Rectal Prolapse in the Elderly: Trends in Surgical Management and Outcomes from the American College of Surgeons National Surgical Quality Improvement Program Database Clarence E Clark III, MD, FACS, Dan C Jupiter, PhD, J Scott Thomas, MD, FACS, Harry T Papaconstantinou, MD, FACS BACKGROUND: Full thickness rectal prolapse (FTRP) is managed with an abdominal or perineal operation. Traditionally, the approach has been determined by patient age and comorbidities. Our aim was to determine operative trends and outcomes for repair of FTRP in elderly patients using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. STUDY DESIGN: We queried the ACS NSQIP database from 2006 to 2009 for patients with FTRP who were 70 years of age or older. Patients were grouped according to type of surgical repair: laparoscopic (LR), open (OR), or perineal (PR) technique. We reviewed demographics, operative trends of surgical technique, and short-term outcomes for each group. RESULTS: A total of 816 patients were analyzed; 596 (73%) PR, 130 (16%) OR, and 90 (11%) LR patients. Patients who received OR and LR had lower mean American Society of Anesthesiol- ogists (ASA) scores than PR patients (2.6, 2.5, and 2.7, respectively, p  0.001). The percentage of LR and OR procedures decreased as age increased by decade; the inverse was seen for PR (p  0.001). The distribution of operative techniques has not changed from year to year. Length of stay was significantly shorter for LR (3.77 days) and PR (3.44 days) patients vs OR patients (6.23 days) (p  0.01). Complication rates were 2.22%, 8.72%, and 12.31% for LR, PR, and OR, respectively (p  0.021). Open surgery was the only factor associated with an increased complication rate, with an odds ratio of 6.29 (95% CI 1.38 to 28.6, p  0.02). CONCLUSIONS: Despite the appeal of perineal proctectomy in the elderly and debilitated patient, the approach to FTRP is slowly evolving in the era of laparoscopic surgery. Laparoscopic repair of FTRP in the elderly is associated with improved short-term outcomes when compared with OR and PR. (J Am Coll Surg 2012;215:709–714. © 2012 by the American College of Surgeons) There are a number of procedures described for the repair of full thickness rectal prolapse (FTRP), all of which fall into 1 of 2 categories: an abdominal repair or a perineal repair. Surgical training, patient age, American Society of Anesthesiologists (ASA) score, and history of previous pel- vic surgery have influenced the approach to repair in the past, with age and ASA score being a focus in the literature. Various studies have shown the safety and efficacy of a perineal approach in elderly patients, especially if the pa- tient is debilitated. 1-7 These studies support the use of this approach in a cohort of patients who may not tolerate an abdominal operation, thereby optimizing short-term outcomes. 1-7 However, studies have shown a significantly higher recurrence rate in the perineal approach when com- pared with abdominal repairs. 8,9 The application of minimally invasive laparoscopic tech- niques to colorectal surgery have improved outcomes, with a significant reduction in postoperative length of hospital stay (LOS), return of bowel function, complication rate, and post- operative pain when compared with open surgery. 10-14 Lapa- CME questions for this article available at http://jacscme.facs.org Disclosure Information: Authors have nothing to disclose. Timothy J Eberlein, Editor-in-Chief, has nothing to disclose. Presented at the ACS-NSQIP National Conference, Boston, MA, July 2011. Received May 2, 2012; Revised June 30, 2012; Accepted July 3, 2012. From the Department of Surgery-Section of Colon and Rectal Surgery, Scott and White Memorial Hospital and Clinic, Texas A&M University System Health Science Center College of Medicine, Temple, TX. Correspondence address: Clarence E Clark III, MD, FACS, Department of Surgery, Scott and White Memorial Hospital/Texas A&M Health Science Center, 2401 S 31st St, Temple, TX 76508. email: cec156@yahoo.com 709 © 2012 by the American College of Surgeons ISSN 1072-7515/12/$36.00 Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jamcollsurg.2012.07.004