Postoperative Outcomes Associated With Procedural Sedation Conducted by Physician and Nonphysician Anesthesia Providers: Findings From the Prospective, Observational African Surgical Outcomes Study.

BACKGROUND: There is an unmet need for essential surgical services in Africa. Limited anesthesia services are a contributing factor. Nonphysician anesthesia providers are utilized to assist with providing anesthesia and procedural sedation to make essential surgeries available. There is a paucity of data on outcomes following procedural sedation for surgery in Africa. We investigated the postoperative outcomes following procedural sedation by nonphysicians and physicians in Africa. We hypothesized that the level of training of the sedation provider may be associated with the incidence of severe postoperative complications and death. METHODS: A secondary analysis of a prospective cohort of inhospital adult surgical patients representing 25 African countries was performed. The primary outcome was a collapsed composite of inhospital severe postoperative complications and death. We assessed the association between receiving procedural sedation conducted by a nonphysician (versus physician) and the composite outcome using logistic regression. We used the inverse probability of treatment weighting propensity score method to adjust for potential confounding variables including patient age, hemoglobin level, American Society of Anesthesiologists (ASA) physiological status, diabetes mellitus, urgency of surgery, severity of surgery, indication for surgery, surgical discipline, seniority of the surgical team, hospital level of specialization, and hospital funding system using public or private funding. All patients who only received procedural sedation for surgery were included. RESULTS: Three hundred thirty-six patients met the inclusion criteria, of which 98 (29.2%) received sedation from a nonphysician provider. The incidence of severe postoperative complications and death was 10 of 98 (10.2%) in the nonphysician group and 5 of 238 (2.1%) in the physician group. The estimated association between procedural sedation conducted by a nonphysician provider and inhospital outcomes was an 8-fold increase in the odds of severe complications and/or death, with an odds ratio (95% confidence interval [CI]) of 8.3 (2.7-25.6). CONCLUSIONS: The modest number of observations in this secondary data analysis suggests that shifting the task of procedural sedation from physicians to nonphysicians to increase access to care may be associated with severe postoperative complications and death in Africa. Research focusing on identifying factors contributing to adverse outcomes associated with procedural sedation is necessary to make this practice safer.

The role of carcinoembryonic antigen as an assessment tool for predicting disease severity among patients with colorectal cancer in resource-poor setting of Kwazulu-Natal, South Africa.

INTRODUCTION: the most reliable screening tool for colorectal cancer, colonoscopy, is not readily accessible in resource-deprived settings of KwaZulu-Natal. The aim of this study was to determine whether serum carcinoembryonic antigen (CEA) levels in patients symptomatic for lower gastrointestinal (GI) pathology correlates with the histological presence and severity of primary colorectal cancer in a large referral centre. Perhaps CEA may have a larger role as a marker for colorectal cancer (CRC) development in these resource deprived communities. METHODS: this study was a retrospective analysis of prospectively collected clinical data of 380 pretreatment patients with colorectal cancer attending a tertiary referral centre in KwaZulu-Natal. Data were analyzed using descriptive statistics and findings were compared with those from the existing literature. RESULTS: the mean CEA level of the study population was 170.0 ± 623.3 µg/l. The number of participants with a CEA level <5 µg/l was 151 (39.74%) whilst the majority 229 (60.26%) had a CEA level ≥ 5 µg/l. There was no significant correlation between CEA levels and gender (p=0.8) or age (p=0.6). CEA levels were highest in the black African race group. Pairwise comparison demonstrated a statistically significant difference between the black and Indian population groups (p=0.02). The current study demonstrates an upregulation of CEA as the stage of CRC progresses (p<0.0001). CONCLUSION: there was no significant difference in CEA levels across age and gender. A positive correlation was noted between CEA level and stage of CRC. Carcinoembryonic antigen levels were highest in the black race group. Low sensitivity of CEA as a screening test for CRC was confirmed.

Development of a Clinical Prediction Model for In-hospital Mortality from the South African Cohort of the African Surgical Outcomes Study.

