Journal: Perineal resectional procedures for the treatment of complete rectal prolapse: A systematic review of the literature

Reasoning:

• Several procedures exist for the surgical management of complete rectal prolapse via the abdominal or perineal approach, including Altemeier procedure, Delorme procedure, and perineal stapled prolapse resection (PSR)
• Given the psychiatric history of our patient, what is the best treatment option for her?

Purpose:

• The purpose of this systematic review is to assess the various outcomes of perineal resectional procedures as listed above in the treatment of external, full-thickness rectal prolapse

Methods:

• Databases utilized included: PubMed/Medline, SCOPUS, Cochrane Library to screen though 1077 initial articles to include 39 final studies
• Primary outcome studied was the clinical recurrence of full-thickness rectal prolapse
• Secondary outcomes studied included postop improvement of constipation/fecal incontinence, functional bowel scores, mortality rates/complications, operative time, and length of hospital stay

Key Points:

• Surgical management for rectal prolapse is achieved through either resection or suspension/fixation of rectum
• Altemeier procedure: full thickness excision of rectum + part of sigmoid colon
• Delorme procedure: mucosal resection + plication of muscle layer of rectum
• Although there is interest in laparoscopic approach and abdominal approach is thought to have lower recurrence rates than the perineal approach, there is no evidence to support superiority of abdominal over perineal approach
• Overall recurrence rate ~16%
  • Altemeier had slightly lower median recurrence rate but was statistically insignificant
• Improvement in bowel function/continence
  • Altemeier 60%, Delorme 70%, < 25% PSR
  • All perineal resections resulted in significant improvement of constipation, especially after Altemeier
• However, there are no differences in life quality between abdominal and perineal approaches
• PSR has shorter operation time due to simpler technique but Delorme was shown to have shorter hospital stay
• 10% of patients experienced major complications after Delorme/PSR (suture/staple line bleeding) as compare to 60% of Altemeier patients (commonly anastomotic dehiscence/leak)

Conclusion:

• Abdominal approaches are not associated with lower recurrence and higher morbidity rates than perineal approaches
• Although perineal approaches are associated with relatively high recurrence rate, there is low complication rate and satisfactory improvement in bowel function

This entry is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International license.