Prospective multicentre clinical trial of stapled transanal rectal resection for obstructive defaecation syndrome

Outcomes of a modified Bresler procedure for the treatment of rectocele with rectal intussusception

Background

Obstructed defecation syndrome (ODS) is a condition that is frequently caused by rectocele and rectal intussusception. This study aimed to evaluate the effectiveness of a modified Bresler procedure for the treatment of ODS. The outcomes of this modified procedure were compared with the stapled transanal rectal resection (STARR) procedure.

Methods

We performed a retrospective analysis of the clinical data from 76 female patients who presented with ODS between June 2014 and June 2016. The patients were divided into two treatment groups, namely Modified and STARR. Patients in the Modified group (n = 36) underwent the modified Bresler procedure, which involved posterior rectal-wall resection using a circular tubular stapler with multilevel purse-string sutures. Patients in the STARR group (n = 40) underwent the standard STARR procedure. We analysed post-operative complications, Wexner constipation scores (WCS), rectocele depths, and four-point post-operative satisfaction scales.

Results

Patients in the Modified group exhibited shorter operative times and fewer post-operative complications (both P < 0.05). At 12 months post-operatively, both the Modified and STARR groups displayed a significant improvement in the Wexner constipation score and the depth of rectocele. The post-operative WCS for the Modified group were significantly improved compared to those for the STARR group (P < 0.05), while there was no significant difference in the rectocele depth between the two groups (P > 0.05). Post-operative interviews at post-operative 12 months showed that patients in the Modified group had a better satisfaction (P = 0.05).

Conclusions

Our modified procedure may be an effective treatment strategy for patients experiencing ODS caused by rectocele and rectal intussusception, with fewer complications and effective relief of symptoms.

Khubchandani’s procedure combined with stapled posterior rectal wall resection for rectocele

BACKGROUND

Obstructed defecation syndrome (ODS) is a widespread disease in the world. Rectocele is the most common cause of ODS in females. Multiple procedures have been performed to treat rectocele and no procedure has been accepted as the gold-standard procedure. Stapled transanal rectal resection (STARR) has been widely used. However, there are still some disadvantages in this procedure and its effectiveness in anterior wall repair is doubtful. Therefore, new procedures are expected to further improve the treatment of rectocele.

AIM

To evaluate the efficacy and safety of a novel rectocele repair combining Khubchandani’s procedure with stapled posterior rectal wall resection.

METHODS

A cohort of 93 patients were recruited in our randomized clinical trial and were divided into two different groups in a randomized manner. Forty-two patients (group A) underwent Khubchandani’s procedure with stapled posterior rectal wall resection and 51 patients (group B) underwent the STARR procedure. Follow-up was performed at 1, 3, 6, and 12 mo after the operation. Preoperative and postoperative ODS scores and depth of rectocele, postoperative complications, blood loss, and hospital stay of each patient were documented. All data were analyzed statistically to evaluate the efficiency and safety of our procedure.

RESULTS

In group A, 42 patients underwent Khubchandani’s procedure with stapled posterior rectal wall resection and 34 were followed until the final analysis. In group B, 51 patients underwent the STARR procedure and 37 were followed until the final analysis. Mean operative duration was 41.47 ± 6.43 min (group A) vs 39.24 ± 6.53 min (group B). Mean hospital stay was 3.15 ± 0.70 d (group A) vs 3.14 ± 0.54 d (group B). Mean blood loss was 10.91 ± 2.52 mL (group A) vs 10.14 ± 1.86 mL (group B). Mean ODS score in group A declined from 16.50 ± 2.06 before operation to 5.06 ± 1.07 one year after the operation, whereas in group B it was 17.11 ± 2.57 before operation and 6.03 ± 2.63 one year after the operation. Mean depth of rectocele decreased from 4.32 ± 0.96 cm (group A) vs 4.18 ± 0.95 cm (group B) preoperatively to 1.19 ± 0.43 cm (group A) vs 1.54 ± 0.82 cm (group B) one year after operation. No other serious complications, such as rectovaginal fistula, perianal sepsis, or deaths, were recorded. After 12 mo of follow-up, 30 patients’ (30/34, 88.2%) final outcomes were judged as effective and 4 (4/34, 11.8%) as moderate in group A, whereas in group B, 30 (30/37, 81.1%) patients’ outcomes were judged as effective, 5 (5/37, 13.5%) as moderate, and 2 (2/37, 5.4%) as poor.

CONCLUSION

Khubchandani’s procedure combined with stapled posterior rectal wall resection is an effective, feasible, and safe procedure with minor trauma to rectocele.

Prognostic and predictive value of interstitial cells of Cajal populations following stapled transanal rectal resection (STARR) in patients with obstructed defecation syndrome

Objective

The present study was designed to evaluate the functional outcome of stapled transanal rectal resection (STARR) and to examine the relationship between the population density of the interstitial cells of Cajal (ICC) and the efficacy of the STARR operation in the management of obstructed defecation syndrome (ODS) patients.

Methods

Full-thickness rectal samples were obtained from 50 ODS patients who underwent STARR. Samples were analysed using ICC immunohistochemistry. Clinical and functional parameters obtained with defecography and anorectal manometry were compared with 20 controls.

Results

ICCs were significantly decreased in patients in the submucosal (SM), intramuscular (IM) and myenteric (MY) regions when compared with the control group (P < 0.05). The mean pre-operative Cleveland Constipation Score (CCS) was 24.2 ± 4.1, whilst the CCS at 1, 2, 3, 4 and 5 years post-operatively decreased significantly (P < 0.05). At 3 post-operative years, 58.3% (28/48) of the patients reported a favorable outcome (CCS ≤ 10). On univariate analysis, the functional results were worse in those with pre-operative digitation (P = 0.017), a decreased ICC-MY cell population (P = 0.067), a higher resting anal canal pressure (P = 0.039) and a higher rectal sensory threshold (P = 0.073). Multivariate analysis showed the decreased ICC-MY cell population was an independent predictor for low unfavorable functional outcome (odds ratio = 0.097, 95% confidence interval: 0.012–0.766).

Conclusions

STARR achieved acceptable results at the cost of a slight deterioration over a more prolonged follow-up. Patients with a decreased ICC number in the rectal specimen showed an unfavorable functional outcome where pre-operative histological assessment of a full-thickness rectal sample might predict for the functional outcome following STARR.

A Modification of the Stapled TransAnal Rectal Resection (STARR) Procedure for Rectal Prolapse

PURPOSE

This study was designed to assess the safety, efficacy, and postoperative outcomes of the modified Stapled TransAnal Rectal Resection (modified STARR) in patients presenting with cases of limited external rectal prolapse.

METHODS

A prospective cohort of patients with mild rectal prolapse undergoing rectal resection with the Tissue-Selecting Technique Stapled TransAnal Rectal Resection Plus (TSTStarr Plus) stapler between February 2014 and September 2016 was reviewed retrospectively.