BACKGROUND: Data on the factors that influence mortality after surgery in South Africa are scarce, and neither these data nor data on risk-adjusted in-hospital mortality after surgery are routinely collected. Predictors related to the context or setting of surgical care delivery may also provide insight into variation in practice. Variation must be addressed when planning for improvement of risk-adjusted outcomes. Our objective was to identify the factors predicting in-hospital mortality after surgery in South Africa from available data. METHODS: A multivariable logistic regression model was developed to identify predictors of 30-day in-hospital mortality in surgical patients in South Africa. Data from the South African contribution to the African Surgical Outcomes Study were used and included 3800 cases from 51 hospitals. A forward stepwise regression technique was then employed to select for possible predictors prior to model specification. Model performance was evaluated by assessing calibration and discrimination. The South African Surgical Outcomes Study cohort was used to validate the model. RESULTS: Variables found to predict 30-day in-hospital mortality were age, American Society of Anesthesiologists Physical Status category, urgent or emergent surgery, major surgery, and gastrointestinal-, head and neck-, thoracic- and neurosurgery. The area under the receiver operating curve or c-statistic was 0.859 (95% confidence interval: 0.827-0.892) for the full model. Calibration, as assessed using a calibration plot, was acceptable. Performance was similar in the validation cohort as compared to the derivation cohort. CONCLUSION: The prediction model did not include factors that can explain how the context of care influences post-operative mortality in South Africa. It does, however, provide a basis for reporting risk-adjusted perioperative mortality rate in the future, and identifies the types of surgery to be prioritised in quality improvement projects at a local or national level.

Clinicopathological spectrum of colorectal cancer among the population of the KwaZulu-Natal Province in South Africa.

INTRODUCTION: the burden of colorectal carcinoma (CRC), once considered rare in Africa, may be changing with the disease being increasingly diagnosed and there is a suggestion that age and race influence tumour behaviour. We sought to describe the clinicopathological spectrum of CRC among the different race and age groups in a South African setting. METHODS: analysis of prospectively collected data from an on-going colorectal cancer database, including demographics, clinical presentation, site, staging and grading on all patients enrolled over an 18-year period. RESULTS: a total of 2232 patients with CRC were accrued over the study period (Africans, 798; Indians, 890; Coloureds, 104; and Whites, 440). Mean age was 57.7 (SD 14.4) but varied considerably by race (p < 0.001) with Africans being significantly younger. Young adults (aged < 40 years) totalled 305 and older patients (aged > 40 years) totalled 1927. The proportion of young patients (< 40 years old) was 28%, 7%, 9% and 3% among Africans, Indian, Coloured and White patients respectively. There were minimal variations in anatomical sub-site distribution. There was no difference in tumour stage between the various races and between older and young adults. Mucinous differentiation was more common in Africans and in young patients and poor differentiation was more common in African patients. Africans had a significantly lower resection rate compared to the other race groups (p < 0.001). Younger patients had a significantly lower resection rate compared to the older age group (p < 0.001). CONCLUSION: African patients were the youngest compared to the other race groups. Mucinous differentiation predominated in Africans and young adults. Poor differentiation predominated in Africans. Resection rate was lower for African patients and in young patients.

Out-patient visits for gastrointestinal cancer at a quaternary South African hospital-trends and geospatial distribution.

