01 June 2023: Articles
A 54-Year-Old Man with a Large Rectal Prolapse Treated with Perineal Proctosigmoidectomy with Levatorplasty (Altemeier Procedure): Presentation of Case and Review of Literature
Rare diseaseAndriana Purnama 1ABCDEFG, Reno Rudiman 1ABCDEFG*, Tovan Perinandika 2ABCDEFG
Am J Case Rep 2023; 24:e939508
BACKGROUND: The surgical procedure of perineal proctosigmoidectomy with levatorplasty is known as the Altemeier procedure. This report presents the case of a 54-year-old man with a large rectal prolapse treated with perineal proctosigmoidectomy with levatorplasty (Altemeier procedure).
CASE REPORT: A 54-year-old male had a large bulging in the rectum since 5 months ago. At first, the bulging was small, but its size had increased to approximately 10 cm at presentation. The patient also stated that the bulging used to reduce spontaneously after defecating or manually by applying sufficient pressure, but lately it had been irreducible. Another concern was chronic constipation over the last few years, which was treated with over-the-counter laxatives and stool softeners. Physical examination of the perianal region revealed a full-thickness, irreducible, prolapsed bowel segment, approximately 10 cm long, with multiple mucosal ulcerations. Grade V rectal prolapse was diagnosed. Follow-up at 7, 14, and 30 days after surgery showed complete resolution of symptoms and no recurrence.
CONCLUSIONS: Individually tailored and prompt surgical treatment for all patients with rectal prolapse is vital. The Altemeier procedure, which has good efficacy with low morbidity, complications, and recurrence, should be considered in elderly patients with an irreducible, large rectal prolapse.
Keywords: Colorectal Surgery, Proctocolectomy, Restorative, Rectal Prolapse
Rectal prolapse is an external protrusion of the rectal mucosa through the external anal sphincter . Rectal prolapse affects all ages but is more common in children, women, and patients >50 years of age . Some factors have been shown to be associated with the development of rectal prolapse, but the exact cause of rectal prolapse is unknown. Other risk factors included chronic diarrhea in 15% of cases, constipation in 30% to 67% of cases, history of previous surgery, cystic fibrosis, chronic obstructive pulmonary disease, pertussis, multiple sclerosis, and paralysis. Rectal prolapse in women is often associated with weakness of the pelvic floor muscles caused by repeated vaginal deliveries . Rectal prolapse is also associated with a spectrum of coexisting anatomic abnormalities, such as an abnormally deep cul-de-sac, redundant sigmoid colon, patulous anal sphincter, levator ani diastasis, and loss or attenuation of the rectal sacral attachments .
Clinical manifestations of rectal prolapse include discomfort of prolapsing tissue both internally and externally, bloody or mucus discharge from the rectum, and fecal incontinence or constipation . Rectal prolapse significantly affects an individual’s quality of life . Rectal prolapse can occur spontaneously when the patient is standing or during the Valsalva maneuver during defecation or coughing. Other findings include edematous, ulcerated, and brittle mucosa of the herniated rectal segment. Most rectal prolapses can resolve spontaneously or by manual reduction. In some cases, the prolapsed segment cannot be reduced and becomes incarcerated, which can lead to complications including severe pain, bleeding, strangulation, and even perforation .
The current Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons advise individually tailored and prompt surgical treatment for all patients with rectal prolapse, including elderly patients, to avoid complications and risk of recurrence. There are certain challenges of surgical procedures in elderly patients, such as complication rates, comorbidities, morbidity, mortality, and recurrence rates . This report presents the case of a 54-year-old man with a large rectal prolapse treated with perineal proctosigmoidectomy with levatorplasty (Altemeier procedure). This case report was constructed in line with the SCARE 2020 criteria .
