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Introduction:
The perineal approach to rectal prolapse repair is commonly chosen over open abdominal rectopexy for high-risk patients. A higher risk of recurrence has been accepted as a tradeoff for reduced morbidity. Increasingly rectopexy is now performed laparoscopically and this approach may reduce the incidence of complications while maintaining the durability of an abdominal procedure. The aim of this study was to compare the 30-day outcomes of laparoscopic versus perineal rectal prolapse repair using outcomes from a national clinical database.
Methods:
Laparoscopic and perineal rectal prolapse surgeries were selected from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP, 2005-2010) by cross referencing Current Procedural Terminology codes (CPT codes 45400, 45130, and 45541) and International Classification of Disease, 9th edition codes (ICD-9 codes) for rectal prolapse. Patient demographics, preoperative risk factors and operative variables were recorded. The primary outcome was occurrence of major complication (mortality, organ space infection, return to OR, renal failure, venous thromboembolism, cardiac, neurological or respiratory complications). Univariate (χ²), and multivariate (logistic regression) analysis was performed to identify independent predictors of major complications.
Results:
During the study period 1385 patients underwent rectal prolapse repair by perineal approach and 248 had laparoscopic rectopexy. Perineal cases were older (p=0.0001) with a higher ASA class (p=0.0001) and more pre-operative comorbidities {cardiac (p=0.009) and neurological (p=0.005)}. Operative time was longer with a laparoscopic approach (mean 135 min vs. 87 min, p=0.0001). Univariate analysis showed no difference in the complication rate between laparoscopic and perineal approach (4% vs 6.9%, p=0.09). After risk adjustment for age, ASA, pre-operative comorbidities and operative time, the difference in major complications between laparoscopic and perineal approach remained non significant on multivariate analysis. Independent predictors of major complication included presence of pulmonary disease (OR=1.91, 95%CI= [1.03, 3.55], p=0.04), bleeding disorder (OR=3.42, 95%CI= [1.65, 7.10], p=0.001), and anemia (OR=2.09, 95%CI= [1.06, 4.10], p=0.033).
Conclusion:
This study shows that even after risk adjustment the complication rate for laparoscopic rectopexy is no higher than perineal approach. Laparoscopic approach for repair of rectal prolapse should therefore be the preferred approach in most patients in view of the lower recurrence rate.