BACKGROUND: This study sought to determine trends in out-patient visits for gastrointestinal cancer (GC) at a quaternary hospital in KwaZulu-Natal (KZN), South Africa; and identify geographical regions which contribute most to GC-related out-patient clinic utilization at this hospital. METHOD: Data for GC-related outpatient visits over an 11-year period was obtained from the hospital's administrative database. Trends were analyzed using simple regression and trend line analyses. Patient residential postal codes from the administrative database were used to determine the geospatial distribution of complex GC in KZN. RESULTS: Strong increasing trends in GC-related out-patient visits were noted for age >65 years old (R2=0.8014), male (R2=0.7020), female (R2=0.7292), lower GC (R2=0.7094), and rural residence (R2=0.7008). Moderate increasing trends in GC-related out-patient visits were noted for age ≤65 years old (R2=0.6556), upper GC (R2=0.6498), and urban residence (R2=0.6988). The magnitude at which the number of out-patient visits increased was greater for urban residence when compared with rural residence (p=0.006). Urban centers and some regions along the North and South coast of KZN contributed the most toward GC-related out-patient visits. CONCLUSION: Out-patient visits for complex GC in KZN are increasing. Several regions have been identified for anti-cancer interventions and decentralized out-patient services.

Definition of the Rectum: An International, Expert-based Delphi Consensus.

BACKGROUND: The wide global variation in the definition of the rectum has led to significant inconsistencies in trial recruitment, clinical management, and outcomes. Surgical technique and use of preoperative treatment for a cancer of the rectum and sigmoid colon are radically different and dependent on the local definitions employed by the clinical team. A consensus definition of the rectum is needed to standardise treatment. METHODS: The consensus was conducted using the Delphi technique with multidisciplinary colorectal experts from October, 2017 to April, 2018. RESULTS: Eleven different definitions for the rectum were used by participants in the consensus. Magnetic resonance imaging (MRI) was the most frequent modality used to define the rectum (67%), and the preferred modality for 72% of participants. The most agreed consensus landmark (56%) was "the sigmoid take-off," an anatomic, image-based definition of the junction of the mesorectum and mesocolon. In the second round, 81% of participants agreed that the sigmoid take-off as seen on computed tomography or MRI achieved consensus, and that it could be implemented in their institution. Also, 87% were satisfied with the sigmoid take-off as the consensus landmark. CONCLUSION: An international consensus definition for the rectum is the point of the sigmoid take-off as visualized on imaging. The sigmoid take-off can be identified as the mesocolon elongates as the ventral and horizontal course of the sigmoid on axial and sagittal views respectively on cross-sectional imaging. Routine application of this landmark during multidisciplinary team discussion for all patients will enable greater consistency in tumour localisation.

Perioperative patient outcomes in the African Surgical Outcomes Study: a 7-day prospective observational cohort study.

BACKGROUND: There is a need to increase access to surgical treatments in African countries, but perioperative complications represent a major global health-care burden. There are few studies describing surgical outcomes in Africa. METHODS: We did a 7-day, international, prospective, observational cohort study of patients aged 18 years and older undergoing any inpatient surgery in 25 countries in Africa (the African Surgical Outcomes Study). We aimed to recruit as many hospitals as possible using a convenience sampling survey, and required data from at least ten hospitals per country (or half the surgical centres if there were fewer than ten hospitals) and data for at least 90% of eligible patients from each site. Each country selected one recruitment week between February and May, 2016. The primary outcome was in-hospital postoperative complications, assessed according to predefined criteria and graded as mild, moderate, or severe. Data were presented as median (IQR), mean (SD), or n (%), and compared using t tests. This study is registered on the South African National Health Research Database (KZ_2015RP7_22) and ClinicalTrials.gov (NCT03044899). FINDINGS: We recruited 11 422 patients (median 29 [IQR 10-70]) from 247 hospitals during the national cohort weeks. Hospitals served a median population of 810 000 people (IQR 200 000-2 000 000), with a combined number of specialist surgeons, obstetricians, and anaesthetists totalling 0·7 (0·2-1·9) per 100 000 population. Hospitals did a median of 212 (IQR 65-578) surgical procedures per 100 000 population each year. Patients were younger (mean age 38·5 years [SD 16·1]), with a lower risk profile (American Society of Anesthesiologists median score 1 [IQR 1-2]) than reported in high-income countries. 1253 (11%) patients were infected with HIV, 6504 procedures (57%) were urgent or emergent, and the most common procedure was caesarean delivery (3792 patients, 33%). Postoperative complications occurred in 1977 (18·2%, 95% CI 17·4-18·9]) of 10 885 patients. 239 (2·1%) of 11 193 patients died, 225 (94·1%) after the day of surgery. Infection was the most common complication (1156 [10·2%] of 10 970 patients), of whom 112 (9·7%) died. INTERPRETATION: Despite a low-risk profile and few postoperative complications, patients in Africa were twice as likely to die after surgery when compared with the global average for postoperative deaths. Initiatives to increase access to surgical treatments in Africa therefore should be coupled with improved surveillance for deteriorating physiology in patients who develop postoperative complications, and the resources necessary to achieve this objective. FUNDING: Medical Research Council of South Africa.