A 54-year-old male patient (body mass index: 24.2 kg/m2) came to the surgical outpatient department with concerns of a large bulging in the rectum since 5 months ago. At first, the bulging was small, but its size had increased until approximately 10 cm at presentation. The patient also stated that the bulging used to reduce spontaneously after defecating or manually by applying sufficient pressure, but lately it had been irreducible. Other concerns included chronic constipation over the last few years, which he treated with over-the-counter laxatives and stool softeners. The patient felt very uncomfortable, as he was not able to sit normally. He had a history of controlled hypertension and denied any family history of a similar disease, history of surgery, and/or other diseases.
The patient’s vital signs and general examination were within normal limits. Physical examination of the perianal region revealed a full-thickness, irreducible, prolapsed bowel segment, approximately 10 cm long, with multiple mucosal ulcerations (Figure 1). Grade V rectal prolapse was diagnosed. Before the surgery, the patient underwent a colonoscopy, which had a normal result. Preoperative laboratory test results and imaging were unremarkable.
The planning for the patient was surgery as soon as possible, with the technique of choice being perineal proctosigmoidectomy with levatorplasty (Altemeier procedure). The patient’s ASA score was 2. He was administered prophylaxis antibiotic one hour before surgery, which was done by an experienced digestive surgeon at a general hospital.
The patient was positioned in lithotomy, under spinal anesthesia, with the prolapsed tissue fully exteriorized. First, marking of the resection line 1 to 2 cm proximal to the dentate line was done with an ultrasonic knife (Figure 2). Then, a circumferential incision was made on the pre-marked line, including all layers of the rectal wall (Figure 3). The peritoneum was opened, and then reduction and resection of the prolapsed rectal and part of sigmoid colon were done (Figure 4). The rectal blood vessels were ligated. Then, a subsequent posterior levatorplasty was performed. Finally, a coloanal anastomosis was done with placement of circumferential interrupted sutures placement using 3-0 absorbable sutures.
The postoperative result showed successful results (Figure 5). The patient had complete resolution of symptoms and was discharged 7 days after the surgery with satisfactory quality of life. Follow-up was done 14 days after surgery, which showed good recovery and no recurrence. The pathological examination of the resected segments revealed no abnormalities but local inflammation. During an outpatient follow-up visit at 1 month after surgery, the patient did not experience any symptoms, and was satisfied with the type of treatment he received.
Several factors might influence the choice of surgery in treating rectal prolapse; the Altemeier procedure is one of the more beneficial surgical techniques.
Rectal prolapse is an external protrusion of the rectal mucosa through the external anal sphincter . It is classified in to 3 clinical subtypes: mucosal invagination, incomplete (partial; internal), and complete (full-thickness; external) . Fecal incontinence, obstructed defecation, incomplete rectal evacuation, rectal pressure, and pain are some of the symptoms that can result from rectal prolapse .
Treatments such as lifestyle improvements and biofeedback from the pelvic floor can provide temporary relief of rectal prolapse symptoms. However, surgical management is the only definitive treatment that can improve quality of life and bowel function . When a rectal prolapse is irreducible, whether there is necrosis or not, immediate surgical repair is required . In this case, there was an irreducible, large rectal prolapse with a length of 10 cm and multiple lacerations. Therefore, the patient required definitive treatment of surgery to prevent further complications caused by delay in surgery.
Preoperative evaluation includes a colonoscopy, which is required in all patients because polyps, cancer, and colitis can be the underlying cause in some patients . In this case, we performed a colonoscopy, which had a normal result.
A surgical procedure to correct rectal prolapse has 3 main goals: (1) to eliminate the prolapse through either resection or restoration of normal anatomy, (2) to correct associated functional abnormalities of constipation or incontinence, and (3) to avoid the creation of de novo bowel dysfunction . Various surgical techniques and procedures have been described in historical literature and can be classified into an abdominal approach (ie, Wells, Ripstein, Orr-Loygue) and perineal approach (ie, Altemeier, Delorme) [4,8].
Several factors might influence the choice of surgery, including age, sex, incontinence, comorbidities, repair of the previous prolapse, physiological testing, the experience of the surgeon, and the presence of preoperative constipation .