RESULTS

Twenty-five eligible patients underwent rectal resection with the TSTStarr Plus stapler. The median vertical height of the resected specimen was 5.0 cm (range = 3.1-10 cm) with all cases being confirmed histologically as full-thickness resections. Over a follow-up of 33.6 ± 9.4 months, only 1 case (4%) was encountered with recurrence. The mean postoperative Wexner score was significantly improved when compared with the preoperative scores (preoperative: median = 3, range = 0-20, vs postoperative: median = 2, range = 0-20, respectively; P = .010). The median preoperative Symptom Severity Score and Obstructed Defecation Score were both decreased compared with the postoperative scores ( P = .001).

CONCLUSIONS

Modified STARR in management of mild rectal prolapse appear to be a safe and effective technique. The initial results would encourage a more formal prospective assessment of this technique as part of a randomized trial for the management of mild rectal prolapse.

Treatment of obstructed defecation syndrome due to rectocele and rectal intussusception with a high volume stapler (TST STARR-plus)

BACKGROUND

In recent years, stapled transanal resection (STARR) has been adopted worldwide with convincing short-term results. However, due to the high recurrence rate and some major complications after STARR, there is still controversy about when the procedure is indicated. The aim of this study was to assess the safety, efficacy and feasibility of STARR performed with a new dedicated device for tailored transanal stapled surgery.

METHODS

All the consecutive patients affected by obstructed defecation syndrome (ODS) due to rectocele or/and rectal intussusception, who underwent STARR with the TST STARR-Plus stapler, were included in a prospective study. Pain, Cleveland Clinic Score for Constipation (CCCS) and incontinence, patient satisfaction, number of hemostatic stitches, operative time, hospital stay and perioperative complications were recorded. Postoperative complications and recurrence were also reported.

RESULTS

Forty-five consecutive patients (median age 50; range 24-79) were included in the study. Median resected volume was 15 cm³ (range 12-19 cm³) with a median height of surgical specimen of 5.6 cm (range 4.5-10 cm). The mean CCCS decreased from 17.26 (± 3.77) to 5.42 (± 2.78) postoperatively (p < 0.001). Patient satisfaction grade was excellent in 14 patients (31.1%), good in 25 (55.5%), sufficient in three (6.7%) and poor in three patients (6.7%). No major complications occurred. Five patients (11%) reported urgency after 30 days and two patients (4%) after 12 months. The Cleveland Clinic Incontinence score did not significantly change. At a median follow-up of 23 months (range 12-30 months), only three patients (6.7%) reported recurrent symptoms of obstructed defecation comparable to those reported at baseline.

CONCLUSIONS

TST STARR-Plus seems to be safe and effective for the treatment of ODS due to rectocele and rectal intussusception, and technical improvement could reduce the risk of some complications. However, careful patient selection is still the best means of preventing complications.

Surgery for constipation: systematic review and practice recommendations: Results III: Rectal wall excisional procedures (Rectal Excision)

AIM

To assess the outcomes of rectal excisional procedures in adults with chronic constipation.

METHOD

Standardised methods and reporting of benefits and harms were used for all CapaCiTY reviews that closely adhered to PRISMA 2016 guidance. Main conclusions were presented as summary evidence statements with a summative Oxford Centre for Evidence-Based Medicine (2009) level.

RESULTS

Forty-seven studies were identified, providing data on outcomes in 8340 patients. Average length of procedures was 44 min and length of stay (LOS) was 3 days. There was inadequate evidence to determine variations in procedural duration or LOS by type of procedure. Overall morbidity rate was 16.9% (0-61%), with lower rates observed after Contour Transtar procedure (8.9%). No mortality was reported after any procedures in a total of 5896 patients. Although inconsistently reported, good or satisfactory outcome occurred in 73-80% of patients; a reduction of 53-91% in Longo scoring system for obstructive defecation syndrome (ODS) occurred in about 68-76% of patients. The most common long-term adverse outcome is faecal urgency, typically occurring in up to 10% of patients. Recurrent prolapse occurred in 4.3% of patients. Patients with at least 3 ODS symptoms together with a rectocoele with or without an intussusception, who have failed conservative management, may benefit from a rectal excisional procedure.

CONCLUSION

Rectal excisional procedures are safe with little major morbidity. It is not possible to advise which excisional technique is superior from the point of view of efficacy, peri-operative variables, or harms. Future study is required.

Value and limits of stapled transanal rectal repair for obstructed defecation syndrome: 10 years-experience with 450 cases

BACKGROUND/OBJECTIVE

In the late's 90' a new surgical treatment, the stapled trans-anal rectal resection (STARR) was born to treat obstructed defecation syndrome (ODS). In this study we retrospectively analyze a series of 450 cases that underwent STARR in 10 years.

METHODS

Between January 2001 to December 2011, 450 patients, diagnosed with ODS syndrome caused by rectocele or intussusception, underwent to STARR procedure. The presence of rectocele and/or intussusception was verified by dynamic defecography. The preoperative evaluation was completed with anorectal manometry and colonoscopy. Follow-up visits were scheduled 1 week, 1 month, 3 months, 1 years, 3 years and 5 years after surgery.

RESULTS

Mean operative time was 30,2 min. In 408 cases (90.7%) hospital discharge occurred 24 hours after surgery. Among postoperative complications urinary retention was observed in 35 patients (7.8%). Five (1.1%) patients presented an early rectal bleeding and 8 (1.8%) patients presented a late bleeding. In 5 (1.1%) patients a stable pelvic hematoma was found. Six (1.3%) patients presented pelvic sepsis due to subperitoneal perforation. An asymptomatic partial dehiscence of stapler row occurred in 19 patients (4.2%).125 patients (27.8%) reported defecation urgency that completely vanished at 3 months follow-up in 83 patients (66,4%) and in further 42 patients (33,6%) at 6-months. The average preoperative ODS score was 14.1; 3.1 at one year; 4.3 at 3 years and 6.4 after five years.

CONCLUSIONS

In expert hands, with right indications, STARR procedure is safe with good results in terms of improvement of the ODS score.

[Intraoperative pitfalls and complications in defecation disorders and rectal prolapse]

BACKGROUND

No generally accepted gold standard exists for the operative therapy of rectal prolapse in its variety of manifestations. Existing evidence suggests that an individualized choice of procedure provides the best result for each single patient. Knowledge of possible pitfalls and intraoperative management of complications in frequently applied procedures are important prerequisites for reliable treatment of affected patients.

MATERIAL AND METHODS

A consecutive series of 233 patients (June 2011-May 2016) with individualized choice of operative procedure in patients with rectal prolapse and rectocele based on an algorithm for a clinical treatment pathway and stapled hemorrhoidopexy were included. Intraoperative pitfalls and complications and their management (iPCM) were prospectively documented and analyzed.

