Is the Abdominal Repair of Rectal Prolapse Safer than Perineal Repair in the Highest Risk Patients? An NSQIP Analysis

Fang, Sandy H.; Cromwell, John W.; Wilkins, Kirsten Bass; Eisenstat, Theodore E.; Notaro, Joseph R.; Alva, Suraj; Bustami, Rami; Chinn, Bertram T.

doi:10.1097/dcr.0b013e31826ab5e6

Cited by 43 publications

(32 citation statements)

References 11 publications

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“…A meta-analysis by Purkayastha et al also showed laparoscopic abdominal rectopexy to have equivalent efficacy to open repair in terms of recurrence rates and morbidity, with decreased length of hospital stay [21]. There are very few studies comparing laparoscopic resection and/or rectopexy with perineal repair [24][25][26]. Those that have been published are small single-institution studies or retrospective database reviews.…”

Section: Resultsmentioning

confidence: 99%

Surgical treatments for rectal prolapse: how does a perineal approach compare in the laparoscopic era?

et al. 2014

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Background Patients with rectal prolapse often have significant comorbidities that lead surgeons to select a perineal resection for treatment despite a reported higher recurrence rate over abdominal approaches. There is a lack of data to support this practice in the laparoscopic era. The objective of this study was to evaluate if risk-adjusted morbidity of perineal surgery for rectal prolapse is actually lower than laparoscopic surgery.Design A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database as performed for patients undergoing surgical treatment of rectal prolapse between 2005 and 2011. Outcomes were analyzed according to procedure-type: laparoscopic rectopexy (LR), laparoscopic resection/rectopexy (LRR), open rectopexy (OR), open resection/rectopexy (ORR), and perineal resection (PR). A multivariate logistic regression was used to compare riskadjusted morbidity and mortality between each procedure. Main outcome measures were 30-day morbidity and mortality.Results Among 3,254 cases sampled, a laparoscopic approach was used in 22 %, an open abdominal approach in 30 %, and PR in 48 %. Patients undergoing PR were older (76) and had a higher ASA (3) compared to laparoscopic (58, 2) and open abdominal procedures (58, 2). Risk-adjusted mortality could not be assessed due to a low overall incidence of mortality (0.01 %). Overall morbidity was 9.3 %. ORR was associated with a higher risk-adjusted morbidity compared to PR (OR: 1.89 CI (1.19-2.99), p = 0.03). There were no significant differences in risk adjusted morbidity found between LR and LRR compared to PR p = 0.18;), p = 0.18). Laparoscopic cases averaged 27 min longer than open cases (p\0.001).Conclusion Laparoscopic rectal prolapse surgery has comparable morbidity and mortality to perineal surgery. A randomized trial is indicated to validate these findings and to assess recurrence rates and functional outcomes.The Delorme procedure for the surgical treatment of rectal prolapse was first described by the French surgeon Edmond Delorme in 1900 [1,2]. Since that time, over 100 different surgical procedures have been proposed for the management of this condition [3,4]. Although the majority of these procedures are now of only historical interest, many different techniques are still being used today. Procedures to address rectal prolapse can broadly be split into two main approaches-abdominal and perineal. The primary goals of the operation are to correct the prolapse, alleviate preoperative discomfort, and to prevent or improve fecal incontinence or constipation [5]. Traditionally, a perineal approach has been considered the operation of choice in any elderly or high-risk patient, because it was associated with lower perioperative morbidity, decreased pain, and a shorter length of hospital stay [6]. However, advances in minimally invasive techniques have called into question the optimal procedure for rectal prolapse, especially when considering long-term outcomes such as recurrence or an...

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Section: Resultsmentioning

confidence: 99%

Surgical treatments for rectal prolapse: how does a perineal approach compare in the laparoscopic era?

et al. 2014

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“…20 Proctectomy cases performed by a general surgery (including colorectal surgery) primary team and included in the NSQIP “proctectomy basket” of CPT codes were organized into 16 procedure groups (Table 1). 5 In consideration of the different risk profile of patients undergoing surgery for rectal prolapse, 21 these patients were excluded unless diagnoses other than rectal prolapse were specified. Emergency cases and patients requiring chronic ventilator use were excluded.…”

