Managing emergent irreducible rectal prolapse: pros and pitfalls of Altemeier procedure and review of perineal strategies

Marisa C. Ferreira; Maria I. Coelho; Alexandra Rocha; Patrícia Bárbara; Vera Pedro; Miguel C. Dos Santos; Gilberto Figueiredo

doi:10.18203/2349-2902.isj20260850

Authors

Marisa C. Ferreira Unidade Local de Saude Região de Leiria, Rua das Olhalvas, Pousos, Leiria, Portugal
Maria I. Coelho Unidade Local de Saude Região de Leiria, Rua das Olhalvas, Pousos, Leiria, Portugal
Alexandra Rocha Unidade Local de Saude Região de Leiria, Rua das Olhalvas, Pousos, Leiria, Portugal
Patrícia Bárbara Unidade Local de Saude Região de Leiria, Rua das Olhalvas, Pousos, Leiria, Portugal
Vera Pedro Unidade Local de Saude Região de Leiria, Rua das Olhalvas, Pousos, Leiria, Portugal
Miguel C. Dos Santos Unidade Local de Saude Região de Leiria, Rua das Olhalvas, Pousos, Leiria, Portugal
Gilberto Figueiredo Unidade Local de Saude Região de Leiria, Rua das Olhalvas, Pousos, Leiria, Portugal

DOI:

https://doi.org/10.18203/2349-2902.isj20260850

Keywords:

Incarcerated rectal prolapse, Altemeier procedure, Perineal approach, Emergency surgery

Abstract

Rectal prolapse is a debilitating condition predominantly affecting older adults and may be exacerbated by chronic constipation, frailty, or psychiatric comorbidities. Perineal approaches, including the Altemeier procedure, offer an effective treatment option for selected patients, particularly when abdominal surgery carries elevated risk. We report the case of a 62-year-old woman with schizophrenia, hemorrhoidal disease, and chronic constipation who presented with a large, irreducible full-thickness rectal prolapse of several years’ duration and underwent emergency perineal rectosigmoidectomy. A 23-cm rectosigmoid segment was resected and a hand-sewn coloanal anastomosis performed. Histopathological examination showed mucosal hemorrhage, ulceration, and vascular congestion without dysplasia or malignancy. Postoperative recovery was uneventful, with restoration of bowel function by postoperative day 8 and discharge on day 9. Transient flatus incontinence resolved spontaneously. At two-year follow-up, the patient remained asymptomatic, without recurrence, constipation, or significant incontinence. However, recurrence of rectal prolapse was documented five years after surgery and additional post-recurrence evaluation will be performed.
Rectal prolapse is an uncommon but debilitating condition, particularly in patients with comorbidities such as chronic constipation or psychiatric disorders. Incarcerated prolapse requires prompt surgical intervention; in this case, the Altemeier procedure was chosen due to irreducibility, chronicity, and patient frailty. Postoperative recovery was uneventful, with restoration of bowel function and good two-year functional outcomes. Although recurrence remains a concern—especially with large or long-standing prolapses—the procedure is a pragmatic and reproducible option for high-risk patients. The Altemeier procedure is an effective option for irreducible rectal prolapse, offering good functional outcomes in high-risk patients. Long-term recurrence remains possible, highlighting the need for individualized management and ongoing postoperative follow-up.

Metrics

Metrics Loading ...

References

Bordeianou L, Paquette I, Johnson E, Holubar SD, Gaertner W, Feingold DL, et al. Clinical Practice Guidelines for the Treatment of Rectal Prolapse. Dis Colon Rectum. 2017;60(11):1121-31. DOI: https://doi.org/10.1097/DCR.0000000000000889

Deen KI, Grant E, Billingham C, Keighley MR. Abdominal resection rectopexy with pelvic floor repair versus perineal rectosigmoidectomy and pelvic floor repair for full-thickness rectal prolapse. Br J Surg. 1994;81(2):302-4. DOI: https://doi.org/10.1002/bjs.1800810253

Tou S, Brown SR, Nelson RL. Surgery for complete (full-thickness) rectal prolapse in adults. Cochrane Database Syst Rev. 2015;2015(11):CD001758. DOI: https://doi.org/10.1002/14651858.CD001758.pub3

Karas JR, Uranues S, Altomare DF, Binda GA, De Nardi P, Hurschler C, et al. Rectal Prolapse Recurrence Study Group. No rectopexy versus rectopexy following rectal mobilization for full-thickness rectal prolapse: a randomized controlled trial. Dis Colon Rectum. 2011;54(1):29-34. DOI: https://doi.org/10.1007/DCR.0b013e3181fb3de3

Cirocco WC, Brown AC. Anterior resection for the treatment of rectal prolapse: a 20-year experience. Am Surg. 1993;59(4):265-9.

Novell JR, Osborne MJ, Winslet MC, Lewis AA. Prospective randomized trial of Ivalon sponge versus sutured rectopexy for full-thickness rectal prolapse. Br J Surg. 1994;81(6):904-6. DOI: https://doi.org/10.1002/bjs.1800810638

Raftopoulos Y, Senagore AJ, Di Giuro G, Bergamaschi R. Rectal Prolapse Recurrence Study Group. Recurrence rates after abdominal surgery for complete rectal prolapse: a multicenter pooled analysis of 643 individual patient data. Dis Colon Rectum. 2005;48(6):1200-6. DOI: https://doi.org/10.1007/s10350-004-0948-6

Aitola PT, Hiltunen KM, Matikainen MJ. Functional results of operative treatment of rectal prolapse over an 11-year period: emphasis on transabdominal approach. Dis Colon Rectum. 1999;42(6):655-60. DOI: https://doi.org/10.1007/BF02234145

Luukkonen P, Mikkonen U, Järvinen H. Abdominal rectopexy with sigmoidectomy vs. rectopexy alone for rectal prolapse: a prospective, randomized study. Int J Colorectal Dis. 1992;7(4):219-22. DOI: https://doi.org/10.1007/BF00341225

Madiba TE, Baig MK, Wexner SD. Surgical management of rectal prolapse. Arch Surg. 2005;140(1):63-73. DOI: https://doi.org/10.1001/archsurg.140.1.63

Ripstein CB, Lanter B. Etiology and surgical therapy of massive prolapse of the rectum. Ann Surg. 1963;157(2):259-64. DOI: https://doi.org/10.1097/00000658-196302000-00012

McMahan JD, Ripstein CB. Rectal prolapse: an update on the rectal sling procedure. Am Surg. 1987;53(1):37-40.