RESULTS

The iPCM could be classified into three different categories: group I: iPCM was immediately noted and intraoperatively treated with no impact on the further clinical course (n = 20), group II: iPCM was successfully treated conservatively within a short time after the procedure (n = 9) and group III: iPCM required surgical revision (n = 5).

CONCLUSION

Individualized treatment of rectal prolapse and rectocele requires a broad spectrum of methods in specialized coloproctology units. A clinical treatment pathway facilitates the optimal choice of procedure. Overall the complication rates during surgical treatment of transanal rectal prolapse are low; however, available operative procedures hold specific risks and knowledge of these risks helps to avoid them. Once complications occur, measures demonstrated in this study lead to normal clinical courses in the majority of cases.

A transanal procedure using TST STARR Plus for the treatment of Obstructed Defecation Syndrome: 'A mid-term study'

PURPOSE

The aim of this study was to assess the safety, efficacy and outcomes of TST STARR (Stapled Transanal Rectal Resection) plus to treat Obstructed Defecation Syndrome (ODS) at mid-term follow-up.

METHODS

From April 2013 to September 2014, 50 cases (7 male patients) with ODS caused by rectocele and/or internal rectal prolapse were treated with the new TST STARR Plus. Clinical data from the 18 month mid-term follow up, including efficacy and constipations were recorded.

RESULTS

The average duration of surgery was 21 ± 4 min (range 12-35 min). The average postoperative hospital stay was 5 days (range 4-8 days). The pathological findings showed that the specimens contained full-thickness rectal tissue in all patients. The mean volume of resected specimen was 12.3 cm(3). Postoperative complications included five cases with transient faecal urgency that dissipated after 3 months; one patient suffered anastomotic bleeding on the sixth day after surgery, with successful haemostasis achieved through conservative therapy. The Wexner constipation score improved in patients affected by ODS from 13.96 ± 2.37 preoperatively to 7.00 ± 3.90, 7.28 ± 3.91, 8.10 ± 4.05 and 8.44 ± 4.08 at 3,6,12 and 18 months postoperatively, respectively, with all p < 0.05. Overall outcome was reported as ''excellent'' in 42% of patients, ''good'' in 36% of patients, ''adequate'' in 12% of patients, and ''poor'' in 10% of patients after 18 months of follow-up.

CONCLUSIONS

The TST STARR Plus is a simple, safe, and effective option for selected patients with ODS. Long-term prospective clinical studies are needed to validate the advantages of this emerging, novel procedure.

Impact of Rising Grades of Internal Rectal Intussusception on Fecal Continence and Symptoms of Constipation

BACKGROUND

A theory of rectal intussusception has been advanced that intrarectal intussusception, intra-anal intussusception, and external rectal prolapse are points on a continuum and are a cause of fecal incontinence and constipation.

OBJECTIVE

This study evaluates the association among rectal intussusception, constipation, fecal incontinence, and anorectal manometry.

DESIGN

Patients undergoing defecography were studied from a prospectively maintained database and classified according to the Oxford Rectal Prolapse Grade as normal or having intra-rectal, intra-anal, or external intussusception. Patient symptoms were assessed using the Constipation Severity Index and the Fecal Incontinence Severity Index. Quality-of-life surveys were also used. Patients also underwent anorectal manometry.

SETTINGS

The study was conducted at a tertiary care university medical center (Massachusetts General Hospital).

PATIENTS

The study included 147 consecutive patients undergoing evaluation for evacuatory dysfunction and involved defecography, symptoms questionnaires, and anorectal physiology testing from January 2011 to December 2013.

MAIN OUTCOME MEASURES

Symptom severity and quality-of-life scores were measured, as well as anal manometry results.

RESULTS

Increasing Oxford grade was associated with an increase in severity of fecal incontinence (median score: normal = 23.9, intrarectal = 21.0, intra-anal = 30.0, external prolapse = 35.3; β = 4.71; p = 0.009), which persisted in a multivariable model including age (β = 2.13; p = 0.03), and decreased sphincter pressures (median mean resting pressure: normal = 75.4, intra-rectal = 69.7, intra-anal = 64.3, external prolapse = 48.3; β = -8.57; p = 0.003), which did not persist in a multivariable model. Constipation severity did not increase with rising intussusception (mean score: normal = 37.4, intrarectal = 35.0, intra-anal = 41.4, external prolapse = 32.9; p = 0.79), and balloon expulsion improved rather than worsened (normal = 47.1%, intrarectal = 60.5%, intra-anal = 82.9%, external prolapse = 93.1%; p < 0.001).

LIMITATIONS

The study was limited because it was an observational study from a single center.

CONCLUSIONS

Increasing grades of rectal intussusception are associated with increasing fecal incontinence but not constipation.

Rectal prolapse traumatizes rectal neuromuscular microstructure explaining persistent rectal dysfunction

PURPOSE

Internal rectal prolapse is common and correlates with age. It causes a plug-like physical obstruction and is a major cause of defecation disorder. The progressive distortion of the prolapsing rectum likely causes secondary defects in the rectal wall, which may exacerbate rectal dysfunction. We undertook a prospective observational study to detect and quantify the neurologic and histopathologic changes in the rectal wall.

METHODS

We examined dorsal and ventral rectal wall specimens from consecutive patients with internal rectal prolapse undergoing stapled transanal rectal resection (STARR). We subjected specimens to histopathologic and neuropathologic assessment, including immunohistochemistry. We also recorded patients' clinical and demographic characteristics and sought correlations between these and the pathologic findings.

RESULTS

We examined 100 specimens. The severity of rectal prolapse and the extent of descent of the perineum correlated significantly with age. Concomitant hemorrhoidal prolapse was noted in all male patients and in 79 % of female patients. Muscular and neuronal defects were detected in 94 and 90 % of the specimens, respectively. Only four specimens (4 %) were free of significant structural defects.

CONCLUSION

Rectal prolapse traumatizes the rectum causing neuromuscular defects. The tissue trauma is due to shearing forces and ischemia caused by the intussusception. This initiates a self-reinforcing vicious circle of physical and functional obstruction, further impairing rectal evacuation and causing constipation and incontinence. The correlation between extent of prolapse and age suggests that internal rectal prolapse can be considered a degenerative disorder. Neural and motor defects in the wall of the rectum caused by rectal prolapse are likely irreversible.

