STARR with Contour Transtar: prospective multicentre European study

Transanal minimally invasive (TAMIS) mucosal resection with muscular plication for patients with obstructed defecation syndrome-A prospective pilot study

BACKGROUND

Rectocele and intussusception are frequently observed during defecography as potential contributors to obstructed defecation syndrome (ODS). We aimed to describe our initial experience with transanal minimally invasive surgery (TAMIS) mucosectomy with muscular plication, as a novel surgical approach to treat patients with ODS.

METHODS

Conducted between August 2021 and October 2023 at the Medical University of Vienna, 11 patients (8 female) were prospectively enrolled and underwent TAMIS mucosectomy with circular mucosectomy and longitudinal muscular plication (internal Delorme's procedure). Functional outcome and quality of life were assessed by using standardized questionnaires pre- and postoperatively. The median follow up time was 16 months.

RESULTS

In defecography rectal intussusception could be observed in all patients and rectocele was found in nine patients (81.8%). The median age at the time of surgical procedure was 56 years (range 28-76 years). Neither intraoperative nor postoperative complications occurred. The median ODS score decreased from 16 to 11 points (p = 0.171), and four out of five patients (80%) with preexistent fecal incontinence reported improvement of their symptoms postoperatively (80%), though one patient had new onset of fecal incontinence symptoms. No significant changes could be demonstrated in terms of quality life by using the Short-Form Health Survey 12 (SF-12) survey.

CONCLUSIONS

Our initial results showed that TAMIS mucosectomy is a safe technique, offering a viable alternative transanal approach for treating symptomatic ODS. Future studies with a larger sample size and a longer follow-up period should enhance the robustness of our preliminary findings.

Surgical management of the rectocele - An update

Rectocele is defined as a hernia of the rectum with protrusion of the anterior rectal wall through the posterior wall of the vagina. This condition occurs commonly, with an estimated prevalence of 30-50% of women over age 50. The symptomatology that leads to consultation is variable but consists predominantly of anorectal and/or gynecological complaints such as dyschezia, requiring digital disimpaction maneuvers, pelvic heaviness, anal incontinence, or dyspareunia. Rectocele may be isolated or associated with other disorders of pelvic stasis involving cystocele and uterine prolapse. Complementary exams (dynamic imaging and anorectal manometry) are essential before deciding on the surgical management of this condition. The indications for surgical management of rectocele are based on the intensity of symptoms and the resulting deterioration in quality of life, and surgery should be discussed after failure of medical treatment. Different approaches are possible, although there is currently no real consensus in the literature. The initial approach depends on the type of rectocele: if it involves the low or mid rectum or is isolated, an approach from below (transanal, transperineal, or transvaginal approach) can be proposed, while, in the presence of a high rectocele and/or associated with various disorders of pelvic stasis, transabdominal rectopexy is more suitable.

Perirectal Hematoma and Intra-Abdominal Bleeding after Stapled Hemorrhoidopexy and STARR-A Proposal for a Decision-Making Algorithm

Background and Objectives: The present study aims to assess the effectiveness and current evidence of the treatment of perirectal bleeding after stapled haemorrhoidopexy. Materials and methods: A systematic literature review was performed that combined the published and the obtained original data after a search of PubMed, Web of Science, and SCOPUS. Results: The present systematic review includes 16 articles with 37 patients. Twelve papers report perirectal and six report intra-abdominal bleeding. Stapled hemorrhoidopexy (SH) was performed in 57% of cases (3 PPH 01 and 15 PPH 03), stapled transanal rectal resection (STARR) in 13%, and for 30% information was not available. The median age was 49 years (±11.43). The sign and symptoms of perirectal bleeding were abdominal pain (43%), pelvic discomfort without rectal bleeding (36%), urinary retention (14%), and external rectal bleeding (21%). The median time to bleeding was 1 day (±1.53 postoperative days), with median hemoglobin at diagnosis 8.8 ± 1.04 g/dL. Unstable hemodynamic was reported in 19%. Computed tomography scan (CT) was the first examination in 77%. Only two cases underwent the abdominal US, but subsequently, a CT scan was also conducted. Non-operative management was performed in 38% (n = 14) with selective arteriography and percutaneous angioembolization in two cases. A surgical treatment was performed in 23 cases - transabdominal surgery (3 colostomies, 1 Hartmann' procedure, 1 low anterior resection of the rectum, 1 bilateral ligation of internal iliac artery and 1 ligation of vessels located at the rectal wall), transanal surgery (n = 13), a perineal incision in one, and CT-guided paracoccygeal drainage in one. Conclusions: Because of the rarity and lack of experience, no uniform tactic for the treatment of perirectal hematomas exists in the literature. We propose an algorithm similar to the approach in pelvic trauma, based on two main pillars -hemodynamic stability and the finding of contrast CT.