D’Hoore A, Penninckx F. Laparoscopic ventral recto(colpo)pexy for rectal prolapse: surgical technique and outcome for 109 patients. Surg Endosc. 2006;20(12):1919-23. DOI: https://doi.org/10.1007/s00464-005-0485-y

Bordeianou L, Hicks CW, Kaiser AM, Alavi K, Sudan R, Wise PE. Rectal prolapse: an overview of clinical features, diagnosis, and patient-specific management strategies. J Gastrointest Surg. 2014;18(6):1059-69. DOI: https://doi.org/10.1007/s11605-013-2427-7

Boons P, Collinson R, Cunningham C, Lindsey I. Laparoscopic ventral rectopexy for external rectal prolapse improves constipation and avoids de novo constipation. Colorectal Dis. 2010;12(6):526-32. DOI: https://doi.org/10.1111/j.1463-1318.2009.01859.x

McKee RF, Lauder JC, Poon FW, Aitchison MA, Finlay IG. A prospective randomized study of abdominal rectopexy with and without sigmoidectomy in rectal prolapse. Surg Gynecol Obstet. 1992;174(2):145-8.

Lonne MLR, Sakata S, Papas CP, Stevenson ARL. How to Do a Delorme's Sleeve Mucosectomy and Muscular Plication for Full-Thickness Rectal Prolapse. ANZ J Surg. 2023;93(6):1694-6. DOI: https://doi.org/10.1111/ans.18448

Chun SW, Pikarsky AJ , You SY, Choi HS, Kim NK, Sohn SK. Perineal rectosigmoidectomy for rectal prolapse: role of levatorplasty. Tech Coloproctol. 2004;8(1):3-8. DOI: https://doi.org/10.1007/s10151-004-0042-z

Wijffels NA, Collinson R, Cunningham C, Lindsey I. What is the best surgical option for full-thickness rectal prolapse?. Dis Colon Rectum. 2011;54(5):648-53.

Madoff RD, Mellgren A. One hundred years of surgery for rectal prolapse: lessons learned. Dis Colon Rectum. 1999;42(3):351-62. DOI: https://doi.org/10.1007/BF02234164

Glasgow SC, Birnbaum EH, Kodner IJ, Fleshman JW, Dietz DW. Recurrence and quality of life following perineal proctectomy for rectal prolapse. J Gastrointest Surg. 2008;12(8):1446-51. DOI: https://doi.org/10.1007/s11605-008-0531-x

Altomare DF, Binda G, Ganio E, De Nardi P, Giamundo P, Pescatori M. Rectal Prolapse Study Group. Long-term outcome of Altemeier's procedure for rectal prolapse. Dis Colon Rectum. 2009;52(4):698-703. DOI: https://doi.org/10.1007/DCR.0b013e31819ecffe

Ris F, Colin JF, Chilcott M, Remue C, Jamart J, Kartheuser A. Altemeier's procedure for rectal prolapse: analysis of long-term outcome in 60 patients. Colorectal Dis. 2012;14(9):1106-11. DOI: https://doi.org/10.1111/j.1463-1318.2011.02904.x

Schabl L, Hull TL, Ban KA, Steele SR, Spivak AR. Recurrence Rates and Risk Factors in the Altemeier Procedure for Rectal Prolapse: A Multicenter Study. Dis Colon Rectum. 2024;67(11):1465-74. DOI: https://doi.org/10.1097/DCR.0000000000003439

Boccasanta P, Venturi M, Barbieri S, Roviaro G. Impact of new technologies on the clinical and functional outcome of Altemeier's procedure: a randomized, controlled trial. Dis Colon Rectum. 2006;49(5):652-60. DOI: https://doi.org/10.1007/s10350-006-0505-6

Kim M, Reibetanz J, Schlegel N, Krajinovic K, Köstler H, Germer CT, et al. Recurrence after perineal rectosigmoidectomy: when and why?. Colorectal Dis. 2014;16(11):920-4. DOI: https://doi.org/10.1111/codi.12756

Nugent E, Spivak A, Gurland BH, Shawki S, Hull TL, Zutshi M. Does the Length of the Prolapsed Rectum Impact Outcome of Surgical Repair?. Dis Colon Rectum. 2021;64(5):601-8. DOI: https://doi.org/10.1097/DCR.0000000000001856

Marceau C, Parc Y, Debroux E, Tiret E, Parc R. Complete rectal prolapse in young patients: psychiatric disease a risk factor of poor outcome. Colorectal Dis. 2005;7(4):360-5. DOI: https://doi.org/10.1111/j.1463-1318.2005.00762.x

Tarasconi A, Perrone G, Davies J, Coimbra R, Moore E, Azzaroli F, et al. Anorectal emergencies: WSES-AAST guidelines. World J Emerg Surg. 2021;16(1):48. DOI: https://doi.org/10.1186/s13017-021-00384-x