Management of obstructed defecation

The management of obstructed defecation syndrome (ODS) is mainly conservative and mainly consists of fiber diet, bulking laxatives, rectal irrigation or hydrocolontherapy, biofeedback, transanal electrostimulation, yoga and psychotherapy. According to our experience, nearly 20% of the patients need surgical treatment. If we consider ODS an “iceberg syndrome”, with “emerging rocks”, rectocele and rectal internal mucosal prolapse, that may benefit from surgery, at least two out of ten patients also has “underwater rocks” or occult disorders, such as anismus, rectal hyposensation and anxiety/depression, which mostly require conservative treatment. Rectal prolapse excision or obliterative suture, rectocele and/or enterocele repair, retrograde Malone’s enema and partial myotomy of the puborectalis muscle are effective in selected cases. Laparoscopic ventral sacral colporectopexy may be an effective surgical option. Stapled transanal rectal resection may lead to severe complications. The Transtar procedure seems to be safer, when dealing with recto-rectal intussusception. A multidisciplinary approach to ODS provides the best results.

Surgery for obstructed defecation syndrome-is there an ideal technique

Obstructive defecation syndrome (ODS) is a common disorder with a considerable impact on the quality of life of affected patients. Surgery for ODS remains a challenging topic. There exists a great variety of operative techniques to treat patients with ODS. According to the surgeon’s preference the approach can be transanal, transvaginal, transperineal or transabdominal. All techniques have its advantages and disadvantages. Notably, high evidence based studies are significantly lacking in literature, thus making accurate assessments difficult. Careful patient’s selection is crucial to achieve optimal functional results. It is mandatory to assess not only defecation disorders but also evaluate overall pelvic floor symptoms, such as fecal incontinence and urinary disorders for choosing an appropriate and tailored strategy. Radiological investigation is essential but may not explain complaints of every patient.

Apex technique in the treatment of obstructed defecation syndrome associated with rectal intussusception and full rectal mucosa prolapse

BACKGROUND

The aim of the current study was to demonstrate the use of a modified stapling technique, called the apex technique, to treat rectal intussusception and full rectal mucosal prolapse. It was conducted as a retrospective study at 3 centers (2 in Brazil and 1 in Chile).

TECHNIQUE

The apex technique is performed by using a HEM/EEA-33 stapler. A pursestring suture is placed at the apex of the prolapse, on the 4 quadrants, independent of the distance to the dentate line. A second pursestring is then placed to define the band of rectal mucosa to be symmetrically resected.

MAIN OUTCOME MEASURES

Outcome measures included width of the resected full-thickness rectal wall; the intensity of postoperative pain on a visual analog scale from 1 to 10; full mucosal prolapse and rectal intussusception assessed by physical examination, cinedefecography, or echodefecography; and change in the constipation scale.

RESULTS

Forty-five patients (30 women/15 men; mean age, 59.5 years) with rectal intussusception and full mucosal prolapse were included. The median operative time was 17 (range, 15-30) minutes. Bleeding after stapler fire requiring manual suture occurred in 3 patients (6.7%); 25 (55.6%) patients reported having no postoperative pain. Hospital stay was 24 hours. The mean width of the resected rectal wall was 5.9 (range, 5.0-7.5) cm. Stricture at the staple line was seen in 4 patients, of whom 1 required dilation under anesthesia. The median follow-up time was 120 (range, 90-120) days. A small residual prolapse was identified in 6 (13.3%) patients. Imaging demonstrated complete disappearance of rectal intussusception in all patients, and the mean postoperative constipation score decreased from 13 (range, 8-15) to 5 (range, 3-7).

CONCLUSIONS

The apex technique appears to be a safe, quickly performed, and low-cost method for the treatment of rectal intussusception. In this series, imaging examinations showed the disappearance of rectal intussusception, and a significant decrease in constipation score suggested improvement in functional outcomes.

Posterior pelvic floor disorders and obstructed defecation syndrome: clinical and therapeutic approach

There are no clear recommended imaging guidelines for the assessment of patients presenting primarily with obstructed defecation syndrome and defecation difficulty. The gold standard has always been the defecating proctogram which may require a rather poorly tolerated extended technique involving high-radiation exposure in young women which includes cystography, vaginography, small bowel opacification, and occasional peritoneography. The development of dynamic magnetic resonance imaging has obviated many of these extended techniques and may be supplemented by novel ultrasonographic methods including dynamic transperineal sonography, real-time 3D translabial ultrasound and 3D dynamic echodefecography. Patients potentially suitable for surgical treatment display a multiplicity of pelvic floor and perineal soft-tissue anomalies where one pathology (such as rectocele or enterocele) are considered dominant. Despite the introduction of recent stapled and robotic technologies, there is a dual dialog concerning the functional outcome of these procedures. Imaging and surgical algorithms for these patients are provided.

Tailored prolapse surgery for the treatment of haemorrhoids and obstructed defecation syndrome with a new dedicated device: TST STARR Plus

OBJECTIVE

The aim of the study was to assess the safety, efficacy and feasibility of stapled transanal procedures performed by a new dedicated device, TST STARR Plus, for tailored transanal stapled surgery.

METHODS

All the consecutive patients admitted to eight referral centres affected by prolapses with III-IV degrees haemorrhoids or obstructed defecation syndrome (ODS) with rectocele and/or rectal intussusception that underwent stapled transanal resection with TST STARR plus were included in the present study. Haemostatic stitches for bleeding of the suture line, specimen volume, operative time, hospital stay and perioperative complications were recorded.

RESULTS

From 1 November 2012 to 31 March 2013, 160 consecutive patients (96 females) were enrolled in the study. In 94 patients, the prolapse was over the half of the circular anal dilator (CAD). The mean duration of the procedure was 25 min. The mean resected volume of the specimen was 13.3 cm(3), the mean hospital stay was 2.2 days. In 88 patients (55%), additional stitches on the suture line were needed (mean 2.1). Suture line dehiscence was reported in four cases, with intraoperative reinforcement. Bleeding was reported in seven patients (5%). Urgency after 30 days was reported in one patient. No major complication occurred.

CONCLUSIONS

The new device seems to be safe and effective for a tailored approach to anorectal prolapse due to haemorrhoids or obstructed defecation.

In patients with rectoceles and obstructed defecation syndrome, surgery should be the option of last resort

BACKGROUND

The indications for operation in patients with obstructed defecation syndrome (ODS) with rectocele are not well defined.

METHODS

A total of 90 female patients with ODS and rectocele were prospectively evaluated and treated with fiber supplements and biofeedback training. Univariate and multivariate regression was used to determine factors predictive of failing medical management.

RESULTS

Obstructive symptoms were the most prevalent presenting complaint (82.2%). Ultimately, 71.1% of patients responded to medical management and biofeedback. Multivariate regression analysis suggested that the presence of internal intussusception was associated with a lower chance of undergoing surgery to address ODS symptoms [odds ratio 0.18; P = .05], whereas inability to expel balloon, contrast retention on defecography, and splinting were not (P ≥ .15).