Section: Methodsmentioning

confidence: 99%

Effect of BMI on Outcomes in Proctectomy

Hrabe

Sherman

Charlton

et al. 2014

Diseases of the Colon &Amp; Rectum

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Background The unique surgical challenges of proctectomy may be amplified in obese patients. We examined surgical outcomes of a large, diverse sample of obese patients undergoing proctectomy. Objective To determine whether increased body mass index is associated with increased complications in proctectomy. Design A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program database (2010 and 2011). Patients Patients undergoing non-emergent proctectomy, excluding rectal prolapse cases. Patients were grouped by body mass index using the World Health Organization (WHO) classification: underweight (body mass index <18.5); normal (18.5-24.9); overweight (25-29.9); class I (30-34.9), class II (35-39.9), and class III (≥40) obesity. Main Outcome Measures We analyzed the effect of pre- and intra-operative factors on 30-day outcomes. Continuous variables were compared with Wilcoxon Rank-Sum tests, proportions with the Fisher's Exact or Chi-squared tests. Logistic regression controlled for the effects of multiple risk factors. Results Among 5570 patients, class I, II, and III obesity were significantly associated with higher rates of overall complications (44.0%, 50.8%, and 46.6%, respectively, vs. 38.1% for normal weight patients; p<0.05). Superficial wound infection was significantly higher in classes I, II, and III (11.6%, 17.8%, and 13%, respectively, vs. 8.0% for normal weight patients; p<0.05).Operative times for all obesity classes were significantly longer than for normal weight patients. On multivariate analysis, an obese body mass index independently predicted complications; odds ratios (95% confidence intervals) were 1.36 (1.14-1.62) for class I obesity, 1.99 (1.54-2.54) for class II, and 1.42 (1.02-1.96) for class III. Limitations Retrospective design with limited follow up. Conclusions Class I, II, and III obese patients were at significantly increased risk for morbidity compared to normal BMI patients. Class II obese patients had the highest rate of complications, a finding that deserves further investigation.

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“…These formed 16 primary procedure categories, as described[16]. Due to the unique risk profile of rectal prolapse surgery[18], prolapse procedures were excluded, except for proctopexy with sigmoid resection which was included when diagnoses other than rectal prolapse were designated. Low anterior resection is not supplied with the “proctectomy basket”.…”

Section: Methodsmentioning

confidence: 99%

Development of an Improved Risk Calculator for Complications in Proctectomy

Sherman

Hrabe

Charlton

et al. 2014

Journal of Gastrointestinal Surgery

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Rectal surgery is associated with high complication rates, but tools to prospectively define surgical risk are lacking. Improved preoperative risk assessment could better inform patients and refine decision making by surgeons. Our objective was to develop a validated model for proctectomy risk prediction. We reviewed non-emergent ACS-NSQIP proctectomy data from 2005-2011 (n=13,385). Logistic regression identified variables available prior to surgery showing independent association with 30-day morbidity in 2010-2011 (n=5,570). The resulting risk model's discrimination and calibration were tested against the NSQIP-supplied morbidity model, and performance was validated against independent 2005-2009 data. Overall morbidity for proctectomy in 2010-2011 was 40.2%; significantly higher than the 23.0% rate predicted by the NSQIP-provided general and vascular surgery risk model. Frequent complications included bleeding (16.3%), superficial infection (9.2%), and sepsis (7.4%). Our novel model incorporating 17 preoperative variables provided better discrimination and calibration (p<0.05) than the NSQIP model, and was validated against 2005-2009 data. A web-based calculator makes this new model available for prospective risk assessment. We conclude that the NSQIP-supplied risk model underestimates proctectomy morbidity and that this new, validated risk model and risk-prediction tool (http://myweb.uiowa.edu/sksherman) may allow clinicians to counsel patients with accurate risk estimates using data available in the preoperative setting.

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Is the Abdominal Repair of Rectal Prolapse Safer than Perineal Repair in the Highest Risk Patients? An NSQIP Analysis

Cited by 43 publications

References 11 publications

Surgical treatments for rectal prolapse: how does a perineal approach compare in the laparoscopic era?

Surgical treatments for rectal prolapse: how does a perineal approach compare in the laparoscopic era?

Effect of BMI on Outcomes in Proctectomy

Development of an Improved Risk Calculator for Complications in Proctectomy

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