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.

Standard stapled transanal rectal resection versus stapled transanal rectal resection with one high-volume stapler to prevent complications in the elderly

BACKGROUND

The causes of obstructed defecation syndrome (ODS) can actually be either functional or mechanical (primary or secondary deficit of the sensitivity, slow bowel transit, pelvic floor dyssynergia, internal and external rectal prolapse, recto-anal intussusceptions, anterior or posterior rectocele and pelvic prolapse of the bladder, uterus, bowel or sigma). The aim of our study was to evaluate the safety, efficacy and feasibility of stapled transanal rectal resection (STARR) procedure performed by a single or double stapler through clinical and functional outcomes for transanal stapled surgery.

METHODS

From January 2016 to October 2017, ninety patients with ODS secondary to rectal prolapse, anal-rectal intussusception and anterior rectocele, that underwent to a STARR procedure were enrolled. Thirty of these underwent a STARR procedure with double circular stapler PPH-01 (Group A); 30 with single circular stapler CPH34HV with a purse string suture (Group B); and 30 with single circular stapler CPH34HV with a "parachute technique" (Group C). All patients were selected with clinical examination, Wexner score for fecal incontinence and ODS score for constipation. Patients also underwent a Defeco RMN for an anatomical and dynamic evaluation of the pelvic floor.

RESULTS

No recurrence rates were observed in the three groups. The mean operative time was 46.3 minutes in group A; 34.5 minutes in group B; and 37.6 minutes in Group C. The volume of the resected specimen was 17 mL in group A; 15 mL in group B; and 16 mL in Group C. Complications were bleeding (3.3% in group A); fecal urgency (6.6% in group A, 10% in group B and 3.3% in group C); rectal hematoma (3.3% in group A). all symptoms significantly improved after the operation without differences between groups.

CONCLUSIONS

The STARR technique performed with a single stapler CPH34HV is safe, faster and less expensive than the STARR performed by a double PPH01. Besides, with the parachute technique, it is possible to resect asymmetric prolapses.

Perineal Stapled Rectal Prolapse Resection in Elderly Patients: Long-term Follow-up

BACKGROUND

Full-thickness rectal prolapse has a significant negative impact on quality of life. The therapeutic options, specifically in elderly patients, are imperfect. Perineal stapled rectal prolapse resection is a novel operation for treating external rectal prolapse. Long-term follow-up following this procedure is lacking. In our study, we report a long-term follow-up of 30 patients, analyzing the long-term recurrence rate, morbidity, and functional outcome.

OBJECTIVE

This study aimed to examine the long-term results of perineal stapled rectal resection in a population unfit for prolonged general anesthesia.

DESIGN

This was a cohort study with a prospective follow-up.

SETTINGS

This study was conducted at a single tertiary referral center.

PATIENTS

Patients undergoing perineal stapled rectal resection from January 2010 to June 2013 were included.

INTERVENTIONS

Perineal stapled rectal prolapse resection was performed.

MAIN OUTCOME MEASURES

The primary outcome measured was prolapse recurrence.

RESULTS

A total of 30 patients underwent the surgical intervention. The median follow-up period was 61 months (range, 37-65). No intraoperative or postoperative complications occurred. Six patients (20%) had recurrent rectal prolapse, and continence was not achieved in any of the patients. Two patients who had recurrence underwent a redo perineal stapled rectal resection.

LIMITATIONS

This study was limited by the small cohort of selected patients.

CONCLUSIONS

Frail patients that can only endure a short procedure under regional anesthesia should be considered for perineal stapled rectal prolapse resection. The lack of mortality and morbidity, specifically in this population, along with the low long-term recurrence rates, make this a favorable surgical alternative. See Video Abstract at http://links.lww.com/DCR/A745.

The evolution of transanal surgery for obstructed defecation syndrome: Mid-term results from a randomized study comparing double TST 36 HV and Contour TRANSTAR staplers

A randomized study was carried out to compare the mid-term outcome of transanal rectal resection with the CCS-30 TRANSTAR and two TST36 staplers in patients with obstructed defecation syndrome. After selection, patients were randomly assigned to 2 groups:104 underwent a TRANSTAR operation and 104 a transanal rectal resection with two TST36 staplers. Patients were followed up with clinical examination, and defecography. Cumulative complication rate was significantly higher in TRANSTAR operation (P = 0.019). All symptoms and defecographic parameters significantly improved (P < 0.001), without differences. Costs were significantly lower with double TST (P = 0.035). Recurrence rates were 6.2% in TRANSTAR group and 11.4% with double TST (P = 0.206). Two circular TST 36 staplers consent to obtain the same clinical and functional results than the CCS-30, with significantly lower complication rate and costs.