CONCLUSION

Rectoceles with concomitant intussusception in patients with ODS appear to portend a favorable response to biofeedback and medical management. We argue that all patients considered for surgery for rectoceles because of ODS should first undergo appropriate bowel retraining.

Correlation between outcome and instrumental findings after stapled transanal rectal resection for obstructed defecation syndrome

OBJECTIVE

Several studies show that stapled transanal rectal resection (STARR) significantly improves constipation in most patients, while others remain symptomatic for obstructed defecation syndrome (ODS). The aim of the study was to analyze clinical, manometric, and endoanal ultrasonography results in order to find any possible correlation between clinical and instrumental data, particularly in dissatisfied patients, both for those who remain symptomatic for ODS and for patients with new-onset fecal disorders.

PATIENTS AND METHODS

All patients underwent a preoperative and postoperative assessment based on clinical evaluation, proctoscopy, defecography, anorectal manometry, and endoanal ultrasonography. Furthermore, we asked patients about a subjective satisfaction grading of outcome.

RESULTS

From January 2007 to December 2009, 103 patients were treated in our department with STARR for ODS. Postoperative endoanal ultrasound did not demonstrate any variations compared with the preoperative one. Postoperative scores showed statistically significant improvement, with respect to the preoperative value, with good and sufficient scores in 79.6% of patients, and an overall rate of satisfaction of 87.1%. Fecal disorders, including also the slightest alteration of continence, occurred in 24% of patients, in particular soiling 1.8%, urgency 7.4%, occasional gas leakage 5.5%, and liquid/solid leakage 9.3%. Anorectal manometry revealed a statistically significant reduction only in sensitivity threshold and maximum tolerated volume compared to patients with no disorders of continence.

CONCLUSION

Results indicate good satisfaction grading and a statistically significant improvement in scores of constipation. There is no close correlation between satisfaction grading and scores. Besides, the assessment of patient's satisfaction often does not match the objective functional outcome.

Midterm outcome of stapled transanal rectal resection for obstructed defecation syndrome: A single-institution experience in China

AIM: To assess midterm results of stapled transanal rectal resection (STARR) for obstructed defecation syndrome (ODS) and predictive factors for outcome.

METHODS: From May 2007 to May 2009, 75 female patients underwent STARR and were included in the present study. Preoperative and postoperative workup consisted of standardized interview and physical examination including proctoscopy, colonoscopy, anorectal manometry, and defecography. Clinical and functional results were assessed by standardized questionnaires for the assessment of constipation constipation scoring system (CSS), Longo’s ODS score, and symptom severity score (SSS), incontinence Wexner incontinence score (WS), quality of life Patient Assessment of Constipation-Quality of Life Questionnaire (PAC-QOL), and patient satisfaction visual analog scale (VAS). Data were collected prospectively at baseline, 12 and 30 mo.

RESULTS: The median follow-up was 30 mo (range, 30-46 mo). Late postoperative complications occurred in 11 (14.7%) patients. Three of these patients required procedure-related reintervention (one diverticulectomy and two excision of staple granuloma). Although the recurrence rate was 10.7%, constipation scores (CSS, ODS score and SSS) significantly improved after STARR (P < 0.0001). Significant reduction in ODS symptoms was matched by an improvement in the PAC-QOL and VAS (P < 0.0001), and the satisfaction index was excellent in 25 (33.3%) patients, good in 23 (30.7%), fairly good in 14 (18.7%), and poor in 13 (17.3%). Nevertheless, the WS increased after STARR (P = 0.0169). Incontinence was present or deteriorated in 8 (10.7%) patients; 6 (8%) of whom were new onsets. Univariate analysis revealed that the occurrence of fecal incontinence (preoperative, postoperative or new-onset incontinence; P = 0.028, 0.000, and 0.007, respectively) was associated with the success of the operation.

CONCLUSION: STARR is an acceptable procedure for the surgical correction of ODS. However, its impact on symptomatic recurrence and postoperative incontinence may be problematic.

Are rectoceles the cause or the result of obstructed defaecation syndrome? A prospective anorectal physiology study

AIM

To determine the relationship between obstructed defaecation syndrome (ODS) and rectoceles.

METHOD

From December 2007 to November 2011, all female patients with ODS were prospectively evaluated with full interview, clinical examination and anorectal physiology testing. The characteristics of patients with and without rectoceles were compared, and logistic regression was utilized to identify factors predictive of patients having a rectocele beyond the introitus.

RESULTS

Of 239 patients with ODS, 90 (mean age: 52.3 ± 1.7 years) had a rectocele. Patients with rectoceles (R+) had a similar prevalence of incomplete emptying compared with patients with no rectocele (R-) (P ≥ 0.21), but only R+ patients reported splinting with defaecation (36.7% vs 0%; P < 0.0001). Anorectal manometry measurements, including mean resting pressure, maximum resting pressure and maximum squeeze pressure, were similar between groups (P ≥ 0.12). There were also no significant differences in rectal compliance (maximum tolerated volume) or rectal sensitivity (volume of first sensation) (P ≥ 0.65). R+ patients had greater difficulty expelling a 60 cm(3) balloon (70.1% R+ patients vs 57.5% R- patients; P = 0.05), but the prevalence of pelvic floor dyssynergia, as quantified by nonrelaxation on electromyography (EMG) testing, was similar to that of R- patients (P = 0.49). Logistic regression suggested that only difficulty with balloon expulsion was associated with higher odds of having a rectocele (OR = 3.00; P = 0.002), whereas mean resting pressure, EMG nonrelaxation and symptoms of incomplete emptying were not (P ≥ 0.12).

CONCLUSION

Rectoceles are not associated with an increased severity of ODS-type symptoms, anorectal abnormalities or pelvic floor dyssynergia in patients with ODS. This suggests that rectoceles may be the result, rather than the cause, of ODS.

Emerging technologies in coloproctology: results of the Italian Society of Colorectal Surgery Logbook of Adverse Events

BACKGROUND

The aim of this paper is to present the results of the Italian Society of Colorectal Surgery [or Società Italiana di Chirurgia Colorettale (SICCR)] Logbook of adverse events (AE) occurring in relation to emerging technologies in coloproctology (ETCs), over a 3-year period.

METHODS

A total of 245 AE were reported (patients age: mean = 49.6 years, range = 20-75 years; gender: 155 = F, 90 = M). The "observations" originated from the same institution of the AEs in 44 cases (18.0%), while 201 patients (82.0%) had been operated on somewhere else.

