Surgical treatments for rectal prolapse: how does a perineal approach compare in the laparoscopic era?
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Patients with rectal prolapse often have significant comorbidities that lead surgeons to select a perineal resection for treatment despite a reported higher recurrence rate over abdominal approaches. There is a lack of data to support this practice in the laparoscopic era. The objective of this study was to evaluate if risk-adjusted morbidity of perineal surgery for rectal prolapse is actually lower than laparoscopic surgery.
A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database as performed for patients undergoing surgical treatment of rectal prolapse between 2005 and 2011. Outcomes were analyzed according to procedure-type: laparoscopic rectopexy (LR), laparoscopic resection/rectopexy (LRR), open rectopexy (OR), open resection/rectopexy (ORR), and perineal resection (PR). A multivariate logistic regression was used to compare risk-adjusted morbidity and mortality between each procedure. Main outcome measures were 30-day morbidity and mortality.
Among 3,254 cases sampled, a laparoscopic approach was used in 22 %, an open abdominal approach in 30 %, and PR in 48 %. Patients undergoing PR were older (76) and had a higher ASA (3) compared to laparoscopic (58, 2) and open abdominal procedures (58, 2). Risk-adjusted mortality could not be assessed due to a low overall incidence of mortality (0.01 %). Overall morbidity was 9.3 %. ORR was associated with a higher risk-adjusted morbidity compared to PR (OR: 1.89 CI (1.19–2.99), p = 0.03). There were no significant differences in risk-adjusted morbidity found between LR and LRR compared to PR (OR 0.44 CI (0.19–1.03), p = 0.18; OR 1.55 CI (0.86–2.77), p = 0.18). Laparoscopic cases averaged 27 min longer than open cases (p < 0.001).
Laparoscopic rectal prolapse surgery has comparable morbidity and mortality to perineal surgery. A randomized trial is indicated to validate these findings and to assess recurrence rates and functional outcomes.
KeywordsRectal prolapse Perineal Rectopexy Laparoscopic
Dr. Stamos has received educational grants and speaker fees paid to the Department of Surgery, University of California, Irvine, from Ethicon, Gore, Covidien, and Olympus. Dr. Mills and Dr. Carmichael received Ethicon educational grants paid to the Department of Surgery, University of California, Irvine. Dr. Pigazzi is a consultant for Intuitive Surgical and has also received consultancy fees and educational grants paid to the Department of Surgery, University of California, Irvine. Dr. Jafari, Dr. Young and Michael Phelan have no disclosures. Dr. Young and Michael Phelan had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
American College of Surgeons National Surgical Quality Improvement Program and the hospitals participating in the ACS NSQIP are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors.
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