The current Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons advise individually tailored and prompt surgical treatment for all patients with rectal prolapse, including elderly patients, to avoid complications and risk of recurrence. The Altemeier procedure consists of perineal rectosigmoidectomy, a transanal full-thickness resection of the prolapsed rectum, and a coloanal anastomosis. This procedure has been associated with higher recurrence rates, but when combined with a levatorplasty, its recurrence rate is reduced to 7% [4,8].
A case series by Nguyen et al recommended that the Altemeier procedure should be strongly considered when the prolapse is irreducible, whether there is necrosis or not . The Altemeier procedure is also preferred for cases of longer rectal prolapse . The present case of an irreducible, large rectal prolapse was suitable for treatment with the Altemeier procedure.
The Altemeier procedure can be performed under spinal anesthesia and does not cause laparotomy trauma, allowing for faster gastrointestinal recovery, mobility, and shorter hospital stay . In previous studies, morbidity ranges from 3% to 35%, with mortality rarely reported. Its complication rates is also lower compared to that of surgery with an abdominal approach, which requires general anesthesia and can cause complications of pelvic adhesions, the risk of infertility in young women, and impotence in young men .
Complications of using total anesthesia in the abdominal approach are why the perineal approach is chosen to treat rectal prolapse in elderly patients with comorbidities . The American College of Surgeon’s National Surgical Quality Improvement Program (NSQIP) divides rectal prolapse complications into major and minor complications. Major complications include organ space infections, thromboembolism, cardioembolism, dependence on ventilators, renal failure, and sepsis, while surgical site infections and urinary tract infections are minor complications . Anastomotic leakage (1.88%) was found to be the most common complication after the Altemeier procedure .
In a previous study, 153 major complications were reported in the 30-day postoperative period involving 94 patients (7.4%), and 86 minor complications were reported in 85 (6.7%) patients. A recent study reported a major complication rate of 2.3%, with listed complications including aspiration pneumonia and lung failure . Patients were treated according to the complications that occurred: 14 patients with minimal anatomic leakage were successfully treated conservatively, and 4 patients with postoperative anemia required blood transfusion, resulting in no postoperative mortality at 30 days .
At a median interval of 49 months, 34 patients were assessed. Six patients were deceased for reasons not related to the prolapse and 3 were lost to follow-up. Rectal prolapse recurrence was found in 2 patients, who therefore underwent re-operation, with 1 redo-Altemeier procedure, and 1 Goldberg procedure .
The authors of studies of the Altemeier procedure have concluded that it is still the main choice in elderly patients and patients with severe comorbidities, resulting in good results, and is associated with low morbidity, mortality and recurrence [4,5,9]. The patient presented in this case report was an elderly person with an irreducible, large rectal prolapse. Therefore, the most appropriate surgical technique was the Altemeier procedure.
The patient reported no complications at follow-up 7, 14, and 30 days after surgery. The patient also reported complete resolution of symptoms and no recurrence, which significantly improved his quality of life.
Individually tailored and prompt surgical treatment for all patients with rectal prolapse is vital. The Altemeier procedure, which has good efficacy with low morbidity, complications, and recurrence, should be considered in elderly patients with an irreducible, large rectal prolapse.
FiguresFigure 1.. An irreducible, large rectal prolapse with mucosal ulceration, with an approximate length of 10 cm. Figure 2.. Marking of the resection line 1 to 2 cm proximal to the dentate line was done with an ultrasonic knife. Figure 3.. A circumferential incision on the pre-marked line, including all layers of the rectal wall. Figure 4.. Resected prolapsed rectum and part of the sigmoid colon. Figure 5.. The postoperative result.