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.

Internal Delorme's Procedure for Treating ODS Associated With Impaired Anal Continence

OBJECTIVE

The aim of this study was to evaluate the medium-term outcomes of internal Delorme's procedure for treating obstructed defecation syndrome (ODS) patients with impaired anal continence.

PATIENTS AND METHODS

In a retrospective study, 41 ODS patients who underwent internal Delorme's procedure between 2011 and 2015 were divided into 3 subgroups according to their associated symptoms of impaired continence, as urgency, passive fecal incontinence and both, before study. Then the patients' preoperative statuses, perioperative complications, and postoperative outcomes were investigated and collected from standardized questionnaires, including Altomare ODS score, Fecal Incontinence Severity Index (FISI), Patient Assessment of Constipation-Quality of Life Questionnaire (PAC-QoL), and Fecal Incontinence Quality of Life Scale (FIQLS). All results with a 2-tailed P < .05 were considered statistically significant.

RESULTS

At an average 2.8 years of follow-up, there were significant improvements ( P < .01) in Altomare ODS score, FISI, PAC-QoL, and FIQLS in all patients when comparing scores from before the operation with those at the final follow-up. Similar results were also observed in both the urgency subgroup and passive fecal incontinence subgroup, but there were no statistically significant improvements ( P > .05) in Altomare ODS score, FISI, PAC-QoL, or FIQLS in the urgency and passive fecal incontinence subgroups. Anorectal manometry showed the mean value of anal resting pressure increased 20%. Additionally, no major complications occurred.

CONCLUSION

Internal Delorme's procedure is effective without major morbidity for treating ODS associated with urgency or passive fecal incontinence, but it may be less effective for treating ODS associated with both urgency and passive fecal incontinence.

Internal rectal prolapse: Definition, assessment and management in 2016

Internal rectal prolapse (IRP) is a well-recognized pelvic floor disorder mainly seen during defecatory straining. The symptomatic expression of IRP is complex, encompassing fecal continence (56%) and/or evacuation disorders (85%). IRP cannot be characterized easily by clinical examination alone and the emergence of dynamic defecography (especially MRI) has allowed a better comprehension of its pathophysiology and led to the proposition of a severity score (Oxford score) that can guide management. Decision for surgical management should be multidisciplinary, discussed after a complete work-up, and only after medical treatment has failed. Information should be provided to the patient, outlining the goals of treatment, the potential complications and results. Stapled trans-anal rectal resection (STARR) has been considered as the gold standard for IRP treatment. However, inconsistent results (failure observed in up to 20% of cases, and fecal incontinence occurring in up to 25% of patients at one year) have led to a decrease in its indications. Laparoscopic ventral mesh rectopexy has substantial advantages in solving the functional problems due to IRP (efficacy on evacuation and resolution of continence symptoms in 65-92%, and 73-97% of patients, respectively) and is currently considered as the gold standard therapy for IRP once the decision to operate has been made.

[Transtar™ operation for rectocele and obstructed defecation syndrome]

The Contour® Transtar™ operation represents a further methodological development of conventional transanal stapled rectal resection (STARR) for the treatment of obstructed defecation syndrome (ODS) and/or full thickness rectal prolapse. In contrast to the conventional STARR technique a specially designed single curved stapler is used with which the rectal wall is incised in a circular fashion and anastomosed. This results in a monoblock resection with almost unlimited extent of resection. In multicenter studies the procedure has generally been shown to be effective for treatment of ODS with intussusception and rectocele. In comparison to conventional STARR the resected tissue samples are larger and the functional effectiveness is comparable. Furthermore, data from prospective randomized trials revealed higher effectiveness in long-term follow-up. With reference to full thickness rectal prolapse, feasibility studies have been performed which showed low morbidity but long-term follow-up studies suggest a high recurrence rate of >40 %.

Transanal surgery for obstructed defecation syndrome: Literature review and a single-center experience

Obstructed defecation syndrome (ODS) is a functional disorder commonly encountered by colorectal surgeons and gastroenterologists, and greatly affects the quality of life of patients from both societal and psychological aspects. The underlying anatomical and pathophysiological changes of ODS are complex. However, intra-rectal intussusception and rectocele are frequently found in patients with ODS and both are thought to play an important role in the pathogenesis of ODS. With the development of evaluation methods in anorectal physiology laboratories and radiology studies, a great variety of new operative procedures, especially transanal procedures, have been invented to treat ODS. However, no procedure has been proved to be superior to others at present. Each operation has its own merits and defects. Thus, choosing appropriate transanal surgical procedures for the treatment of ODS remains a challenge for all surgeons. This review provides an introduction of the current problems and options for treatment of ODS and a detailed summary of the essential assessments needed for patient evaluation before carrying out transanal surgery. Besides, an overview of the benefits and problems of current transanal surgical procedures for treatment of ODS is summarized in this review. A report of clinical experience of some transanal surgical techniques used in the authors’ center is also presented.