RESULTS

The three most reported ETCs were: Procedure for prolapsed haemorrhoids (PPH) (n = 120-48.9%), stapled transanal rectal resection (STARR (n = 96-39.2%), and transanal haemorrhoidal dearterialization (THD) (n = 11-4.5%). PPH, STARR, and THD together accounted for n = 227 (92.6%) observations. For the three main reported ETCs, the various AEs are listed. Chronic pain after PPH was 46/120 (38.3%), and after STARR of 21/96 (21.9%). The overall re-operation rate was n = 135 (55.1%) versus n = 110 (44.9%) no reoperation. In particular, for the three main reported ETCs, n = 68/120 (56.7%) following an AE after PPH, n = 47/94 (50.0%) following an AE after STARR, and n = 6/11 (54.5) following an AE post-THD. The various types of treatment to solve AE after each of the three most observed ETCs are reported in the text.

CONCLUSIONS

Our results do not allow us to draw statistical conclusions; however, this was not the aim of our survey. ETCs are important, yet they are not without major risks. Manufacturers should help colorectal surgeons to convey the right message to patients.

Stapled transanal rectal resection for the surgical treatment of obstructed defecation syndrome associated with rectocele and rectal intussusception

Obstructed defecation syndrome (ODS) is one of the most widespread clinical problems which frequently affects middle-aged females. There is a new surgical technique called stapled transanal rectal resection (STARR) that makes it possible to remove the anorectal mucosa circumferential and reinforce the anterior anorectal junction wall with the use of a circular stapler. This surgical technique developed by Antonio Longo was proposed as an effective alternative for the treatment of ODS. In this study we present our preliminary results with the STARR operation for the treatment of ODS. For this purpose, 40 consecutive female patients with ODS due to rectal intussusception (RI) and/or rectocele (RE) were recruited in this prospective clinical study, from May 2008 to October 2010. No major operative or postoperative complications were recorded, and after 12-month follow-up, significant improvement in the ODS score system was observed, and the symptoms of constipation improved in 90% of patients; 20% of patients judged their final clinical outcome as excellent, 55% as good, and 15% as moderate, with only 10% having poor results. After analyzing our results we can conclude that STARR is an effective and safe procedure for the treatment of obstructed defecation syndrome due to rectal intussusception and/or rectocele and can be performed safely without major morbidity.

Results in the long-term course after stapled transanal rectal resection (STARR)

PURPOSE

Stapled transanal rectal resection (STARR) has recently been recommended for patients with obstructed defecation caused by rectocele and rectal wall intussusception. Our study investigates the long-term results and predictive factors for outcome.

METHODS

Between November 2002 and February 2007, 80 patients (69 females) were operated on using the STARR procedure and included in the following study. Symptoms were defined according to the ROME II criteria. Preoperative assessment included clinical examination, colonoscopy, video defecography, and dynamic MRI. Preoperatively and during follow-up visits, we evaluated the Cleveland Constipation Score (CCS) to rate the severity of outlet obstruction and the Wexner Incontinence Score to rate anal incontinence. Patients were asked to judge the outcome of the operation as improved or poor/dissatisfied. We performed a univariate analysis for 11 patient- and disease-related factors to detect an association with outcome.

RESULTS

The median follow-up was 39 months (range 20-78). Major postoperative complications (one staple line insufficiency, one urosepsis, one prolonged urinary dysfunction with indwelling catheter) were found in 3.8%. The result after STARR procedure was a success in the long-term follow-up in 62 patients (77.5%), although the improvement did not persist in 15 patients (18.7%). The mean value of the CCS decreased significantly from 9.3 before surgery to 4.6 after 2 years and increased again slightly to 6.5 after 4-6 years. The Median Wexner Incontinence Score was 3.3 at baseline, but rose significantly to 6.0. However, a third of patients who reported deteriorated continence developed the symptoms 1-4 years after surgery. Of the factors investigated for the prediction of outcome, we could only identify the number of pelvic floor changes in defecography or dynamic MRI as being associated with the success of the operation.

CONCLUSION

Our study indicates that STARR is a safe procedure. A significant improvement of symptoms is to be expected, but this improvement may deteriorate with time. Patients' satisfaction is also associated with the occurrence of urge to defecate or incontinence. It remains difficult to predict outcome.

A transanal procedure using an endoscopic linear stapler for obstructed defecation syndrome: the first Chinese experience

BACKGROUND

Transanal surgery using an endoscopic linear stapler is a recognized, but not widely performed technique for the treatment of obstructed defecation syndrome (ODS). A study of consecutive patients was conducted to evaluate the safety and effectiveness of the technique for the treatment of ODS in Chinese patients.

METHODS

From November 2008 to December 2010, 43 female patients with ODS caused by rectocele and/or rectal intussusception underwent transanal surgery using an endoscopic linear stapler in three Chinese hospitals. Clinical and functional data including the Wexner constipation score and outcome classification were analyzed retrospectively.

RESULTS

The average duration of surgery was 23 ± 4 min (range 15-30 min). Blood loss was 10 ± 2 ml (range 5-15 ml). The average postoperative hospital stay was 5 days (range 4-6 days). The pathologic findings showed that the specimen contained rectal muscle in all patients. Postoperative complications included 4 patients with transient fecal urgency, 3 patients with anorectal pain, and one patient with mild bleeding from the stapled suture line. Three patients reported minor fecal incontinence (Wexner score less than 3). During a median follow-up of 12 months (range, 3-26 months), the mean constipation score improved from preoperative 13.56 to postoperative 5.07 at 1 year (P < 0.05). The outcome at 1 year was excellent in 18 of 43 patients, good in 13, fairly good in 7, and poor in 5. Postoperative defecography was performed in 28 patients. Rectocele disappeared in 15 patients. Rectocele depth was reduced from 34 ± 4 mm preoperatively to 17 ± 3 mm postoperatively (P < 0.05).

CONCLUSION

The transanal procedure using an endoscopic linear stapler is an easy, safe, and effective option for selected patients with ODS. Long-term prospective, randomized, controlled studies are needed to confirm the advantages of this procedure in comparison with the traditional transanal and stapled transanal rectal resection (STARR) techniques.

Resected specimen evaluation, anorectal manometry, endoanal ultrasonography and clinical follow-up after STARR procedures

AIM

To investigate stapled transanal rectal resection (STARR) procedures as surgical techniques for obstructed defecation syndrome (ODS) by analyzing specimen evaluation, anorectal manometry, endoanal ultrasonography and clinical follow-up.

METHODS

From January to December 2007, we have treated 30 patients. Fifteen treated with double PPH-01 staplers and 15 treated using new CCS 30 contour. Resected specimen were measured with respect to average surface and volume. All patients have been evaluated at 24 mo with clinical examination, anorectal manometry and endoanal ultrasonography.

RESULTS

Average surface in the CCS 30 group was 54.5 cm² statistically different when compared to the STARR group (36.92 cm²). The average volume in the CCS 30 group was 29.8 cc, while in the PPH-01 it was 23.8 cc and difference was statistically significant. The mean hospital stay in the CCS 30 group was 3.1 d, while in the PPH-01 group the median hospital stay was 3.4 d. As regards the long-term follow-up, an overall satisfactory rate of 83.3% (25/30) was achieved. Endoanal ultrasonography performed 1 year following surgery was considered normal in both of the studied groups. Mean resting pressure was higher than the preoperative value (67.2 mmHg in the STARR group and 65.7 mmHg in the CCS30 group vs 54.7 mmHg and 55.3 mmHg, respectively). Resting and squeezing pressures were lower in those patients not satisfied, but data are not statistically significant.

