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

Abstract

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...

Laparoscopic ventral mesh rectopexy vs Delorme's operation in management of complete rectal prolapse: a prospective randomized study

“…A study on 3254 patients compared the laparoscopic approach, open abdominal approach and perineal approach revealing that open resection rectopexy was associated with a higher morbidity compared with the perineal approach ( P = 0.03) while morbidity of the laparoscopic rectopexy group was comparable. The overall incidences of mortality and morbidity of laparoscopic rectopexy were 0.01% and 9.3% .…”

Long-term outcome of perineal rectosigmoidectomy for rectal prolapse

“…Rectal prolapse is generally associated with other comorbidities [2,6,7,[11][12][13][14][15]24], and the clinical presentation can be varied, ranging from progressive incontinence to constipation due to obstructive evacuation [11]. Hatch and Steele estimate that fecal incontinence is reported by 75% of patients with rectal prolapse and constipation occurs in 10% to 65% [7].…”

“…There are more than 100 surgical procedures for the treatment of rectal prolapse, suggesting that no technique has achieved satisfactory results [1,2,4,5,9,10,12,13,17,25]. The approach may be abdominal or perineal, the first with lower relapse rates, however having higher complication rates [7,14].…”

Delorme’s Procedure for Complete Rectal Prolapse: A Study of Recurrence Patterns in the Long Term

“…In our opinion, age or surgical risk should not discourage an abdominal approach. A recent survey performed on the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) revealed that the morbidity and mortality of laparoscopic surgery were similar to those of perineal surgery in elderly patients [ 22 ].…”