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. 2023 Jan 3;66(1):E8-E12.
doi: 10.1503/cjs.008421. Print 2023 Jan-Feb.

A comparison of perineal stapled prolapse resection and the Altemeier procedure at 2 Canadian academic hospitals

Haven M Roy  1 , Zarrukh Baig  2 , Ahmer A Karimuddin  2 , Manoj J Raval  2 , Carl J Brown  2 , P Terry Phang  2 , Dilip Gill  2 , D Nathan Ginther  2
Affiliations

A comparison of perineal stapled prolapse resection and the Altemeier procedure at 2 Canadian academic hospitals

Haven M Roy et al. Can J Surg. .

Abstract
in English, French

Background: The preferred perineal repair method for full-thickness rectal prolapse is the Altemeier procedure, a perineal proctosigmoidectomy with handsewn anastomosis. A recently described variant of this procedure combines the resection and anastomosis into 1 step by means of linear and transverse stapling. There are few published data comparing the characteristics and outcomes of these 2 approaches.

Methods: This retrospective review, performed at 2 Canadian academic hospitals, compares surgical and cost outcomes between the perineal stapled prolapse resection (PSPR) and the Altemeier procedure. All patients who underwent these procedures between 2015 and 2019 were included.

Results: There were 25 patients in the PSPR group and 19 in the Altemeier group. Patients in the PSPR group were significantly older than those in the Altemeier group (81 [95% confidence interval (CI) 70-92] yr v. 74 [95% CI 63-85] yr; p = 0.047), had a lower body mass index (21.4 [95% CI 17.7-25.1] v. 24.4 [95% CI 18.5-30.3]; p = 0.042) and had equivalent American Society of Anesthesiologists scores (2.84 [95% CI 2.09-3.59] v. 2.68 [95% CI 1.93-3.43]; p = 0.49). The operative time for PSPR was significantly less (30.3 [95% CI 16.3-44.3] min v. 67 [95% CI 43-91] min; p < 0.001), as were the operative costs. Recurrence (28.0% v. 36.8%; p = 0.53) and complication rates were equivalent.

Conclusion: PSPR is a safe, efficient and effective approach to perineal proctosigmoidectomy. It is associated with surgical outcomes comparable to those of the Altemeier procedure, but with a significant reduction in operative time and cost.

Contexte:: La technique de réparation périnéale privilégiée pour le prolapsus rectal de pleine épaisseur est la technique d’Altemeier, une proctosigmoïdectomie périnéale avec anastomose manuelle. Une variante de cette intervention décrite récemment allie la résection et l’anastomose en 1 seule étape, par agrafage linéaire et transverse. Peu de données ont été publiées pour comparer les caractéristiques et les résultats de ces 2 approches.

Méthodes:: La présente revue rétrospective, effectuée dans 2 centres hospitaliers universitaires canadiens, compare les résultats chirurgicaux et les coûts de la résection du prolapsus par agrafage péritonéal (RPAP) et par technique d’Altemeier. Tous les patients ayant subi ces 2 types d’interventions entre 2015 et 2019 ont été inclus.

Résultats:: On comptait 25 patients dans le groupe soumis à la RPAP et 19 dans le groupe soumis à la technique d’Altemeier. Les patients du groupe RPAP étaient significativement plus âgés que ceux du groupe Altemeier (81 [intervalle de confiance (IC) de 95 % 70–92] ans c. 74 [IC de 95 % 63–85] ans; p = 0,047), avaient un indice de masse corporelle plus bas (21,4 [IC de 95 % 17,7–25,1] c. 24,4 [IC de 95 % 18,5–30,3]; p = 0,042) et un score de l’American Society of Anesthesiologists semblable (2,84 [IC de 95 % 2,09–3,59] c. 2,68 [IC de 95 % 1,93–3,43]; p = 0,49). Le temps opératoire pour la RPAP a été significativement moindre (30,3 [IC de 95 % 16,3–44,3] min c. 67 [IC de 95 % 43–91] min; p < 0,001), tout comme les coûts chirurgicaux. Les taux de récurrences et de complications ont été équivalents entre les 2 groupes (28,0 % c. 36,8 %; p = 0,53).

Conclusion:: La RPAP est une approche sécuritaire, efficiente et efficace pour la proctosigmoïdectomie périnéale. Elle est associée à des résultats chirurgicaux comparables à ceux de la technique d’Altemeier, mais abrège significativement le temps opératoire et réduit les coûts.

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Conflict of interest statement

Competing interests: C. Brown has received speaker fees from Ethicon and Amgen, unrelated to the current study. N. Ginther is a member of the Video-based Education Committee of the American Society of Colon and Rectal Surgeons and Saskatchewan governor of the American College of Surgeons.

Figures

Fig. 1
Fig. 1
The prolapsed rectum is divided with a linear cutting stapler at the left lateral and right lateral positions. Image by Nexus Illustration.
Fig. 2
Fig. 2
The stapled rectum is split into anterior and posterior leaflets. This figure shows the appearance after the linear cutting stapler has been fired down one side. A second stapler firing is then performed on the other side to create the anterior and posterior leaflets. Image by Nexus Illustration.
Fig. 3
Fig. 3
A Contour stapler then divides the individual leaflets, simultaneously anastomosing and resecting the prolapsed segment. In this figure, the posterior leaflet is being deflected downward and the anterior leaflet is being positioned in the Contour stapler. The placement of stay sutures distal to the linear staple lines on the left and right may be considered before leaflet division to help prevent retraction and improve visualization of the staple line for oversewing. Image by Nexus Illustration.
See this image and copyright information in PMC

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