Incidence of chemotherapy-induced neutropenia in HIV-infected and uninfected patients with breast cancer receiving neoadjuvant chemotherapy.

BACKGROUND: Chemotherapy-induced neutropenia (CIN) can result in poor tolerance of chemotherapy, leading to dose reductions, delays in therapy schedules, morbidity and mortality. Actively identifying predisposing risk factors before treatment is of paramount importance. We hypothesised that chemotherapy is associated with a greater increase in CIN and its complications in HIV-infected patients than in those who are not infected. OBJECTIVE: To establish the incidence of CIN in HIV-infected and uninfected patients undergoing chemotherapy. METHODS: A retrospective chart review and analysis was conducted in the oncology departments at Inkosi Albert Luthuli Central Hospital and Addington Hospital, Durban, South Africa. The study population consisted of 65 previously untreated women of all ages with stage II - IV breast cancer and known HIV status treated with neoadjuvant chemotherapy from January 2012 to December 2015. RESULTS: HIV-infected patients formed 32.3% of the group, and 95.2% of them were on antiretroviral therapy. The mean age (standard deviation (SD)) of the cohort was 48.5 (13.2) years (40.6 (9.6) years for the HIV-infected group v. 52.0 (13.1) years for the uninfected group; p<0.001). Ninety-five neutropenia episodes were observed (rate 0.85 per 1 year of follow-up time). Following multivariate adjustment, patients with HIV infection were almost two times more likely to develop CIN (hazard ratio (HR) 1.76, 95% confidence interval (CI) 1.06 - 2.92; p=0.029. A high baseline absolute neutrophil count (ANC) (HR 0.80, 95% CI 0.68 - 0.95; p=0.005) remained significantly associated with protection against CIN. CONCLUSIONS: HIV-infected patients were younger than those who were not infected, and presented at a more locally advanced stage of disease. HIV infection was an independent predictor for CIN. HIV-infected patients had an almost two-fold increased risk of developing CIN and developed neutropenia at a much faster rate. A high baseline white cell count and ANC were protective against CIN.

Critical care admission of South African (SA) surgical patients: Results of the SA Surgical Outcomes Study.

BACKGROUND: Appropriate critical care admissions are an important component of surgical care. However, there are few data describing postoperative critical care admission in resource-limited low- and middle-income countries. OBJECTIVE: To describe the demographics, organ failures, organ support and outcomes of non-cardiac surgical patients admitted to critical care units in South Africa (SA). METHODS: The SA Surgical Outcomes Study (SASOS) was a 7-day national, multicentre, prospective, observational cohort study of all patients ≥16 years of age undergoing inpatient non-cardiac surgery between 19 and 26 May 2014 at 50 government-funded hospitals. All patients admitted to critical care units during this study were included for analysis. RESULTS: Of the 3 927 SASOS patients, 255 (6.5%) were admitted to critical care units; of these admissions, 144 (56.5%) were planned, and 111 (43.5%) unplanned. The incidence of confirmed or strongly suspected infection at the time of admission was 35.4%, with a significantly higher incidence in unplanned admissions (49.1 v. 24.8%, p<0.001). Unplanned admission cases were more frequently hypovolaemic, had septic shock, and required significantly more inotropic, ventilatory and renal support in the first 48 hours after admission. Overall mortality was 22.4%, with unplanned admissions having a significantly longer critical care length of stay and overall mortality (33.3 v. 13.9%, p<0.001). CONCLUSION: The outcome of patients admitted to public sector critical care units in SA is strongly associated with unplanned admissions. Adequate 'high care-dependency units' for postoperative care of elective surgical patients could potentially decrease the burden on critical care resources in SA by 23%. This study was registered on ClinicalTrials.gov (NCT02141867).

