Perineal rectosigmoidectomy for incarcerated rectal prolapse (Altemeier’s procedure)

Abstract

Perineal procedures have higher recurrence and lower mortality rates than abdominal alternatives for the treatment of rectal prolapse. Presence of incarceration and strangulation also influences treatment choice. Perineal rectosigmoidectomy is one of the treatment options in patients with incarceration and strangulation, with low mortality and acceptable recurrence rates. This operation can be performed especially to avoid general anesthesia in old patients with co-morbidities. We aimed to present perineal rectosigmoidectomy and diverting loop colostomy in a patient with neurological disability due to spinal trauma and incarcerated rectal prolapse. Keywords:Altemeier's procedure, perineal rectosigmoidectomy, rectal prolapse INTRODUCTIONRectal prolapse is a rare disease with an increased frequency after the fifth decade. Rectoanal inhibitory reflex deterioration, high-pressure intermittent rectal motor activity, anorectal sensation disorders, and pudendal neuropathy have been suggested in its pathophysiology, but still its exact etiology is unknown (1). Clinically, it may present as mucosal prolapse (partial or pseudoprolapsus), internal prolapse (rectal intussusception), or full-thickness prolapse (2). Surgical treatment options can be abdominal and/or perineal approach. Despite the higher recurrence rate, due to its low complication rates and better patient tolerance the perineal approach is often preferred in elderly patients with comorbidities, and can be applied in irreducible cases requiring emergency surgery. In this article, a 60-year-old male patient who had had thoracic spine fractures and neurological sequela due to being trapped in a collapsed building twenty years ago, and who underwent perineal rectosigmoidectomy (Altemeier procedure) and protective sigmoid colostomy for incarcerated rectal prolapse is presented. CASE PRESENTATIONA 60-year-old male patient with reduced sensation and muscle strength in both lower limbs and left drop foot sequela due to a traumatic injury twenty years ago presented to the emergency room with an irreducible mass and pain in the anal region that emerged during defecation 6 hours ago. He had experienced fecal incontinence, constipation, and a rectal prolapse that could be manually reduced for the past 6 months. He had hypertension, diabetes mellitus type 2, and was being treated for benign prostatic hypertrophy. The patient was conscious, cooperative, and oriented. On physical examination, his vital signs were normal except for sinus tachycardia (120/min). On anal inspection, he had 20 cm full-thickness prolapse of the rectum and sigmoid colon. The prolapsed segment was edematous and hyperemic. There were areas of ulceration up to 2 cm in diameter. Bowel sounds were normoactive, there were no signs of abdominal tenderness, defense or rebound tenderness. His neurologic examination revealed a left drop foot, and slightly atrophied muscles in both calves and lower limbs, more prominent on the left. Both lower extremity manual muscle strength was determined as 3/5. Although ...

A retrospective study of rectal prolapse in Chitwan Medical College

“…The need of ileostomy for anastomotic leak also described in the literature. 8 In our study, one patient developed abdominal distension and per rectal bleeding suggestive of anastomotic dehiscence which is managed conservatively.…”

“…Surgical options are more challenging in case of incarceration, due to the increased risk of the anastomotic leak which is 25% in incarcerated prolapse as compared to elective recto sigmoidectomy which is 2-5%. 6,8 The most widely practiced operation in the emergency setting is perineal proctor sigmoidectomy also called Altemeier´s operation. 5,9 Laparotomy is avoided and can be done under spinal anesthesia.…”

Strangulated recurrent rectal prolapse after a Delorme intervention, a case report

“…1 The most common approach for strangulation is Altemeier. 9 To our knowledge, this is the first case describing a necrotic strangulated recurrent prolapse after a Delorme procedure. Two case reports were found describing the phenomenon after an Altemeier operation.…”

Incarcerated complete rectal prolapse managed by Altemeier’s procedure

“…1 To date, <40 cases have been described in the English literature. 2 Rectal incarceration may progress to strangulation, which is life-threatening, but may be the first presentation. 3 Although > 100 operative procedures have been described for the treatment of rectal prolapse, the options are limited in a case of incarceration and strangulation.…”

“…1 A poor outcome of ASV treatment is usually associated with its delayed initiation and associated complications of high dosage, related to allergic reactions. 2…”