Explaining the undulating outcomes of perineal rectosigmoidectomy (Altemeier Procedure) for rectal prolapse over the last century: technique matters!

Perineal rectosigmoidectomy (PR) as definitive treatment for chronic rectal prolapse has a long history going back to a single case in 1882 (Auffret, France [1]) and the first published series in 1889 (Mikulicz, Germany [2]). Miles at St. Mark’s Hospital of London popularized the procedure and reported excellent results with a 3 % recurrence rate in 1933 [3]. However, Hughes [4] and Porter [5] at the same institution were not able to reproduce these results in the decades that followed (1940s–1970s) and recurrence rates of rectal prolapse rose dramatically to 50–60 % as PR fell out of favor and abdominal operations came into vogue. In the past decade, excellent outcomes reported in many countries (Japan, Brazil, Germany, Italy and the USA) spanning several continents have forced a re-evaluation and resurgence of PR as a viable treatment option, especially for the typical patient population of elderly women [6–9]. Given the recent low rates of recurrence following PR of the past few decades, some centers have even suggested PR for all patients suffering from rectal prolapse, regardless of age [6, 9]. Ram et al. [10] present the results of their version of PR using a semicircular stapling device which they refer to as perineal stapled prolapse resection (PSPR), originally described by Scherer et al. [11]. Ram et al. report a short operating time (25–45 min) and hospital length of stay (3–5 days); however, they note a very high rate of recurrence (29 %) which occurred in an alarmingly brief period of time (1, 2, 4 and 6 months into the postoperative period). All of these patients subsequently had their recurrent rectal prolapse corrected by an Altemeier Procedure which combines PR with narrowing of the often stretched and gaping levator hiatus (from the chronic prolapsing rectum) using interrupted absorbable sutures (levatorplasty). In a retrospective review of my own series of 103 patients who underwent an Altemeier Procedure over the decade of the 2000s (zero recurrence over a mean followup period of 43 months), 12 of these patients presented with recurrent rectal prolapse following various abdominal and perineal operations including four patients who previously had an Altemeier Procedure performed elsewhere. I obtained the operative reports of two of these four patients. These two operations had been performed by colorectal surgeons trained at the same prestigious US-based colorectal surgery residency training program, and they both had[20 years of clinical experience. I discovered from the reports dictated by their general surgery residents that the ‘‘(pouch) of Douglas was entered at one point, and this was (immediately) closed with 2-0 vicryl suture’’ in one case, and in the other case, ‘‘the peritoneum was exposed and carefully pushed back cephalad using spongesticks. The peritoneum was not entered.’’ These details of these failed operations confirmed that failure to properly perform the Altemeier Procedure was the reason for recurrence of the rectal prolapse, not the operation itself. The peritoneal cavity should be breached early in the dissection in order to fully mobilize the rectum allowing for a more complete rectosigmoid resection resulting in a lower rate of recurrence. Ram et al. acknowledge in their introduction that ‘‘to excise a larger amount of prolapsed rectal tissue’’ is the goal of their ‘‘novel technique.’’ However, PSPR does not allow for proper exposure and complete dissection of the rectum which ultimately is counterproductive to performance of a recurrence-free PR or Altemeier Procedure. Tschuor et al. [12] essentially agree with this conclusion W. C. Cirocco (&) Division of Colon & Rectal Surgery, Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, USA e-mail: william.cirocco@yahoo.com