Purpose: Recurrence of rectal prolapse following the Altemeier procedure is reported with rates up to 40%. The optimal surgical management of recurrences has limited data available. Ventral mesh rectopexy (VMR) is a favored procedure for primary rectal prolapse, but its role in managing recurrences after Altemeier is unclear. VMR for recurrent prolapse involves implanting the mesh on the colon, which has a thinner wall, more active peristalsis, no mesorectum, less peritoneum available for covering the mesh, and potential diverticula. These factors can affect mesh-related complications such as erosion, migration, or infection. This study assessed the feasibility and perioperative outcomes of VMR for recurrent rectal prolapse after the Altemeier procedure. Methods: We queried our prospectively maintained database between 01/01/2008 and 06/30/2022 for patients who had experienced a recurrence of full-thickness rectal prolapse following Altemeier’s perineal proctosigmoidectomy and subsequently underwent ventral mesh rectopexy. Results: Ten women with a median age of 67 years (range 61) and a median BMI of 27.8 kg/m² (range 9) were included. Five (50%) had only one Altemeier, and five (50%) had multiple rectal prolapse surgeries, including Altemeier before VMR. No mesh-related complications occurred during a 65-month (range 165) median follow-up period. Three patients (30%) experienced minor postoperative complications unrelated to the mesh. Long-term complications were chronic abdominal pain and incisional hernia in one patient, respectively. One out of five (20%) patients with only one previous prolapse repair had a recurrence, while all patients (100%) with multiple prior repairs recurred. Conclusion: Mesh implantation on the colon is possible without adverse reactions. However, high recurrence rates in patients with multiple previous surgeries raise doubts about using VMR for secondary or tertiary recurrences.

BACKGROUND: Perineal proctosigmoidectomy (Altemeier) is a surgical procedure that is commonly used for the treatment of rectal prolapse. However, there is a diverse range of recurrence rates after Altemeier procedure repair that has been reported in the literature. OBJECTIVE: To identify primary and subsequent recurrence rates after perineal proctosigmoidectomy and to define potential risk factors for recurrence. DESIGN: Cohort study. SETTINGS: Conducted at 6 hospitals affiliated with the Cleveland Clinic. PATIENTS: The study included patients who were older than 18 years and were treated with the Altemeier procedure for rectal prolapse between 2007 and 2022. MAIN OUTCOME MEASURES: Primary outcomes were rates of primary and subsequent recurrences. Secondary outcomes included potential risk factors for recurrence previously mentioned in the literature. RESULTS: We identified 182 patients, of whom 95.1% were women, with a mean age of 79 years (SD 11.4). Overall, procedures were elective in 92.1% of patients, and 14.3% had previously undergone prolapse repairs (Delorme, Thiersch, abdominal suture rectopexy, and abdominal mesh rectopexy). At a mean follow-up period of 27.5 months (SD 45.7), 37.9% of patients experienced recurrence, with 16.5% of patients having multiple recurrences. A subsequent Altemeier procedure was performed in 72.5% of instances. Other treatments included Delorme, abdominal suture rectopexy, abdominal mesh rectopexy, or conservative management. This study identified connective tissue disorders and time since surgery as significant risk factors for recurrence. LIMITATIONS: Retrospective design and varying follow-up periods. CONCLUSIONS: Perineal proctosigmoidectomy is associated with a significant risk of recurrence. The risk of recurrence increased with the presence of a connective tissue disorder and in proportion to the elapsed time since surgery. These discoveries assist health care professionals in counseling and managing patients who undergo perineal proctosigmoidectomy for rectal prolapse. See Video Abstract. TASAS DE RECURRENCIA Y FACTORES DE RIESGO EN EL PROCEDIMIENTO DE ALTEMEIER PARA EL PROLAPSO RECTAL: UN ESTUDIO MULTICÉNTRICO: ANTECEDENTES: La proctosigmoidectomía perineal (Altemeier) es un procedimiento quirúrgico que se utiliza comúnmente para el tratamiento del prolapso rectal. Sin embargo, existe una amplia gama de tasas de recurrencia después de la reparación con el procedimiento de Altemeier que se han informado en la literatura. OBJETIVO: Nuestro objetivo fue identificar las tasas de recurrencia primaria y posterior después de la proctosigmoidectomía perineal, así como definir los posibles factores de riesgo de recurrencia. DISEÑO: Estudio de cohorte. AJUSTES: Realizado en 6 hospitales afiliados a la Clínica Cleveland. PACIENTES: Se incluyeron pacientes mayores de 18 años que fueron tratados con procedimiento de Altemeier por prolapso rectal entre 2007 y 2022. PRINCIPALES MEDIDAS DE VALORACIÓN: Los resultados primarios fueron las tasas de recurrencias primarias y posteriores. Los resultados secundarios incluyeron factores de riesgo potenciales de recurrencia mencionados anteriormente en la literatura. RESULTADOS: Se identificaron 182 pacientes, de los cuales el 95,1% eran mujeres con una edad media de 79 años (DE 11,4). En general, el 92,1% fueron electivos y el 14,3% se habían sometido previamente a reparaciones de prolapso (Delorme, Thiersch, rectopexia con sutura abdominal y rectopexia con malla abdominal). En un período de seguimiento medio de 27,5 meses (DE 45,7), el 37,9% de los pacientes experimentó recurrencia, y el 16,5% de los pacientes tuvo recurrencias múltiples. En el 72,5% de los casos se realizó un procedimiento de Altemeier posterior. Otros tratamientos incluyeron Delorme, rectopexia con sutura abdominal, rectopexia con malla abdominal o manejo conservador. Este estudio identificó los trastornos del tejido conectivo y el tiempo transcurrido desde la cirugía como factores de riesgo importantes de recurrencia. LIMITACIONES: Diseño retrospectivo y períodos de seguimiento variables. CONCLUSIÓN: La proctosigmoidectomía perineal se asocia con un riesgo significativo de recurrencia. El riesgo de recurrencia aumentó con la presencia de un trastorno del tejido conectivo y en proporción al tiempo transcurrido desde la cirugía. Estos descubrimientos ayudan a los profesionales de la salud a asesorar y tratar a los pacientes que se someten a proctosigmoidectomía perineal por prolapso rectal. (Traducción—Dr. Ingrid Melo)