Evaluating the Surgeons’ Perception of Difficulties of Two Techniques to Perform STARR for Obstructed Defecation Syndrome

Background. After initial enthusiasm in the use of a dedicated curved stapler (CCS-30 Contour Transtar) to perform stapled transanal rectal resection (STARR) for obstructed defecation syndrome (ODS), difficulties have emerged in this surgical technique. Objective. First, to compare surgeons’ perception of difficulties of STARR performed with only Transtar versus STARR performed with the combined use of linear staplers and Transtar to cure ODS associated with large internal prolapse and rectocele; second, to compare the postoperative incidence of the urge to defecate between the 2 STARR procedures. Design and Setting. An Italian multicenter randomized trial involving 25 centers of colorectal surgery. Patients. Patients with obstructed defecation syndrome and rectocele or rectal intussusception, treated between January and December 2012. Interventions. Participants were randomly assigned to undergo STARR with a curved alone stapler (CAS group) or with the combined use of linear and curved staplers (LCS group). Main Outcome Measures. Primary end-points were the evaluation of surgeons’ perception of difficulties score and the incidence of the “urge to defecate” at 3-month follow up. Secondary end-points included duration of hospital stay, rates of early and late complications, incidence of “urge to defecate” at 6 and 12 months, success of the procedures at 12 months of follow-up. Results. Of 771 patients evaluated, 270 patients (35%) satisfied the criteria. Follow-up data were available for 254 patients: 128 patients (114 women) in the CAS group (mean age, 52.1; range, 39-70 years) and 126 (116 women) in LCS group (mean age, 50.7 years; range, 41-75 years). The mean surgeons’ perception score, was 15.36 (SD, 3.93) in the CAS group and 12.26 (SD, 4.22) in the LCS group ( P < .0001; 2-sample t test). At 3-month follow-up, urge to defecate was observed in 18 (14.6%) CAS group patients and in 13 (10.7%) LCS group patients ( P = .34; Fisher’s exact test). These values drastically decrease at 6 months until no urge to defecate in all patients at 12 months was observed. At 12-month follow-up, a successful outcome was achieved in 100 (78.1%) CAS group patients and in 105 (83.3%) LCS group patients ( P = .34; Fisher’s exact test). No significant differences between groups were observed in the hospital stay and rates of early or late complications occurring after STARR. Conclusions. STARR with Transtar associated with prior decomposition of prolapse, using linear staplers, seems to be less difficult than that without decomposition. Both procedures appear to be safe and effective in the treatment of obstructed defecation syndrome resulting in similar success rates and complications.

Semi-closed bilateral partial miotomy of the puborectalis for anismus: a pilot study: Partial miotomy of the puborectalis for anismus

BACKGROUND

Anismus or non relaxing puborectalis muscle (PRM) may cause obstructed defecation (OD). Reported surgical treatment is partial miotomy, followed by sepsis, bleeding, and incontinence. The aim of the present study was to investigate on the feasibility and outcome of a modified mini-invasive operation.

PATIENTS AND METHODS

Consecutive patients with anismus and OD not responding to medical therapy, excluding multiparous females, patients with anal incontinence, recto-rectal intussusception, and disordered psychological pattern. Semi-closed bilateral partial division of PRM, pulled down through 1-cm perianal incisions, was performed. Concomitant significant rectal mucosal prolapse and rectocele, when present, were treated. OD was evaluated using a validated score and anal/vaginal ultrasound (US) was performed pre -and postoperatively. A control group of seven patients with normal bowel habit was also investigated.

RESULTS

Eight patients (seven females), median age 48 years (range 29-71) were operated. Six also had significant mucosal prolapse and rectocele. All were followed up for a median of 12 months (range 2-40). None of them had postoperative sepsis or bleeding. One had just one occasional episode of mild anal incontinence. Symptoms improved in 6 or 75 % and, OD score decreased from 19.6 ± 1.0 to 9.2 ± 2.0 (mean ± s.e.m.), P = 0.007. No patient had anismus after surgery and PRM relaxation changed from 0 to 5.9 ± 0.8 mm being 6.6 ± 1.5 mm in controls.

CONCLUSION

Semi-closed bilateral partial division of PRM achieves muscle's relaxation on straining in all patients without any significant postoperative complication. Further studies are needed prior to consider it a validated procedure.

