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| 번호 | 제목 | 등록일 | 조회수 |
|---|---|---|---|
| 13 | The Altemeier Repair: Outpatient Treatment of Rectal Prolapse [2001년 4월 DCR] | 2011-11-12 | 3210 |
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Mark H. Kimmins, M.D., FRCSC,Brent K. Evetts, M.D.,John Isler, M.D.,Richard Billingham, M.D.
From the Departments cf Surgery, Northwest Hospital and Swedish Hospitals, Northwest Colon and Rectal Clinic, Seattle, Washington, and Meridian Park Hospital, Tualatin, Oregon PURPOSE: Rectal prolapse typically occurs in elderly patients, who are often poor surgical candidates because of the presence of multiple comorbidities. Abdominal approaches to procidentia have low recurrence rates but are associated with higher rates of morbidity and mortality. Perineal rectosigmoidectomy (Altemeier repair) is a safe and effective approach to the treatment of rectal prolapse and can be done as an outpatient procedure. In this article, the results of a series of 63 consecutive Altemeier repairs are presented.
METHODS: Between February 1993 and December 1999, 63 patients (61 females) underwent Altemeier
repair of rectal prolapse. The mean patient age was 79 years. Preoperative, intraoperative, and postoperative data were collected and analyzed for all patients. RESULTS: Median follow-up was 20.8 months. Seventy percent of patients were given a regional or local anesthetic. The average resected specimen length was 11.6 cm, and 83 percent of
anastomoses were stapled. Sixty-two percent of patients were discharged home on the day of surgery, and 80 percent were home within 24 hours. Complications occurred in 10 percent of patients, but there was no perioperative mortality. There was a 6.4 percent recurrence rate, and all recurrences were successfully treated with repeat Altemeier repair. All 63 patients had complete objective resolution of prolapse, and 87 percent had subjective improvement after repair. CONCLUSIONS: Altemeier repair of rectal prolapse is safe, produces minimal discomfort, and does not require a general anesthetic. It is ideally suited to be done on an outpatient basis, as was done in the majority of patients in our series. The recurrence rate is slightly higher than with abdominal resections, but morbidity and cost are lower, and repeat perineal resections are easily and safely
performed. DISCUSSION
It has been stated that the ideal operation for rectal prolapse should be minimally invasive, have no morbidity or mortality, improve continence, and be associated with no recurrences. 13 Obviously the perfect operation does not exist, and surgeons must balance the relative risks and benefits of each procedure in deciding how to proceed.
Perineal proctosigmoidectomy was first described by Mikulicz in 1889 and was later popularized in
Great Britain by- Miles 15 and subsequently by Gabriel. The operation is now known by the name of its American proponent, Altemeier. Perineal repairs initially gained favor in the days before general anesthesia but, for much of the 20th century-, lost popularity because of reported high recurrence rates. Several recent series have highlighted the safety and efficacy of perineal proctosigmoidectomy with much lower recurrence rates than initially published. Most published series looking at transabdominal prolapse repairs suffer from some selection bias, in
that older higher risk patients with procidentia are sometimes excluded from abdominal surgery. Therefore, patients chosen for abdominal repairs may be less likely to recur, simply by virtue of being younger, healthier surgical candidates. Despite this possible bias, a single randomized trial comparing resection rectopexy with perineal rectosigmoidectomy has shown somewhat better functional results and a lower recurrence rate after transabdominal repair. Although transabdominal repairs likely do have lower recurrence rates than perineal repairs, this fact must be weighed against a significant potential increase in morbidity and mortality, especially- when considering repair in high-risk elderly patients. Findings from two previous studies have suggested that levatoroplasty improves bowel function and continence when performed with perineal proctosigmoidectomy. It has also been theorized that the
addition of levatoroplasty might improve recurrence rates by tightening the levator hiatus. In this study, a decision to perform levatoroplasty was made intraoperatively based on tissue integrity and anatomy, and levatoroplasty was performed in 46 percent of patients. The recurrence rate after Altemeier repair was only 6.3 percent in this series, consistent with rates found
recently by other investigators. All recurrences in this series occurred within four months of initial repair, and half of the recurrences occurred within two months of repair. This observation appears contrary to the assumption that the incidence of recurrence is directly related to the duration of followup, although longer follow-up in these patients would presumably detect increased recurrence over time. No previous study has looked directly at the feasibility of treating rectal prolapse patients with outpatient surgery. In the past, patients undergoing full-thickness perineal proctosigmoidectomy have been hospitalized and kept NPO for many days, under the mistaken belief that early feeding was dangerous in these patients. Recent studies have highlighted the safety of early feeding in patients undergoing colorectal operations with anastomoses. In this study, most patients went home on the day of surgery, took minimal doses of oral analgesics, and had no dietary restrictions. Early telephone follow-up showed that most patients were comfortable and pleased to be in a familiar home environment. Early readmission rates were less than 5 percent, and there was no early or late operative mortality. Early and late morbidity was low, and all recurrences were repaired by repeat outpatient perinealineal proctosigmoidectomy. Both objectively and subjectively, this operation was more than 90 percent effective in this series of patients.
Prolonged hospitalization after abdominal surgery in elderly patients is costly and a source of iatrogenic
and nosocomial morbidity and mortality. We believe that the low cost and low morbidity of outpatient surgery easily outweigh a slightly higher recurrence rate after Altemeier repair. Studies looking at the cost savings of outpatient surgery have shown a savings of $1,000 to $2,500 per patient per night of hospitalization. The overall cost and health savings achieved by treating prolapse patients with outpatient surgery are likely to be enormous. |
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