Sigmoido‐rectal intussusception anastomosis in the Altemeier procedure for incarcerated rectal prolapse—A video vignette and 13 case reports

Rectal prolapse is a benign condition of the pelvic floor. While most individuals with prolapse may recover on their own or with assistance, others may develop an entrenched prolapse as a result of an incarcerated rectal prolapse that makes it difficult for the bowel to return. Incarcerated rectal prolapse occurs rarely, in 2%–4% of cases [1]. In the opinion of Yildirim [2], the primary causes of incarcerated rectal prolapse are inadequate pelvic floor function and damage to the anal sphincter. Incarcerated rectal prolapse of the intestinal tube can result in sphincter reversal spasm, ischaemia and hypoxia of the intestinal mucosa, as well as erosion and necrosis. To preserve the patient's life, surgery must be done quickly if manipulation of the rectal prolapse is unsuccessful. Currently, there are many surgical procedures for the treatment of rectal prolapse, but few are suitable for incarcerated rectal prolapse. In 1992, Paravasthu [3] first proved that Altemeier's procedure is an effective surgical procedure for treating incarcerated rectal prolapse. However, it was discovered that fatal complications, such as anastomotic leakage, may occur after Altemeier's procedure, and the rate of postoperative anastomotic complications was significantly higher in incarcerated rectal prolapse than in those in remission from complete rectal prolapse. Numerous scholars have also confirmed that Altemeier's procedure is less invasive, reduces the risk of postoperative abdominal infections in incarcerated rectal prolapse and is the best surgical procedure to replace the abdominal approach for treating incarcerated rectal prolapse [1]. A further structural defect of rectal prolapse is pathological dilatation of the distal rectum, according to our team's synthesis of the idea of ‘intussusception’ [4]. The results demonstrated a considerable reduction in the rate of postoperative problems, and this defect may be the ‘trigger point’ for recurrence following Altemeier's treatment (technical aspects are detailed in Video 1). Our research team applied Altemeier surgery combined with sigmoido-rectal intussusception anastomosis in 13 cases of incarcerated rectal prolapse in three centres, with intraoperative bleeding ranging from 15 to 20 mL (mean 16.78 mL) and an operative duration from 140 to 260 min (mean 195.56 min). The 13 patients were operated on successfully, and none underwent prophylactic ileostomy during the operation. However, two patients had anastomotic bleeding, a typical complication (Table S1), on postoperative days 7 and 12, with one requiring surgical suturing to control the bleeding and the other receiving conservative therapy. None of the individuals with incarcerated rectal prolapse had indications of peritonitis or systemic infection. Our research team believes that the key to effectively reducing surgical problems during the Altemeier operation is to balance the resection of adequate bowel while keeping the anastomosis at only moderate strain. On the one hand, because of the varied lengths of the embedded bowel segments, the intestinal incision should be placed at the split between necrotic and normal gut to avoid leftover necrotic bowel. On the other hand, the sigmoido-rectal intussusception anastomosis approach wraps the anastomosis around the surrounding anal sphincter, anus-raising muscle and pelvic floor muscle, and the anastomotic formation of scarring and aseptic inflammatory reaction firmly fixes the rectal mucosa in the muscularis propria. While preventing anastomotic problems, this procedure is also utilized to address the issue of pathological dilatation of the distal rectum and to reduce postoperative difficulties and recurrence [5]. There was no recurrence in any of the patients after a 21-month (13-36month) follow-up period. The rarity of incarcerated rectal prolapse has led to a lack of clinical experience in its treatment, and to the best of our knowledge the present clincal study contains the largest sample to date. Our experience and review of the literature suggest that the Altemeier procedure is of great value in this rare emergency procedure. Our opinion that the Altemeier procedure combined with sigmoido-rectal intussusception anastomosis can be effective in decreasing the incidence of anastomotic complications and recurrences must be substantiated by future prospective multicentre investigations with large samples. BW: Conceptualization, Writing – original draft. YZ: Investigation, Writing – review & editing. YZ: Methodology, Writing – original draft. CC: Project administration, Writing – review & editing. All authors read and approved the final manuscript. We express our gratitude to all the participants for their valuable contributions and participation in this study. In addition, we need to give special thanks to the founder of this procedure - Prof. Altemeier - for providing a new dawn in the treatment of rectal prolapse. This approval and consent to participate. The study was approved by the Ethics Committee of the Affiliated Hospital of Shandong University of Traditional Chinese Medicine. The author(s) declare financial support was received for the research, authorship, and/or publication of this article. (a) Shandong Traditional Chinese Medicine Science and Technology Development Program (Project No. M-2023305); (b) Affiliated Hospital of Shandong University of Traditional Chinese Medicine “Young Famous Chinese Medicine Practitioners” Cultivation Program for the year of 2023; (c) Qilu Chinese Medicine Advantageous Specialty Cluster Project (Project No. YWC2022ZKJQ0003).. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article. The original contributions presented in the study are included in the article/Supplementary Material, further inquiries can be directed to the corresponding author. Table S1. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.