Is the clinicopathological pattern of colorectal carcinoma similar in the state and private healthcare systems of South Africa? Analysis of a Durban colorectal cancer database.

Previous state hospital-based local studies suggest varying population-based clinicopathological patterns of colorectal cancer (CRC). Patients diagnosed with CRC in the state and private sector hospitals in Durban, South Africa over a 12-month period (January-December 2009) form the basis of our study. Of 491 patients (172 state and 319 private sector patients), 258 were men. State patients were younger than private patients. Anatomical site distribution was similar in both groups with minor variations. Stage IV disease was more common in state patients. State patients were younger, presented with advanced disease and had a lower resection rate. Black patients were the youngest, presented with advanced disease and had the lowest resection rate.

Self-Expandable Metal Stents in Esophageal Cancer in a High HIV Prevalence Area: A Survival Analysis and Evaluation of Prediction Scores.

INTRODUCTION: Esophageal cancer (EC) and human immunodeficiency virus (HIV) are common in parts of South Africa. Squamous cell carcinoma of the esophagus in KwaZulu-Natal, South Africa presents generally in advanced stages and is mostly palliated by the deployment of self-expandable metal stent (SEMS). This study analyses these relationships between coexistent HIV infection, SEMS deployment, and survival scores. METHODOLOGY: Information on patients managed with SEMS between October 2013 and December 2014 was retrieved from a prospective database of EC and followed up until April 2015. Data collected included demographics, HIV status, clinical presentation, prognostic indicators, management, and survival. Prognostic factors were calculated in relation to outcome. RESULTS: One hundred five patients with EC had median ages of 61 (SD±11.4) and median body mass index of 17.45. Squamous cell carcinoma of the esophagus was diagnosed in 90 patients and adenocancer in 7 patients. Tumors were located in the proximal (10), middle (64), and distal (29) esophagus. Stage IV EC had a significant shorter survival of fewer than 3 months compared with stage III cancer (P=0.009). A C-reactive protein >150 mg/L was 3.6 times more likely to predict survival of fewer than 3 months than a value <50 mg/L (P=0.035). A proximal stent position significantly predicted shorter survival (P=0.035). The Steyerberg prognostic score proved ineffective in predicting survival of <3 months in our setting. Of the 84 patients tested for HIV, 23 were positive. Thirteen patients were on highly active antiretroviral therapy surviving significantly longer than those without this medication (P=0.036). CONCLUSIONS: Stage IV cancer and C-reactive protein >150 predicted survival of <3 months significantly better than the Steyerberg prediction score or other markers. Highly active anti-retroviral therapy had a positive impact on survival; however, SEMS placement in the proximal esophagus was associated with shorter survival.

Laparoscopy in the diagnosis and repair of diaphragmatic injuries in left-sided penetrating thoracoabdominal trauma: laparoscopy in trauma.

