EP871 - Open Rectopexy: An Endangered Operation or a Classic Still in Practice?

Purpose/Background: Current surgical options for treatment of rectal prolapse include open abdominal, minimally invasive, and perineal approaches. These differences in practice have usually been dictated by patient age, comorbidities, and surgeon preference or experience. With the surge of minimally invasive techniques, we sought to describe practice patterns and patient characteristics around surgical treatment of rectal prolapse over time.

Methods/Interventions: We conducted a retrospective cohort study using the National Surgical Quality Improvement Program (NSQIP) database from 2013 to 2022. All patients who underwent surgical intervention for a primary diagnosis of rectal prolapse were included. CPT codes indicative of perineal repair (Altemeier, Delorme), open abdominal repair with or without resection, and minimally invasive repair with or without resection (MIS) were included. Patients who underwent repair by both open abdominal and perineal approaches were excluded. Baseline patient and hospital characteristics were compared with significant level of p-values < 0.05. Kendall's Tau was used to trend the rates of surgical approaches over time.

Results/Outcomes: A total of 14,982 patients with a primary diagnosis of rectal prolapse who underwent surgical repair. Nearly half of the overall cohort were 75 years of age or older at the time of their surgery (40.9%) with 92.4% being female. The majority of patients (64.5%) had at least one comorbidity with a median ASA class of 3 [IQR 2, 3]. Roughly half of the cohort, or 7,693 (51.3%) patients, underwent perineal repair, 5,095 (34.0%) underwent MIS repair, and 2,194 (14.6%) underwent open abdominal repair. Compared to MIS approach, patients who underwent perineal repair were more likely to be older, comorbid, and functionally dependent pre-operatively (p < 0.001). Perineal repairs were more likely to be done emergently (2.1% vs 0.3%; p< 0.001) and under locoregional anesthesia (13.1% vs 0.5%; p< 0.001). Operative time was 80 minutes shorter in the perineal cohort (77 min vs 157 min; p< 0.001). Over the 10-year study period, the proportion of open abdominal approach decreased (p=0.0024) while MIS approach increased (p < 0.001). The rate of perineal repairs remained stable (p=0.15). When assessing the trend of bowel resection, the proportion of MIS repairs without resection increased while MIS repairs with resection as well as open repairs with or without resection decreased (all p< 0.001).

Conclusion/Discussion: Our findings highlight a continued shift toward minimally invasive techniques, with a corresponding decline in the use of open repair of rectal prolapse. Despite this trend, the rate of perineal repairs has remained stable, underscoring their continued role as an essential component of the surgical armamentarium for rectal prolapse. Comprehensive training of residents and fellows in all surgical approaches is imperative to ensure optimal patient outcomes and preserve procedural versatility.
Trends in Approaches to Rectal Prolapse Repair Over 10-Year Period

Trends in Minimally Invasive Versus Open Approach With and Without Resection