CONCLUSION

The STARR procedure with two PPH-01 is a safe surgical procedure to correct ODS. The new Contour CCS 30 could help to increase the amount of the resected tissue without differences in early complications, post-operative pain and in hospital stay compared to the STARR with two PPH-01 technique.

Medium-term results of stapled transanal rectal resection (STARR) for obstructed defecation and symptomatic rectal-anal intussusception

AIM

Stapled transanal rectal resection (STARR) is an increasingly accepted treatment for obstructed defaecation syndrome (ODS) associated with internal rectal prolapse (IRP) and rectocoele. The aim of this study is to evaluate the medium to long-term outcomes of STARR for ODS.

METHOD

The intermediate-term results of STARR used over a 9-year period were reviewed from the analysis of a prospectively maintained database. Patients were followed for a median period of 98 (95% CI 85-112, range 5-386) weeks.

RESULTS

Three hundred and forty-four (234 woman) patients of median age 54 (19-90) years underwent STARR over a 9-year period. Preoperative symptoms included pelvic pain (93%), incomplete evacuation (90%), urgency (74%), a sensation of obstruction (65%) and rectal digitation (27%). Thirteen had the solitary rectal ulcer syndrome. Of 326 patients with follow-up data, 249 (76%) were followed beyond 1 year and 149 (43%) beyond 2 years. The ODS score improved [14.6 ± 5.4 pre vs 1.6 ± 3.1 post (P < 0.0001)] as did the faecal incontinence (FI) score [3.5 ± 3.3 pre vs 0.4 ± 1.3 post (P < 0.0001)]. Fifteen (4.3%) patients reported deterioration in FI, and 11 (3.2%) experienced new onset minor incontinence. Urgency was 72% at 8 weeks, 20% at 16 weeks, 11.5% at 52 weeks and 5% at 1.5 years. None of the 29 patients followed beyond 4 years reported urgency. Urgency was unrelated to sex, age or preoperative ODS symptoms (Mantel-Cox log-rank). Recurrent symptoms of ODS occurred in 4.9%. Eighty-one per cent of patients were highly satisfied with STARR and would recommend or have it again.

CONCLUSION

STARR was successful for the treatment of selected patients with ODS and IRP. Postoperative faecal urgency rapidly decreases with time. It is not possible to predict who will develop urgency.

Resected specimen evaluation, anorectal manometry, endoanal ultrasonography and clinical follow-up after STARR procedures

AIM: To investigate stapled transanal rectal resection (STARR) procedures as surgical techniques for obstructed defecation syndrome (ODS) by analyzing specimen evaluation, anorectal manometry, endoanal ultrasonography and clinical follow-up.

METHODS: From January to December 2007, we have treated 30 patients. Fifteen treated with double PPH-01 staplers and 15 treated using new CCS 30 contour. Resected specimen were measured with respect to average surface and volume. All patients have been evaluated at 24 mo with clinical examination, anorectal manometry and endoanal ultrasonography.

RESULTS: Average surface in the CCS 30 group was 54.5 cm² statistically different when compared to the STARR group (36.92 cm²). The average volume in the CCS 30 group was 29.8 cc, while in the PPH-01 it was 23.8 cc and difference was statistically significant. The mean hospital stay in the CCS 30 group was 3.1 d, while in the PPH-01 group the median hospital stay was 3.4 d. As regards the long-term follow-up, an overall satisfactory rate of 83.3% (25/30) was achieved. Endoanal ultrasonography performed 1 year following surgery was considered normal in both of the studied groups. Mean resting pressure was higher than the preoperative value (67.2 mmHg in the STARR group and 65.7 mmHg in the CCS30 group vs 54.7 mmHg and 55.3 mmHg, respectively). Resting and squeezing pressures were lower in those patients not satisfied, but data are not statistically significant.

CONCLUSION: The STARR procedure with two PPH-01 is a safe surgical procedure to correct ODS. The new Contour CCS 30 could help to increase the amount of the resected tissue without differences in early complications, post-operative pain and in hospital stay compared to the STARR with two PPH-01 technique.

Functional and morphologic outcome after stapled transanal rectal resection for obstructed defecation syndrome

BACKGROUND

Stapled transanal rectal resection is a novel surgery for obstructed defecation syndrome. Few data on the functional and morphologic outcome after the surgery have been reported.

OBJECTIVE

This study aimed to evaluate the functional and morphologic outcome after stapled transanal rectal resection.

DESIGN

This is a prospective study of consecutive patients undergoing transanal rectal resection.

SETTING

The study was conducted at a tertiary referral hospital, Beijing, China, from May 2007 to May 2009.

PARTICIPANTS

Eighty-six consecutive female patients with obstructed defecation syndrome were carefully selected.

INTERVENTIONS

All patients underwent stapled transanal rectal resection.

MAIN OUTCOME MEASURES

The main outcome measures were patients' symptoms, obstructed defecation syndrome score, Wexner incontinence score, anorectal manometry and defecography before and 1 year after surgery.

RESULTS

The occurrence of all symptoms were significantly reduced after the procedure (P < .0001). Obstructed defecation syndrome score was decreased from 18.17 ± 4.68 preoperatively to 7.36 ± 3.52 postoperatively (P < .0001) with the Wexner incontinence score unchanged. Maximum tolerable rectal volume was significantly decreased (236.08 ± 50.00 vs 205.25 ± 29.60, P < .0001) after surgery with anal sphincter pressures unchanged. Postoperative defecography was performed in 64 patients. Rectocele disappeared in 40 of 62 patients. The depth of rectocele was reduced from 35.40 ± 4.58 mm preoperatively to 19.77 ± 9.19 mm postoperatively (P < .0001). Incomplete evacuation disappeared in 41 of 51 patients. Intussusception was completely corrected in 39 of 56 patients. The reduction of obstructed defection syndrome score was greater in patients with both rectocele and intussusception corrected than others (12.75 ± 2.24 vs 9.17 ± 3.47; P < .0001).

LIMITATIONS

This study was limited owing to the lack of a control group and the medium-term results.

CONCLUSIONS

Stapled transanal rectal resection is an effective procedure for obstructed defecation syndrome. The functional outcome is good with the preservation of sphincter function and continence postoperatively. The morphologic outcome confirmed its efficacy in correcting rectocele and intussusception, and correlated well with clinical improvement.

Surgery for obstructed defaecation: does the use of the Contour device (Trans-STARR) improve results?