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.

Comparing the outcomes of stapled transanal rectal resection, delorme operation and electrotherapy methods used for the treatment of obstructive defecation syndrome

BACKGROUND

Pathophysiology and treatment of obstructive defecation syndrome (ODS) remains to be defined clearly. Rectal hidden intussusceptions and voluminous hemorrhoids may be the cause. Where conservative treatment is not effective, ODS can be treated by STARR or Delorme operation. In some patients treatment of advance hemorrhoidal disease may resolve the syndrome.

METHODS

81 females out of 183 ODS patients were selected for the treatment by Delorme, STARR or 30 mAmp electrotherapy.

RESULTS

The number of patients treated by STARR, Delorme and Electrotherapy were 34, 31 and 16, with mean postoperative pain ranking of 2.5, 3.7 and 1.5 and mean hospital stay of 2.3, and 3.2 and 1 day respectively. Mean ODS score, preoperatively compared with one-year post operation, improved from 14.5 to 5.1 (P=0.005) in STARR, 13.8 to 4.3 (P=0.006) in Delorme and 14.2 to 12.8 (P=0.725) in electrotherapy groups. The mean severity score (SS) changed from 14.2, 15.18 and 13.90 preoperatively to 3.8, 4.12 and 11.34 postoperatively in all groups respectively. The mean resting pressures decreased from 82 to 65 in STARR (P=0.006), from 87 to 63 in Delorme (P=0.005) and from 79 to 74 mmHg (P=0.797) in electrotherapy groups. Postoperative defecography showed significant reduction in the intussusception parameter in STARR and Delorme (82.4% and 88% respectively; P<0.0001), but unchanged in electrotherapy group.

CONCLUSION

STARR and Delorme are effective modalities for the treatment of patients with ODS, while STARR is simpler, less invasive and less painful. Although, electrotherapy eradicates the voluminous hemorrhoids but is ineffective in the treatment of ODS.

New disc excision procedure for low and mid rectal endometriosis nodules using combined transanal and laparoscopic approach

AIM

Colorectal resection in women with endometriosis involving the low and mid rectum may result in a poorer outcome than conservative procedures. In this technical note we present a new technique for transanal full thickness disc excision of endometriosis nodules involving the rectum.

METHOD

The procedure is performed by combined laparoscopic and transanal routes. The former involves paring the area of the rectum infiltrated by the nodule, which is then made amenable to endoluminal removal using the Contour Transtar stapler to carry out a large disc excision.

RESULTS

The technique can remove a specimen as large as 80 mm in diameter and can be applied to patients with infiltrating rectal endometrial nodules up to 10 cm from the anal margin and 50-60% of the rectal circumference. The procedure is probably less likely to lead to rectal stenosis and denervation than colorectal resection.

CONCLUSION

This technique of transanal rectal disc excision using the Contour stapler is suitable in patients with infiltrating deep endometriosis nodules of the lower and mid rectum. It avoids a low rectal resection with its potential complications and unfavourable function.

Partial prolapsectomy and fixation proctomucopexy: a novel minimally invasive procedure

A novel minimally invasive procedure for the management of anterior external and posterior internal mucosal prolapse is described. The operation, carried out via a transanal route, consists of a partial prolapsectomy and a mucosal proctopexy. Out of six patients, one had severe postoperative bleeding and one had a recurrence of internal prolapse and obstructed defecation. Three patients had pelvic floor rehabilitation for associated dysfunctions. The advantage of the operation is that a circumferential anastomosis is avoided, thus decreasing the risk of dehiscence, and only a short sphincter dilation is required. Moreover, the procedure has very little effect on the rectal reservoir, thus preventing fecal urgency. No reintervention was needed, and almost all patients were cured after 2 years.

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.

STARR with CONTOUR® TRANSTAR™ device for obstructed defecation syndrome: one-year real-world outcomes of the European TRANSTAR registry

PURPOSE

Stapled transanal rectal resection (STARR) in patients with obstructive defecation syndrome (ODS) is limited by the capacity of the circular stapler used. This prospective cohort study was conducted to assess real-world clinical outcomes of STARR with the new CONTOUR® TRANSTAR™ device, shortly named TRANSTAR, at 12 months postoperatively.

METHODS

From January 2009 to January 2011, consecutive patients who underwent TRANSTAR in 22 European colorectal centers were enrolled in the study. Functional outcomes and quality of life were assessed by the changes in a number of scoring systems (Knowles-Eccersley-Scott-Symptom (KESS) score, ODS score, St. Mark's score, Euro Quality of Life-5 Dimension (EQ-5D) score, and Patient Assessment of Constipation-Quality of Life (PAC-QoL) score), at 12 months as compared to baseline. All complications were recorded and analyzed.