BACKGROUND: Diaphragmatic injuries from penetrating thoracoabdominal trauma are notoriously difficult to detect with clinical and radiological evaluation. The aim of this study was to establish the incidence of diaphragmatic injury from penetrating thoracoabdominal trauma, clinical and radiological features predictive of a diaphragmatic injury and the feasibility of laparoscopic repair. METHODS: This is a prospective consecutive case series conducted in a metropolitan hospital complex. Fifty five patients were enrolled into the study and underwent a standardized laparoscopic procedure. Only stable patients were selected and right-sided penetrating thoracoabdominal injuries were excluded. The patients' clinical details, radiological findings, operative procedure, treatment of the diaphragmatic injury and complications were collected and analysed. RESULTS: There were a total of 55 patients, of whom, 22 (40 %) had diaphragmatic injuries. The mean age was 26.3 ± 7.8 years (range 15-44) with a male:female ratio of 10:1. The causes of injury were stab in 54 (98.2 %) patients and firearm in one (1.8 %). Twenty six (47.3 %) patients had positive radiological findings, of which 10 (38.5 %) had a diaphragmatic injury. There were 6 (27.3 %) associated intra-abdominal injuries. Twenty one (95.5 %) of 22 patients with diaphragmatic injuries were successfully repaired laparoscopically. Mean duration of procedure with diaphragmatic repair was 74.9 ± 22.5 min compared to 38.3 ± 16.9 min without diaphragmatic repair. Six patients (10.9 %) had minor intra-operative complications. There were no deaths. Hospital stay was 2.9 ± 3.4 days. CONCLUSIONS: Diaphragmatic injury was present in 40 % of patients with left-sided thoracoabdominal injury. Radiological findings were not reliable in predicting diaphragmatic injury. The majority of these injuries can be safely repaired laparoscopically.

Trends in demographics and management of obstructing colorectal cancer.

INTRODUCTION: Obstructing colorectal cancer (CRC) has an aggressive clinical course and poorer prognosis. With the increasing incidence and differing clinical and pathologic spectrum of CRC among Black patients, as well as a paucity of African studies, regional analysis is required. Our aim was to describe the demographics and management of obstructing CRC among the different racial groups in South Africa and to compare these parameters with international standards. PATIENTS AND METHODS: Patients referred to Inkosi Albert Luthuli Central Hospital, Durban, South Africa, with CRC between 2000 and 2012 were followed prospectively. Demographic information, site of obstruction, and management of patients who underwent emergency surgery for malignant large bowel obstruction were analyzed separately. RESULTS: CRC was diagnosed in 1,425 patients. A total of 203 three patients (14.3 %) required emergent treatment for acute large bowel obstruction. The mean age at presentation with obstructing CRC was 59 years. Black patients presented significantly younger (50 years) than White (64), Indian (60), or Colored (61) patients (p < 0.001). The most common sites of obstruction were the sigmoid colon and rectum. A total of 58 patients (29 %) had concomitant metastatic disease. No difference was found between race, sex, and sex per race in patients with concurrent metastatic disease (p = 0.227, p = 0.415, p = 0.798, respectively). Of the 203 patients, 128 (63 %) were managed by resection, 37 (18 %) by colonic stenting, 35 (17 %) by colostomy, and 3 (2 %) by colonic bypass. Stenting was unsuccessful in six patients. CONCLUSION: Tumor location of patients presenting with obstruction is comparable to that cited in international literature; however, the age of presentation among Black patients is more than a decade earlier than in other ethnic groups. Surgical management should be individualized. Stenting remains a reliable alternative in select cases.

Paediatric head injuries in the Kwazulu-Natal Province of South Africa: a developing country perspective.

We investigated the causes, management and outcome of head injuries in paediatric patients admitted to the paediatric surgery unit at King Edward VIII Hospital over a 3-year period, from 1999 to 2001. There were 506 patients (331 male; M:F ratio 2:1) and the mean age was 71.99 +36.8 months (2 weeks to 180 months). The injuries were due to: motor vehicle crashes (324); falls (121); assault (30); inadvertent injury (23); and unknown (11). Forty-nine patients (9%) were admitted with a Glasgow Coma Scale ≤8. The most common intracranial pathology on computed tomography was: intracranial haematoma/haemorrhage (44); contusion (16); and brain oedema (10). Nineteen patients (3.4%) underwent neurosurgical intervention and the rest were managed conservatively. Eighteen died in hospital (3.6%). The mean hospital stay was 5 ± 12 days. Twenty-three patients (4.5%) were discharged with neurological sequelae. Few paediatric patients are admitted with severe head injury: the majority from blunt injury caused by motor vehicle crashes. Management mainly requires simple neurological observation in a general ward with a surprisingly good prognosis. Specific protocols for paediatric head injuries have been proposed based on these findings.