1.. Segal J, McKeown DG, Tavarez MM: Rectal prolapse, 2022, Treasure Island (FL), StatPearls Publishing Available from: https://www.ncbi.nlm.nih.gov/books/NBK532308/
2.. Tuncer A, Akbulut S, Ogut Z, Sahin TT, Management of irreducible giant rectal prolapse: A case report and literature review: Int J Surg Case Rep, 2021; 88; 106485
3.. Attaallah W, Akmercan A, Feratoglu H, The role of rectal redundancy in the pathophysiology of rectal prolapse: A pilot study: Ann Surg Treat Res, 2022; 102(5); 289-93
4.. Bordeianou L, Paquette I, Johnson E, Clinical practice guidelines for the treatment of rectal prolapse: Dis Colon Rectum, 2017; 60(11); 1121-31
5.. Koizumi N, Kobayashi H, Fukumoto K, Massive chronic irreducible rectal prolapse successfully treated with Altemeier’s procedure: J Surg Case Rep, 2018; 2018(4); 1-3
6.. Agha RA, Franchi T, Sohrabi C, The scare 2020 guideline: Updating consensus surgical case report (scare) guidelines: Int J Surg, 2020; 84; 226-30
7.. Wallace SL, Enemchukwu EA, Mishra K, Postoperative complications and recurrence rates after rectal prolapse surgery versus combined rectal prolapse and pelvic organ prolapse surgery: Int Urogynecol J, 2021; 32(9); 2401-11
8.. Nguyen XH, Pham PK, Steinhagen RM, Case series: Incarcerated massive rectal prolapse successfully treated with Altemeier’s procedure: Int J Surg Case Rep, 2018; 51; 309-12
9.. Trompetto M, Tutino R, Realis Luc A, Altemeier’s procedure for complete rectal prolapse; Outcome and function in 43 consecutive female patients: BMC Surg, 2019; 19(1); 1-7
10.. Lee S-H, Changing trend of rectal prolapse surgery in the era of the minimally invasive surgery: J Minim Invasive Surg, 2019; 22(4); 135-36
11.. Emile SH, Elfeki H, Shalaby M, Perineal resectional procedures for the treatment of complete rectal prolapse: A systematic review of the literature: Int J Surg, 2017; 46; 146-54
12.. Alwahid M, Knight SR, Wadhawan H, Perineal rectosigmoidectomy for rectal prolapsed – the preferred procedure for the unfit elderly patient? 10 years experience from a UK tertiary centre: Tech Coloproctol, 2019; 23(11); 1065-72
06 Jun 2023 : Case reportA Classical Case of Cesarean Scar Endometriosis in a 35-Year-Old Woman Presenting with Cyclical Abdominal P...
Am J Case Rep In Press; DOI: 10.12659/AJCR.940200
05 Jun 2023 : Case reportPeri-Hilar Cystic Lymphangioma Mimicking a Biliary Cystic Lesion Causing Biliary Obstruction: A Case Report...
Am J Case Rep In Press; DOI: 10.12659/AJCR.939421
05 Jun 2023 : Case reportRecurrent Bioprosthetic Valve Serratia marcescens Endocarditis in Intravenous Drug Users
Am J Case Rep In Press; DOI: 10.12659/AJCR.939292
05 Jun 2023 : Case reportSuccessful Treatment of Recurrent Colonic Adenocarcinoma with Metastatic Tumor Thrombus in the Superior Mes...
Am J Case Rep In Press; DOI: 10.12659/AJCR.939156
Most Viewed Current Articles
06 Dec 2021 : Case reportLipedema Can Be Treated Non-Surgically: A Report of 5 Cases
Am J Case Rep 2021; 22:e934406
13 Jul 2022 : Case reportWhistling Scrotum: An Unusual Presentation of Pneumomediastinum in the Setting of an Open Scrotal Wound
Am J Case Rep 2022; 23:e936441
07 Dec 2021 : Case reportEdwardsiella tarda: A Classic Presentation of a Rare Fatal Infection, with Possible New Background Risk Fac...
Am J Case Rep 2021; 22:e934347
23 Feb 2022 : Case reportPenile Necrosis Associated with Local Intravenous Injection of Cocaine
Am J Case Rep 2022; 23:e935250