What is the difference between Altemeier's (perineal rectosigmoidectomy) and Delorme's (rectal mucosectomy) procedures for an 80-year-old patient with rectal prolapse?

Altemeier vs. Delorme Procedures for Rectal Prolapse

For an 80-year-old patient with rectal prolapse, Altemeier's procedure (perineal rectosigmoidectomy) is the preferred operation when the prolapse is large (>5-7 cm), while Delorme's procedure (rectal mucosectomy) is better suited for smaller prolapses with shorter operative time and faster recovery. 1, 2

Key Technical Differences

Altemeier's Procedure (Perineal Rectosigmoidectomy)

• Full-thickness resection of prolapsed rectum and redundant sigmoid colon through a perineal approach 1
• Involves complete excision of the prolapsed bowel segment with colorectal or coloanal anastomosis 3, 4
• Average resected specimen length is approximately 11.6 cm, though can exceed 30 cm in massive prolapse 3, 4
• Often includes levatorplasty to reinforce the pelvic floor 4
• Can be performed under regional or local anesthesia in 70% of cases 3

Delorme's Procedure (Mucosal Sleeve Resection)

• Mucosal stripping only with plication of the underlying muscular wall 1
• Preserves the rectal muscular tube while removing redundant mucosa 5
• Less extensive dissection compared to Altemeier's 2
• Typically reserved for smaller prolapses (mean 4.9 cm vs. 7.3 cm for Altemeier) 2

Clinical Decision Algorithm

Choose Altemeier's When:

• Prolapse length exceeds 5-7 cm on squat position examination 2
• Irreducible or incarcerated prolapse is present 4
• Significant redundant sigmoid colon exists 3, 4
• Patient can tolerate longer operative time (mean 112 minutes) 2

Choose Delorme's When:

• Prolapse is smaller (<5 cm) 2
• Faster recovery is prioritized (mean hospital stay 8.6 vs. 11.3 days) 2
• Shorter operative time is needed (mean 81 vs. 112 minutes) 2
• Patient is extremely frail or high-risk 6, 5

Outcomes Comparison

Recurrence Rates

• Both procedures have similar recurrence rates with no statistically significant difference 2
• Altemeier: 6.4-20.8% recurrence rate 3, 2
• Delorme: 21-31.6% recurrence rate 2
• Recurrences from either procedure can be successfully treated with repeat perineal operations 3

Functional Outcomes

• Both procedures significantly improve quality of life scores (EQ-5D-5L), constipation scores (Longo), and incontinence scores (Wexner) postoperatively 2
• Altemeier shows 87% subjective improvement with complete objective resolution in all patients 3
• Continence improvement occurs with both approaches, though persistent incontinence rates remain higher than abdominal procedures 6, 5

Perioperative Safety

• Complication rates are similar between procedures (approximately 20-21%) 2
• No perioperative mortality reported in modern series 3
• Both can be performed as outpatient procedures, with 62% of Altemeier patients discharged same-day 3

Critical Considerations for the 80-Year-Old Patient

Advantages of Perineal Approaches (Both Procedures)

• Avoid general anesthesia - can use regional or local anesthesia 3
• No abdominal incision or laparotomy required 1
• Lower perioperative morbidity and mortality compared to abdominal approaches 6, 3
• Suitable for patients with multiple comorbidities 3, 5

Common Pitfalls to Avoid

• Do not choose Delorme for large prolapse (>7 cm) as inadequate resection may increase recurrence risk 2
• Do not delay surgery in incarcerated or gangrenous prolapse - immediate intervention required 1
• Ensure adequate bowel length is resected in Altemeier's to prevent recurrence from residual redundant colon 4
• Consider levatorplasty with Altemeier's to reduce recurrence 4

Surgeon Expertise Factor

• The choice ultimately depends on surgeon familiarity with each technique, as the PROSPER study showed no significant outcome differences between various approaches when performed by experienced surgeons 1
• Both procedures require specific technical expertise for optimal results 1