RESULTS

A total of 100 patients (98% female), mean age 60 years, were entered in the study. Statistically significant improvements were seen in the KESS (median 18 vs. 6; p < 0.01), ODS (median 15 vs. 4; p < 0.01), and PAC-Qol scores (median 2.10 vs. 0.86; p < 0.01). St. Mark's and EQ-5D scores improved nonsignificantly. Complications were reported in 11 % of patients, including bleeding (5%), staple line complications (3%), urinary retention (2%), and persistent pain (1%). No major complications or mortality occurred.

CONCLUSION

TRANSTAR facilitated a tailored, real circumferential full-thickness rectal resection, leading to improved patient functional and quality of life outcomes at 12 months postoperatively. It represents a safe and effective treatment for ODS in local clinical practice, although the sustainability of real-world results needs to be proven in the long-term follow-up.

STARR with CONTOUR® TRANSTAR™ device for obstructed defecation syndrome: one-year real-world outcomes of the European TRANSTAR registry

PURPOSE

Stapled transanal rectal resection (STARR) in patients with obstructive defecation syndrome (ODS) is limited by the capacity of the circular stapler used. This prospective cohort study was conducted to assess real-world clinical outcomes of STARR with the new CONTOUR® TRANSTAR™ device, shortly named TRANSTAR, at 12 months postoperatively.

METHODS

From January 2009 to January 2011, consecutive patients who underwent TRANSTAR in 22 European colorectal centers were enrolled in the study. Functional outcomes and quality of life were assessed by the changes in a number of scoring systems (Knowles-Eccersley-Scott-Symptom (KESS) score, ODS score, St. Mark's score, Euro Quality of Life-5 Dimension (EQ-5D) score, and Patient Assessment of Constipation-Quality of Life (PAC-QoL) score), at 12 months as compared to baseline. All complications were recorded and analyzed.

RESULTS

A total of 100 patients (98% female), mean age 60 years, were entered in the study. Statistically significant improvements were seen in the KESS (median 18 vs. 6; p < 0.01), ODS (median 15 vs. 4; p < 0.01), and PAC-Qol scores (median 2.10 vs. 0.86; p < 0.01). St. Mark's and EQ-5D scores improved nonsignificantly. Complications were reported in 11 % of patients, including bleeding (5%), staple line complications (3%), urinary retention (2%), and persistent pain (1%). No major complications or mortality occurred.

CONCLUSION

TRANSTAR facilitated a tailored, real circumferential full-thickness rectal resection, leading to improved patient functional and quality of life outcomes at 12 months postoperatively. It represents a safe and effective treatment for ODS in local clinical practice, although the sustainability of real-world results needs to be proven in the long-term follow-up.

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.

Long-term outcome after transanal rectal resection in patients with obstructed defecation syndrome

BACKGROUND

Stapled transanal rectal resection with a new, curved, multifire stapler (Transtar procedure) has shown promising short- and midterm results for treating obstructed defecation syndrome. However, few results have been published on long-term outcome.

OBJECTIVE

This study aimed to investigate long-term functional results and quality of life after the Transtar procedure.

DESIGN

This is a retrospective study.

SETTING

This study was conducted at a tertiary hospital in Switzerland.

PATIENTS

Seventy consecutive patients (68 female) with obstructed defecation syndrome had a median age of 65 years (range, 20-90).

INTERVENTION

The Transtar procedure was performed between January 2007 and March 2010.

MAIN OUTCOME MEASURES

Postoperative functional results were evaluated with the Symptom Severity Score, Obstructed Defecation Score, and Cleveland Incontinence Score. Quality of life was evaluated with the Fecal Incontinence Quality of Life Score and the SF-36 Health Survey. Data were divided into 4 groups of 1-, 2-, 3-, and 4-year follow-ups.

RESULTS

The functional scores showed significant postoperative improvement throughout the studied period (p = 0.01). The quality-of-life scores showed a tendency for improvement only in the mental components on the SF-36 Health Survey (p = 0.01). Sixteen patients reported postoperative fecal urgency, but this subsided within a few months. Nine patients reported new postoperative episodes of incontinence and required further treatment.

LIMITATIONS

This study was limited by its retrospective nature, the selection bias, and a bias by the small number of questionnaires available for some scores.

CONCLUSION

The Transtar procedure was successful for long-term treatment of obstructed defecation syndrome. Fecal urgency and incontinence were observed, but typically resolved within months. Therefore, the Transtar procedure appears to be a reasonable approach to treating obstructed defecation syndrome in the long term.