Granulomas in acquired immunodeficiency syndrome-associated cutaneous Kaposi sarcoma: evidence for a role for Mycobacterium tuberculosis.

BACKGROUND: Co-lesional acquired immunodeficiency syndrome-associated cutaneous Kaposi sarcoma (AIDS-KS) and Mycobacterium tuberculosis-associated granulomatous inflammation are undocumented. METHOD: Retrospective appraisal of skin biopsies with co-lesional AIDS-KS and microscopic tuberculosis (TB). RESULTS: Sixteen biopsies from nine males and seven females form the study cohort. Histological assessment confirmed nodular and plaque KS in 12 and 4 cases each, respectively. Necrotizing, non-necrotizing and a combination of necrotizing and non-necrotizing granulomatous inflammation were present in nine, two and five biopsies each, respectively. The identification of acid fast bacilli on Ziehl-Neelsen staining and M. tuberculosis on polymerase chain reaction confirmed co-lesional TB in 15/16 biopsies. Co-lesional AIDS-KS and lichen scrofulosorum, hitherto undocumented, were confirmed in one biopsy. The histopathological findings served as a marker of human immunodeficiency virus (HIV) infection, visceral TB, therapeutic noncompliance and multidrug resistant pulmonary TB in nine, eight, five and one patient, respectively. M. tuberculosis was cultured from sputum or nodal tissue of all patients. CONCLUSION: Granulomatous inflammation in KS requires optimal histopathological and molecular investigation to confirm an M. tuberculosis origin. The cutaneous co-lesional occurrence of AIDS-KS and microscopic TB may serve as the sentinel clue to HIV infection, systemic TB, therapeutic noncompliance or multidrug resistant TB.

Surgical management of rectal prolapse.

BACKGROUND: The problem of complete rectal prolapse is formidable, with no clear predominant treatment of choice. Surgical management is aimed at restoring physiology by correcting the prolapse and improving continence and constipation with acceptable mortality and recurrence rates. Abdominal procedures are ideal for young fit patients, whereas perineal procedures are reserved for older frail patients with significant comorbidity. Laparoscopic procedures with their advantages of early recovery, less pain, and possibly lower morbidity are recently added options. Regardless of the therapy chosen, matching the surgical selection to the patient is essential. OBJECTIVE: To review the present status of the surgical treatment of rectal prolapse. DATA SOURCES: Literature review using MEDLINE. All articles reporting on rectopexy were included. STUDY SELECTION: Articles reporting on prospective and retrospective comparisons were included. Case reports were excluded, as were studies comparing data with historical controls. DATA EXTRACTION: The results were tabulated to show outcomes of different studies and were compared. Studies that did not report some of the outcomes were noted as "not stated." DATA SYNTHESIS: Abdominal operations offer not only lower recurrence but also greater chance for functional improvements. Suture and mesh rectopexy produce equivalent results. However, the polyvinyl alcohol (Ivalon) sponge rectopexy is associated with an increased risk of infectious complications and has largely been abandoned. The advantage of adding a resection to the rectopexy seems to be related to less constipation. Laparoscopic rectopexy has similar results to open rectopexy but has all of the advantages related to laparoscopy. Perineal procedures are better suited to frail elderly patients with extensive comorbidity. CONCLUSIONS: Abdominal procedures are generally better for young fit patients; the results of all abdominal procedures are comparable. Suture and mesh rectopexy are still popular with many surgeons-the choice depends on the surgeon's experience and preference. Similarly, the procedure may be done through a laparoscope or by laparotomy. Perineal procedures are preferable for patients who are not fit for abdominal procedures, such as elderly frail patients with significant comorbidities. The decision between perineal rectosigmoidectomy and Delorme procedures will depend on the surgeon's preference, although the perineal rectosigmoidectomy has better outcomes.