Scientific letter
Altemeier procedure for rectal prolapse after intersphincteric low anterior resection with transanal total mesorectal excision
Procedimiento de Altemeier para la reparación de prolapso rectal tras resección anterior de recto interesfinteriana con escisión mesorrectal total por vía transanal
Eloy Maldonado Marcos
, Pere Planellas Giné, Júlia Gil Garcia, Ramon Farrés Coll, Antoni Codina Cazador
Corresponding author
Cirugía General y Digestiva, Unidad de Cirugía Colorrectal, Servicio de Cirugía General y del Aparato Digestivo, Universidad de Girona, Instituto de Investigación Biomédica de Girona (IdIBGi), Girona, Spain
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The incidence is slightly higher when the approach is done laparoscopically or robotically (6.4%).<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Classically, the treatment for coloanal anastomosis prolapse consisted of abdominoperineal resection.</p><p id="par0020" class="elsevierStylePara elsevierViewall">We report the case of a 61-year-old woman with a history of smoking, grade I obesity and tubal ligation, who was diagnosed with low rectal cancer after a fecal occult blood test. Colonoscopy revealed a lesion, whose biopsy was compatible with low-grade adenocarcinoma, 1 cm proximal to the pectineal line. On pelvic MRI, the lesion was observed to be a bilateral posterior and anterolateral tumor of more than 75% of the circumference and 3.5 cm in length. There was invasion of the entire thickness of the internal anal sphincter, but no signs of invasion of the intersphincteric space, and 5 mesorectal lymphadenopathies were in contact with the mesorectal fascia (Rullier III cT3N2M0). Endoanal ultrasound could not be performed due to pain. In the directed anamnesis, the patient reported good baseline continence (0 points on the Wexner scale) and history of an uneventful vaginal delivery. Upon physical examination, which was limited due to pain, the patient presented good tone, contractility, and preserved reflexes.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The patient received neoadjuvant radiochemotherapy. The restaging MRI showed reduction of the tumor and lymphadenopathy (persisting extramural extension). Distant metastatic involvement was ruled out (Rullier II and cT3N0M0). Surgery was indicated, and we proposed two options: Miles’ abdominoperineal resection or sphincter-preserving surgery with total transanal mesorectal excision (TaTME). The patient opted for the latter.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Complete intersphincteric resection was performed by TaTME surgery, including a manual end-to-end coloanal anastomosis with protective ileostomy. The postoperative patient progress was good, without complications, and she was discharged on the seventh day.</p><p id="par0035" class="elsevierStylePara elsevierViewall">During the subsequent follow-up, the patient presented a good general condition but poor adaptation to the ileostomy. The physical examination was normal. Pathology results reported free margins and optimal mesorectal quality, with final staging ypT1N0.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Four months later, the patient presented with spontaneous rectal prolapse, complete with the Valsalva maneuver. Rectal examination revealed the absence of masses and, together with manometry, severe hypotonia. A colonoscopy study ruled out other lesions, and the endoanal ultrasound showed asymmetry of the puborectalis branches (right 12 mm and left 9 mm), absence of an internal anal sphincter and a complete external anal sphincter, with thinning of the left quadrants (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Given the coloplasty prolapse together with the severe hypotonia, we performed prolapse surgery without a definitive colostomy, in accordance with the Altemeier technique.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The surgery involved resection of the coloplasty about 7−8 cm below the previous anastomosis and end-to-end coloanal anastomosis with posterior levatorplasty, with no incidents and good retraction of the repair (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The patient was discharged on the second postoperative day, and the ileostomy was closed 3 months later. In subsequent check-ups, the patient has been in good general health, with a score on the LARS scale of 23 points (minor LARS).<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">Sphincter-preserving surgery for lower rectal cancer is an option whose use is increasing in our setting, with different approaches that include the robotic approach and the TaTME approach.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> TaTME surgery should be performed by teams with established training.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Even when the criteria are met, related complications have been reported. Rectal prolapse related with ultra-low resections is a rare complication, associated with poor anorectal function, including incontinence, exudation, and anal pain.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Factors related to the incidence of colon prolapse after intersphincteric resection have been described, such as advanced age, female sex, and neoadjuvant radiotherapy.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">When treating a patient with rectal prolapse, especially after cancer surgery, the study before surgical indication should rule out recurrence and make a dynamic sphincter evaluation.</p><p id="par0065" class="elsevierStylePara elsevierViewall">There are multiple surgical approaches for the treatment of similar cases, whose objectives are to preserve anorectal function and avoid a definitive colostomy. The techniques described by Delorme and Altemeier, rectopexies, or another resection via the abdominal route are examples.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,10</span></a> In our experience, the Altemeier technique could be one to keep in mind, although there are no randomized clinical trials or case series with long-term follow-up.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Maldonado Marcos E, Planellas Giné P, Gil Garcia J, Farrés Coll R, Codina Cazador A. Procedimiento de Altemeier para la reparación de prolapso rectal tras resección anterior de recto interesfinteriana con escisión mesorrectal total por vía transanal. Cir Esp. 2021;99:389–391.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 404 "Ancho" => 1405 "Tamanyo" => 60864 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Endoanal ultrasound for the study of the prolapse: a) upper anal canal showing asymmetry between the right and left branches of the puborectalis muscle; b) middle anal canal showing thinning of the external anal sphincter in the left quadrants; c) lower anal canal showing no alterations.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1134 "Ancho" => 1505 "Tamanyo" => 311196 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Repair of the anal prolapse with the Altemeier procedure: a) prolapse prior to surgery; b) resection of the coloplasty; c) levatorplasty; d) final appearance.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Long-term results of intersphincteric resection for low rectal cancer" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "K. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 11 | 0 | 11 |
| 2024 October | 78 | 5 | 83 |
| 2024 September | 69 | 6 | 75 |
| 2024 August | 58 | 12 | 70 |
| 2024 July | 54 | 8 | 62 |
| 2024 June | 50 | 3 | 53 |
| 2024 May | 49 | 5 | 54 |
| 2024 April | 53 | 2 | 55 |
| 2024 March | 70 | 4 | 74 |
| 2024 February | 85 | 3 | 88 |
| 2024 January | 123 | 7 | 130 |
| 2023 December | 126 | 7 | 133 |
| 2023 November | 152 | 7 | 159 |
| 2023 October | 180 | 15 | 195 |
| 2023 September | 115 | 1 | 116 |
| 2023 August | 123 | 2 | 125 |
| 2023 July | 155 | 3 | 158 |
| 2023 June | 122 | 7 | 129 |
| 2023 May | 129 | 0 | 129 |
| 2023 April | 135 | 3 | 138 |
| 2023 March | 129 | 9 | 138 |
| 2023 February | 103 | 6 | 109 |
| 2023 January | 118 | 7 | 125 |
| 2022 December | 102 | 5 | 107 |
| 2022 November | 114 | 13 | 127 |
| 2022 October | 88 | 7 | 95 |
| 2022 September | 113 | 8 | 121 |
| 2022 August | 45 | 3 | 48 |
| 2022 July | 48 | 8 | 56 |
| 2022 June | 44 | 7 | 51 |
| 2022 May | 16 | 6 | 22 |
| 2021 May | 0 | 2 | 2 |
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