Abdominal procedures for rectal prolapse (RP) are associated with lower recurrence rates than perineal operations. However, patients with significant comorbidities may be better suited for a perineal approach. The Risk Assessment Index (RAI) is a quick, easy validated tool to measure frailty that correlates with surgical outcomes [1]. The role of a frailty assessment in decision making for rectal prolapse repair is unknown.  The aim of our study was to evaluate how RAI correlates with our existing RP repair decision-making process and postoperative outcomes.

Consecutive cases of rectal prolapse were captured in a prospective registry from 2017-2021. Patient and operative characteristics were recorded. All patients received preoperative Risk Analysis Index scores. RAI scores are categorized as robust (<20), normal (21-29), frail (30-39), or very frail (>=40). Patients with significant cardiac comorbidities were offered a perineal operation based on discretion of a single experienced surgeon. RAI was not formally used in the decision-making process. Postoperative Cleveland Clinic Fecal Incontinence Scores, Obstructed Defecation Scores, and Patient Global Impression of Change scores were recorded.

Of the 115 patients in the registry with postoperative data, 86 (74.8%) underwent an abdominal (ab) operation and 29 (25.2%) underwent a perineal (pn) operation (Table 1). Both cohorts were mostly women (ab: 94.1% vs. pn: 93.1%m p=0.99) with similar preoperative obstructive defecation scores (ab: 8.0 vs. pn: 6.7, p=0.14) and preoperative fecal incontinence scores (ab: 11.8 vs. pn: 13.6, p=0.19). The population of patients who underwent perineal operations were older (mean age- ab: 60 vs. pn: 78y, p<0.001), with a more significant comorbidity burden (ASA score III or IV- ab:23.5% vs. pn: 65.5%, p=<0.001; cardiac comorbidity- ab: 32.6% vs. pn: 69.0%, p=0.001). The mean Risk Analysis Index score was higher in the perineal group (ab:20 vs. pn:31, p<0.001).
Most patients in the abdominal group underwent minimally invasive ventral mesh rectopexy (75.3%), while most patients in the perineal group underwent Altemeier proctosigmoidectomy (75.9%). The mean postoperative length of stay was longer in the perineal group (ab: 1.6 days versus pn: 2.2 days, p=0.03). 
Higher recurrence rate in the perineal group (ab: 10.5% vs. pn: 34.5%, p=0.006) with a median time to recurrence of 246 days for abdominal patients, and 178 for perineal patients. The abdominal group had a higher complication rate (ab:18.6% vs. pn: 13.8%, p=0.78) though most complications were a Clavien-Dindo Grade 2 (ab: 12.0% vs. pn: 6.9%). Patients in both groups experienced a similar significant improvement in CCFIS (mean change: ab:-4.0 vs. pn: -3.0, p=0.55)  and ODS score (mean change: ab:-2.7 vs. pn: -2.9, p=0.87). PGIC scores were similar at a mean of 35.6 days postoperatively (ab: 6.1 vs. pn: 6.0, p=0.64).

The RAI is an easy and quick tool that can be used in clinic and in our cohort, frail patients were more likely to be offered perineal operations. Although these patients had a longer postoperative stay, the complication profile was low, and patients were satisfied with their functional improvement at rates similar to the abdominal cohort. While evaluation of comorbidities can be subjective, the RAI is an objective metric that can help guide the shared decision-making process when determining what operations to offer patients with rectal prolapse. Ongoing research should further refine the role of frailty metrics in guiding decision-making on rectal prolapse surgery.

Frail patients are more likely to undergo perineal operations for rectal prolapse repair, but they tolerate these operations well. Frailty scores can be a useful metric in the shared decision-making process.

Arya S, Varley P, Youk A, et al. Recalibration and External Validation of the Risk Analysis Index: A Surgical Frailty Assessment Tool. Ann Surg. 2020;272(6):996-1005. doi:10.1097/SLA.0000000000003276

Continence 2S2 (2022) 100372
DOI: 10.1016/j.cont.2022.100372