of incontinence. 17 Another major advantage of the perineal approach over the abdominal one, even by laparoscopy, is that the operation is virtually completely painless, and leaves no scar or adhesions. This operation could also be considered in sexually active male patients with a full thickness rectal prolapse because, theoretically, it carries less risk of pelvic nerve injury and sexual dysfunctions than after rectopexy. The median hospital stay in our series was 6 days. This is a relatively short period compared with the hospital stay after a coloanal anastomosis performed for other reasons, but is quite long compared with other series reporting just one day of postoperative hospitalization. 15 This probably reflects a prudent attitude of the surgeons, stemming from a fear of anastomotic failure and its medicolegal implications, rather than a true need for patients. Our results were also comparable with those in the literature with regard to the mean age of the patients (74 vs. 77 years), the percentage of fecal incontinence (75 vs. 70), and the recurrence rate (13 vs. 18), although a very wide variation ranging from 0 to 58 percent has been reported. 4,6,8,14,16,20Y32 (Table 3) The main drawback of this operation is certainly its high recurrence rate, especially after a second Altemeier s procedure. 33 In our experience we were unable to identify any preoperative factors predictive of recurrence other than previous surgical attempts to repair the prolapse, although other studies have indicated that the recurrence rate could be related to the length of follow-up 34 or the performance of a levatorplasty. 12,16 However, in cases of recurrence a repeat Altemeier s procedure can be safely and successfully performed, as also confirmed by other experiences. 33 Fecal incontinence was reported in about 70 percent of the patients in this series, and this is the predominant symptom in many other studies. 23,26 The etiology of fecal incontinence in patients with rectal prolapse is unknown, although pelvic autonomic nerves are likely to be impaired in almost all of these patients and inhibition of the internal anal sphincter by the prolapse itself could be a contributing factor. It is hard to demonstrate whether these factors are secondary or the cause of the prolapse. Altemeier s procedure can positively affect continence thanks to the levatorplasty and a resolution of the sphincter inhibition; in fact, postoperative anal manometry showed a moderate but significant increase in anal pressure. However, the operation involves removal of the rectal ampulla, with loss of its function as a fecal reservoir. For this reason a full restoration of continence is rarely achieved, despite the significant improvement of the continence scores in about half of our series. For that reason a colonic J-pouch has been proposed 35 to improve continence. On the contrary, patients with constipation never complained of deterioration of this symptom. In the light of these results perineal rectosigmoidectomy could be considered the first-choice operation for elderly, high-risk patients affected by full thickness rectal

5 702 ALTOMARE ET AL: ALTEMEIER FOR RECTAL PROLAPSE TABLE 3. Functional results following Altemeier s procedure: literature review Authors Year No. of patients Mean age Follow-up (mo) % Recurrence % Incontinent patients % Improvement Altemeier et al. [4] Porter et al. [18] Y Friedman et al. [19] Gopal et al. [20] Prasad et al. [21] Vasilevsky and Goldberg [22] Ramanujam and Venkatesh [23] Finlay and Atchison [24] Williams et al. [16] Johansen et al. [25] Deen et al. [26] Kim et al. [27] Takesue et al. [6] Kimmins et al. [28] Zbar et al. [29] Chun et al. [30] Habr-Gama et al. [31] Boccasanta et al. [32] Altomare (present series) prolapse exceeding 5 cm, because the procedure is relatively safe and painless, it leaves no scars or wounds needing medication, but the recurrence rate is not negligible. This operation can also improve continence in about 50 percent of patients, although this is unpredictable; general anesthesia is not mandatory for the procedure; and the postoperative in-hospital stay is short. Finally, in cases of recurrence, there are no contraindications to performing a repeat procedure. ACKNOWLEDGMENTS Additional members of the Rectal Prolapse Study Group are as follows: Marcella Rinaldi, M.D. (Bari, Italy); Aldo Infantino, M.D. (S. Vito al Tagliamento, Italy); Giuseppe Dodi, M.D. (Padua, Italy); Nicola Tricomi, M.D. (Palermo, Italy); and Diego Segre, M.D. (Cuneo, Italy). The authors thank Mary Victoria Pragnell for correcting the manuscript, Tiziana De Santis for the statistical analysis, and Marina Fiorino from the SICCR Science Center of the Italian Society of ColoRectal Surgery for help in collecting patients records. REFERENCES 1. Mikulicz J. Zur operative Behandlung des prolapsus recti et coli invaginali. Arch Klin Chir 1889;38:74Y9. 2. Miles WE. Rectosigmoidectomy as a method for procidentia recti. Proc R Soc Med 1933;26:1445Y Altemeier WA, Giuseffi J, Hoxworth P. Treatment of extensive prolapse of the rectum in aged and debilitated patients. Arch Surg 1952;65:72Y Altemeier WA, Culbertson WR, Schowengerdt C, Hunt J. Nineteen years experience with the one-stage perineal repair of rectal prolapsed. Ann Surg 1971;173:993Y Bachoo P, Brazzelli M, Grant A. Surgery for complete rectal prolapse in adults. Cochrane Database Syst Rev 2000;2:CD Takesue Y, Yokoyama T, Murakami Y, et al. The effectiveness of perineal rectosigmoidectomy for the treatment of rectal prolapse in elderly and high-risk patients. Surg Today 1999; 29:290Y3. 7. Habr-Gama A, Jacob CE, Jorge JM, et al. Rectal procidentia treatment by perineal rectosigmoidectomy combined with levator ani repair. Hepatogastroenterology 2006;53:213Y7. 8. American Medical Systems: Fecal incontinence scoring system. Minnetonka: American Medical Systems, Agachan F, Chen T, Pfeifer J, et al. A constipation scoring system to simplify evaluation and management of constipated patients. Dis Colon Rectum 1996;39:681Y Altomare DF, Pucciani F. Rectal prolapse. Diagnosis and clinical management. Berlin: Springer-Verlag, Koh PK, Tang CL, Eu KW, Samuel M, Chan E. A systematic review of the function and complications of colonic pouches. Int J Colorectal Dis 2007;22:543Y Agachan F, Pfeiffer J, Joo JS, et al. Results of perineal procedures for the treatment of rectal prolapse. Am Surg 1997; 63:9Y Tsunoda A, Yasuda N, Yokoyama N, et al. Delorme s procedure for rectal prolapse. Clinical and physiological analysis. Dis Colon Rectum 2003;46:1260Y Pescatori M, Interisano A, Stolfi V, Zoffoli M. Delorme s operation and sphincteroplasty for rectal prolapsed and fecal incontinence. Int J Colorect Dis 1998;13:223Y Chun SW, Pikarsky AJ, You SY, et al. Perineal rectosigmoidectomy for rectal prolapse: role of the levatorplasty. Tech Coloproctol 2004;8:3Y Williams JG, Rothenberger DA, Madoff RD, Goldberg SM. Treatment of rectal prolapse in the elderly by perineal rectosigmoidectomy. Dis Colon Rectum 1992;35:830Y Enker WE, Merchant N, Cohen AM, et al. Safety and efficacy of low anterior resection for rectal cancer: 681 consecutive cases from a specialty service. Ann Surg 1999;230:544Y52.

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