AIM

The objective of the study was to assess safety, efficacy and outcomes of stapled transanal rectal resection (STARR) procedure for obstructed defaecation syndrome (ODS) with two stapling devices, PPH01 and Trans-STARR.

METHOD

Data were collected on all patients undergoing PPH01 or Trans-STARR over a 2 year period. Initially, all were treated using the PPH01 device and during the last 8 months using the Trans-STARR.

RESULTS

During the analysis period, 25 consecutive patients were treated with PPH01 and 27 patients were treated with Trans-STARR. The median follow up was 12 months (range 3-12 months) for the PPH01 group and 6 months (range 3-12 months) for the Trans-STARR group. Although the resected specimen was larger in the Trans-STARR group (P < 0.001), there was no difference in early adverse events, time to discharge or late complications between the groups. In both groups, postoperative urgency was common (occurring more than occasionally in up to 40% at last review) but the incidence was high preoperatively. ODS and symptom severity scores improved with surgery (P < 0.001). However, the degree of improvement was similar with complete resolution of symptoms occurring in 64% of the PPH01 group and 67% of the Trans-STARR group.

CONCLUSION

Our study shows that both procedures are safe and effective in the surgical treatment of obstructed defaecation but despite a larger resection the Trans-STARR procedure does not offer any additional benefit. A policy of individualizing techniques tailored to the extent of prolapse may be appropriate, but requires further evaluation.

Stapled transanal rectal resection for obstructed defecation syndrome associated with rectocele and rectal intussusception

AIM: To evaluate the safety and efficacy of stapled transanal rectal resection (STARR), and to analyze the outcome of the patients 12-mo after the operation.

METHODS: From May 2007 to October 2008, 50 female patients with rectocele and/or rectal intussusception underwent STARR. The preoperative status, perioperative and postoperative complications at baseline, 3, 6 and 12-mo were assessed. Data were collected prospectively from standardized questionnaires for the assessment of constipation [constipation scoring system, Longo’s obstructed defecation syndrome (ODS) score system, symptom severity score], patient satisfaction (visual analogue scale), and quality of life (Patient Assessment of Constipation-Quality of Life Questionnaire).

RESULTS: At a 12-mo follow-up, significant improvement in the constipation scoring system, ODS score system, symptom severity score, visual analog scale and quality of life (P < 0.0001) was observed. The symptoms of constipation improved in 90% of patients at 12 mo after surgery. The self-reported definitive outcome was excellent in 15 (30%) patients, fairly good in 8 (16%), good in 22 (44%), and poor in 5 (10%).

CONCLUSION: STARR can be performed safely without major morbidity. Moreover, the procedure seems to be effective for patients with obstructed defecation associated with symptomatic rectocele and rectal intussusception.

Laparoscopic correction of enterocele associated to stapled transanal rectal resection for obstructed defecation syndrome

BACKGROUND AND AIMS

We report our experience of concomitant laparoscopic treatment for enterocele and stapled transanal rectal resection (STARR) for rectocele and/or rectal prolapse in patients with complex obstructed defecation syndrome (ODS).

PATIENTS AND METHODS

From June 2005 to June 2007, we submitted 20 patients with ODS due to rectal prolapse and/or rectocele, combined with stable enterocele, to STARR and laparoscopic correction of the enterocele. Preoperative assessment included symptom evaluation with standardized questionnaires, clinical examination, colonoscopy, proctoscopy, anal sphincter ultrasonography, video-defecography with synchronous opacification of the ileal loops in all patients and colpography in female patients, and anorectal manometry. Follow-up was performed in the first, third, sixth, 12th, and 24th month after surgery.

RESULTS

Eighteen (90%) patients were submitted to both procedures, simultaneously. One patient, previously submitted to STARR, underwent laparoscopic treatment of the enterocele. Postoperative complications occurred in two (10%) patients: one case of postoperative rectal bleeding and one case of retropneumoperitoneum. Median (range) preoperative and postoperative Altomare's obstructed defecation score was ten (6-14) and two (0-14), respectively (p<0.001). Median (range) preoperative and postoperative quality of life score was 79 (39-109) and 109 (50-126), respectively (p<0.001). No symptom related to ODS was detected at 6-month follow-up (19 patients) and at 24-month follow-up (19 patients).

CONCLUSION

The combination of STARR and laparoscopy provides a safe and effective method to treat ODS caused by rectal internal prolapse and/or rectocele combined with enterocele.

Overview of pelvic floor disorders

Disorders of the pelvic floor are common sources of morbidity, decreased quality of life, and are unfortunately increasing in incidence. Owing to their complex and often coexistent nature, a comprehensive, multidisciplinary strategy of testing and care is required. Many nonoperative and operative approaches for management of the symptoms of pelvic floor disorders are available. This article reviews the evaluation and management for these difficult disorders.

Stapled transanal rectal resection for symptomatic intussusception: morphological and functional outcome

INTRODUCTION

Stapled transanal rectal resection (STARR) was developed to correct intussusception causing obstructed defecation. Some patients, however, do not profit from this operation as anticipated. We aimed to study the relationship between functional outcome and rectal morphology after STARR.

METHODS

Fifteen consecutive female patients with median age of 64 years [interquartile range (IQR) 58-71 years] were studied before and after STARR. All patients had symptoms of obstructed defecation preoperatively. Pre- and postoperative workup consisted of standardized interview (including Wexner score) with physical examination including procto- and rectoscopy, anorectal manometry, and magnetic resonance (MR) defecography. Median follow up was 18 months (IQR 16-22 months).

RESULTS

STARR was technically successful in all 15 patients without intra- or postoperative complications. Median (IQR) Wexner score of fecal incontinence was 0 (0-0) before and 3 (0-4.5) after surgery (p < 0.05). While all patients had repetitive incomplete defecation preoperatively, this symptom was present in seven patients postoperatively (p < 0.01). Third-degree intussusception was diagnosed during MR defecography in all patients preoperatively. After surgery, no patient had third-degree intussusception but one patient had first-degree and one patient had second-degree intussusception (p < 0.05). Size of rectocele was reduced from 2.9 cm (2.0-3.8 cm) to 0.8 cm (0.6-1.9 cm) (p < 0.05). Sphincter pressures were unchanged during anorectal manometry; however, first sensation during balloon distension in the rectum decreased from 50 ml (40-83 ml) before surgery to 30 ml (25-40 ml) after surgery (p < 0.05).

CONCLUSION

Stapled transanal rectal resection (STARR) achieved a high rate of morphological correction of intussusception; however, symptoms of obstructed defecation were not improved to the same extent, which warrants exploration in future studies.

Surgical management of constipation

This review addresses the range of operations suggested to be of contemporary value in the treatment of constipation with critical evaluation of efficacy data, complications, patient selection, controversies and areas for future research.