Stapled transanal rectal resection with contour transtar for obstructed defecation syndrome: lessons learned after more than 3 years of single-center activity

BACKGROUND

Obstructed defecation syndrome is a widespread and disabling disease.

OBJECTIVE

We aim to evaluate the safety and efficacy of stapled transanal rectal resection performed with a new dedicated curved device in the treatment of obstructed defecation syndrome.

DESIGN

A retrospective review of 187 stapled transanal rectal resections performed from June 2007 to February 2011 was conducted.

SETTINGS

The entire study was conducted at a university hospital.

PATIENTS

: All the patients with symptomatic obstructed defecation syndrome and the presence of a rectocele and/or a rectorectal or rectoanal intussusception, in the absence of sphincter contractile deficiency, were included in the treatment protocol.

INTERVENTIONS

All procedures were performed with the use of the Contour Transtar device. We analyzed the functional results of this technique, the incidence and features of the surgical and functional complications, and ways to prevent or treat them.

MAIN OUTCOME MEASURES

Constipation was graded by using the Agachan-Wexner constipation score; use of aids to defecate and patient satisfaction were assessed preoperatively and 6 months after surgery. Intraoperative and postoperative complications were also investigated.

RESULTS

The constipation intensity was statistically reduced from the preoperative mean value of 15.8 (± 4.9) to 5.2 (± 3.9) at 6 months after surgery (p < 0.0001). Of the 151 (80.3%) patients who took laxatives and the 49 (26.2%) who used enemas before treatment, only 25 (13.2%; p < 0.0001) and 7 (3.7%; p < 0.0001) continued to do so after surgery. None of the 17 (9.1%) patients who had previously helped themselves with digitations needed to continue this practice. Almost all patients showed a good satisfaction rate (3.87/5) after the procedure.

LIMITATIONS

Limitations are the short follow-up of 1 year and the design of the study that may introduce potential selection bias.

CONCLUSIONS

The results of this study show that stapled transanal rectal resection performed with the use of the Contour Transtar is a safe and effective procedure to treat obstructed defecation syndrome.

Midterm results after perineal stapled prolapse resection for external rectal prolapse

BACKGROUND

Previous studies showed that perineal stapled prolapse resection for external rectal prolapse improves continence and has short operation times and low complication rates.

OBJECTIVE

The aim of this study was to assess the midterm recurrence rates, functional results, and patient satisfaction after perineal stapled prolapse resection.

DESIGN

This was a retrospective study.

SETTINGS

: The study was performed at a tertiary hospital in Switzerland.

PATIENTS

From November 2007 to October 2011, a total of 56 consecutive patients were included in the study.

MAIN OUTCOME MEASURES

Recurrence rates, functional results according to the Wexner incontinence scale, and patient satisfaction using a visual analog scale were determined.

RESULTS

The median age was 78.5 years (range, 24-94 years), and 2 patients were men. Midterm results were available for 46 (82%) of 56 patients after a median follow-up of 25.5 months (range, 2-47 months). In 10 cases (18%) data collection was not possible. The recurrence rate at 3 years was 19.7% (95% CI 4.2%-32.7%). The Wexner incontinence score improved from a median of 14.5 presurgery to 4.0 points (p < 0.0001) after surgery. Twenty-five patients (54%) stated that their bowel movements were regular postoperatively. On a visual analog scale that measured satisfaction, the median patient score was 9 (range, 0-10), indicating high patient satisfaction.

LIMITATIONS

Limitations included the retrospective study design and the lack of clinical examinations to determine recurrence rates.

CONCLUSIONS

Perineal stapled prolapse resection is an alternative technique for treating rectal prolapse with a recurrence rate similar to the Altemeier-Mikulicz or Delorme procedures. This technique is a quick and reliable procedure for use in patients with advanced age.

Modified technique for performing STARR with Contour Transtar™

Stapled Transanal Rectal Resection (STARR) performed using CCS-30 Contour Transtar™ despite its recent introduction seems to be an effective surgical procedure to treat obstructed defecation syndrome. The major constraint of this procedure is the need to open the prolapse longitudinally using the CCS-30. This is often difficult and can lead to an inadequate or spiralling resection. Our modified technique, presented in this paper, creates the prolapse opening with an electric scalpel between two Kocher clamps, placed to grab the whole prolapsed tissue at 2 and 4 o'clock, respectively. The results of the first 83 procedures confirm that this technique allows the surgeon to simplify the prolapse's longitudinal opening and especially the first loading of the tissue between the CCS-30 jaws, which is necessary to start the circular resection, as confirmed by the absence of spiralling and major complications in this series.

