The Altemeier Procedure: Is It Right for All Ages?

Educational Objectives

The goal of this lecture is to improve the surgical care of patients with rectal prolapse. After hearing and assimilating this lecture, the clinician will be better able to:

1. Consider the Altemeier procedure for patients with rectal prolapse.

Summary

Surgical approaches to rectal prolapse: perineal approaches include Delorme procedure and rectosigmoidectomy (Altemeier procedure); abdominal approaches include low anterior resection

Author’s series: technique — preoperative bowel preparation; operation performed with patient in prone position (Altemeier positioned patients in lithotomy position); some operations performed in combination with gynecologists (eg, for repair of prolapse of other pelvic organs); Lone Star retractor improves exposure; circumferential dissection undertaken above dentate line (important to retain tissue above dentate line); dissection started anteriorly with entry into avascular cul-de-sac; mesentery divided afterwards; after excision of rectum, anastomosis started posteriorly (area of greatest tension); results — 103 patients; mean age 68 yr; youngest patient aged 20 yr; mostly women; mean operative time ≈90 min (some operations prolonged because of combined hysterectomy); mean length of resected specimen 7 cm; patients not fed for 1 to 2 days, because some patients have postoperative ileus and distention; all eating ≤3 to 4 days; length of stay ≈4 days; no mortality; 4 patients returned to operating room, 2 for loosening of overly tight levatorplasty and 2 for temporary diversion for fistulas; constipation improved in most patients; most patients had improved continence but some had worsening incontinence; 9 had previous repairs of rectal prolapse by perineal approach; 3 had previous repairs by abdominal approach; patients in latter group had no complications despite theoretical risk of inadequate blood supply

Review of literature: rate of mortality low (as expected for Altemeier procedure); most series show improvement in continence >50%; rates of recurrence in recent series generally <10%; persistent incontinence — major cause of postoperative patient dissatisfaction despite successful repair of prolapse; groups at University of Minnesota and Mayo Clinic previously believed that levatorplasty unnecessary in repair of rectal prolapse; subsequent report from University of Minnesota (1992) advocated concomitant levatorplasty because of dramatic improvement in fecal incontinence; Wexner recommends attempting levatorplasty; speaker believes that levatorplasty easy to perform, but whether it reduces rate of recurrence and improves fecal incontinence remains uncertain

Age of patients: Altemeier applied procedure to all age groups; University of Minnesota — gradually expanded indications, concluding that results obtained with Altemeier procedure not substantially inferior to those achieved with abdominal repair; 1984 review found that abdominal repair performed in 95% of patients with rectal prolapse; 1999 study found that perineal repair performed in ≈80% of patients with prolapse; in more recent years, trend has favored abdominal approach because of advances in minimally invasive surgery; robotic surgery has popularized rectopexy; series from Washington University (Glasgow et al, 2008) reviewed 106 patients with rectal prolapse repaired by Altemeier procedure; reported excellent results with improvements in obstructive symptoms and fecal incontinence; found greater variety of complications with abdominal approaches (eg, small bowel obstruction, hernias); care must be taken during pelvic dissection in men to avoid sexual dysfunction

Readings

Cirocco WC: The Altemeier procedure for rectal prolapse: an operation for all ages. Dis Colon Rectum 2010 Dec;53(12):1618-23; Glasgow SC et al: Recurrence and quality of life following perineal proctectomy for rectal prolapse. J Gastrointest Surg 2008 Aug;12(8):1446-51; Kim DS et al: Complete rectal prolapse: evolution of management and results. Dis Colon Rectum 1999 Apr;42(4):460-6.

Disclosures

For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Cirocco was recorded at the Ohio Valley Society of Colon and Rectal Surgeons Annual Meeting, presented by the Cleveland Clinic Foundation for Continuing Education and the Ohio Valley Society of Colon and Rectal Surgeons, and held March 25, 2017 in Cleveland, OH. For information on the next Ohio Valley Society of Colon and Rectal Surgeons Annual Meeting, please visit clevelandclinicmeded.com. The Audio Digest Foundation thanks the faculty and the sponsor for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

GS641103

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.