Klinik und Poliklinik für Allgemein-, Viszeral-, Gefäß-

und Kinderchirurgie (Chirurgische Klinik I)

Direktor: Prof. Dr. C.-T. Germer

Risk factors for recurrence in perineal rectosigmoidectomy

M. Kim, J. Reibetanz, N. Schlegel, C.-T. Germer, C. Isbert

No conflicts of interest

Klinik und Poliklinik für Allgemein-, Viszeral-, Gefäß-

und Kinderchirurgie (Chirurgische Klinik I)

Direktor: Prof. Dr. C.-T. Germer

Langzeitergebnisse nach transperinealerRektosigmoidektomie nach Altemeier bei externem

Rektumvollwandprolaps °III

M. Kim, J. Reibetanz, N. Schlegel, C.-T. Germer, C. Isbert

For the therapy of full thickness rectal prolapse

Variety of surgical interventions exist

Abdominal

(laparoscopic vs open, rectopexy vs resectionrectopexy)

Perineal

[Altemeier et al AMA Ann Surg 1952][Altemeier et al. Arch Surg 1964]

Introduction – Perineal rectosigmoidectomy (Altemeier)

Altemeier‘s procedure

Improvement of function and quality of life

Altemeier‘s procedure – Function and Quality of Life

[Kim et al. Br J Surg 2010][Glasgow et al. J Gastrointest Surg 2008]

[Senapati et al. Colorectal Dis 2013][Cirocco et al. Dis Colon Rectum Dis 2010]

[Altomare et al. Dis Colon Rectum 2009]

Altemeier‘s procedure – Recurrence

Recurrence after Altemeier‘s procedure

• 0 – 60% reported recurrence rate vary

• 0 – 18% Monocenter trials

• 20% PROSPER trial (prospective multicenter)

no difference between abdominal procedures

Klinik und Poliklinik für Allgemein-, Viszeral-, Gefäß-

und Kinderchirurgie (Chirurgische Klinik I)

Direktor: Prof. Dr. C.-T. Germer

Langzeitergebnisse nach transperinealerRektosigmoidektomie nach Altemeier bei externem

Rektumvollwandprolaps °III

M. Kim, J. Reibetanz, N. Schlegel, C.-T. Germer, C. Isbert

Aim of this study

Analysis of risk factors for recurrence after Altemeier‘s procedure in

patients with full-thickness rectal prolapse

2004 - 2012

• Number n = 63

• Gender n = 7 male

• Age 79 (30-90) yrs

• ASA I n = 6II n = 30III n = 25IV n = 2

• OP time [mean±SD] 88.8 ± 30.8 min

• Hospital stay [mean±SD] 6.6 ± 3.4 days

• Follow-up [median; range] 53 (3-99) months

Patients and Methods

• Grad I n = 1 partial mucosal necrosis

n = 1 anastomotic dehiscence

• Grad II n = 1 urinary retention

n = 5 urinary tract infection

n = 1 allergic reaction

n = 1 pneumonia

n = 1 tachyarrhythmia

• Grad III A n = 0

• Grad III B n = 1 bleeding

• Grad IV n = 1 myocardial infarction

Results – Morbidity and Recurrence

[Dindo et al. Ann Surg 2004]

• Recurrence n = 8 after 18 (6-43) months

• Follow-up [median; range] 53 (3-99) months

Recurrence No recurrence P

n = 8 n = 55

Age [yrs] 68.5 (18.1) 73.84 (14.8)

Male [n] 1 6

ASA [n] 2.2 (0.07) 2.39 (0.7)

Preop. incontinence [pts] 13.3 (6.76) 12.7 (6.9)

Prolapse anterior compartiment [n] 1 18

Previous pelvic surgery [n] 2 30

Hysterektomy [n] 1 17

OP time [min] 95 (43) 87 (29)

Levatorplasty [n] 5 28

Preop. constipation [pts] 11.9 (6.45) 7.63 (6.3) 0.1

Duration prolapse [mon.; median] 18 (3-732) 6 (1-396) 0.02

Length specimen [cm] 5.97 (1.2) 8.98 (5.07) 0.001

Stapled anastomosis [n] 3 2 0.001

Follow-up [mon] 58.13 (22.2) 50 (23.65)

Results – Risk of Recurrence, univariate

Hazard

Ratio

95% Confidence-

Interval

P

Duration prolapse[≤/> 6 mon] 4.09 0.83 – 20.28 0.06

Length specimen [</≥ 7 cm] 4.06 0.97 - 16.99 0.03

Anastomosis [stapled vs hand] 7.96 1.9 - 33.47 0.001

Results – Risk of Recurrence, multivariate

Type of anastomosis Length resected specimen

Chirurgische Klinik I, Universitätsklinikum Würzburg

Conclusion

Recurrence after Altemeier‘s procedure …

depends on the length of follow-up

is less influenced by patients‘ characteristics

(Age, gender, comorbidities, previous surgery)

but may be influenced by operative techniques

(Length of specimen, kind of anastomosis)

12Chirurgische Klinik I, Universitätsklinikum Würzburg

Schlußfolgerung

Rezidive nach Altemeier Resektion sind …

weniger durch Patienten-Faktoren beeinflusst,

(Alter, Geschlecht, Komorbiditäten, Pathologika des

kleines Beckens)

sondern möglicherweise durch Operationstechniken

beeinflussbar

(Ausmaß der Resektion, Anwendung eines

Klammernahtgeräts)

Thank you for your attention

M. Kim, J. Reibetanz, N. Schlegel, C.-T. Germer, C. Isbert

Department of General, Gastrointestinal, Vascular and Paediatric SurgeryUniversity Hospital Würzburg