Feasibility and safety study of day-case Transtar™ procedure

BACKGROUND

Short hospitalization surgery is cost effective and convenient for both patients and healthcare system. Stapled transanal rectal resection (STARR) conducted with the new curved device, Contour Transtar, has proved an effective and safe procedure for treatment of obstructed defecation syndrome. The aim of this study was to determine the safety and feasibility of STARR, performed as a day-case procedure.

MATERIAL AND METHODS

Retrospective review was performed of all STARR performed as day-case surgery between September 2009 and February 2011. The entire study (intervention, data collection and data analysis) was conducted at the One-day Surgery Unit of the St. Andrea Hospital, Rome, Italy. All patients with surgical indication to STARR for the presence of an obstructed defecation syndrome were included in the study. We excluded from day-case protocol, patients over 65 years old, with an ASA score of III-IV or with a BMI over 35. The surgical technique reflects the original technique proposed by Antonio Longo with the exception of the longitudinal prolapse opening, which was created with the use of an electric scalpel between two Kocher clamps and not by an application of Transtar stapler. To evaluate the feasibility and safety of performing this procedure with short hospitalization, we investigated the presence and the time of presentation of post-operative complications.

RESULTS

Eighty-nine patients underwent STARR as a day-case regimen, and none presented major complications or required an extension of hospital stay or readmission.

CONCLUSIONS

STARR performed with Contour Transtar, in selected patients, is safe and feasible in day-case regimen if performed by expert surgeons and in a structure that allows the physician to keep the patient hospitalized or to re-admit and promptly treat those patients who present major surgical complication.

Five-item score for obstructed defecation syndrome: study of validation

The use of a dedicated score represents an essential tool for the clinical staging of obstructed defecation syndrome (ODS), for subsequent diagnostic and therapeutic options, and for the evaluation of the results. This study was designed to develop and validate a new, simple, and disease-specific scoring system for ODS. The questionnaire consists of 5 items: excessive straining, incomplete rectal evacuation, use of enemas and/or laxatives, vaginal-anal-perineal digitations, and abdominal discomfort and/or pain. Each item was graded from 0 to 5 with a score ranging from 0 (no symptoms) to 20 (very severe symptoms). A specific statistical analysis identifies the new score as a valuable and concise instrument, which demonstrates, overall, excellent concurrent validity, reproducibility, internal consistency, and discriminant validity for the diagnosis and grading of ODS. The use of this questionnaire may improve uniformity in clinical research and may allow a more precise evaluation of symptom severity and treatment effectiveness in ODS.

Early complications after stapled transanal rectal resection performed using the Contour® Transtar™ device

AIM

This study evaluated the early results (with particular reference to complications) of stapled transanal rectal resection (STARR) carried out using the CCS-30 Contour® Transtar™ device. The procedure was performed in a single centre on patients with obstucted defecation caused by rectocele or rectal intussusception.

METHOD

From July 2007 to February 2009, 133 patients were treated. Preoperatively, all underwent clinical examination, transanal ultrasonography, anorectal manometry and cinedefaecography. Obstructed defaecation syndrome was assessed using the Cleveland Clinic Constipation Score (CCC-S). Early postoperative complications and those occurring within 6 months were recorded.

RESULTS

The median follow-up period was 19 (range 12-30) months. The mean ± standard deviation preoperative CCC-S of 19.4 ± 7.1 decreased to 10.1 ± 9.0 postoperatively. The early complication rate was 15.7% and included rectovaginal fistula (n = 1), rectal perforation (n = 1), posterior dehiscence (n = 4), further surgery for retained staples (n = 2), postoperative bleeding (n = 2) and postoperative impaired continence (n = 11).

CONCLUSIONS

STARR using the Contour Transtar device seems to be effective for treating obstructed defaecation. However, serious complications may occur.

STARR With PPH-01 and CCS30 Contour Transtar for Obstructed Defecation Syndrome

Introduction. The stapled transanal rectal resection (STARR) procedure is safe and effective. Objective of the Study. To compare STARR performed with PPH-01 (STARR) and CCS 30 (Transtar). Materials and Methods. Sixty-four patients underwent STARR for obstructed defecation syndrome (32 STARR and 32 Transtar) and were observed from January 2007 to June 2009. Patients were studied by visit with questionnaires, colonoscopy or barium enema, defecography, and anorectal manometry. Postoperatively they were assessed through visit and questionnaires. Results. All patients improved symptoms without statistical differences. The obstructed defecation syndrome score changed from 13 to 1.8 at 6 months and to 1 at 1 year in the STARR group ( P < .05), and the score changed from 15 to 2 at 6 months and to 1 at 1 year in the Transtar group ( P < .05). There were no intraoperative complications in the STARR group, but there were 2 dehiscences of suture in the Transtar group. There were no differences with regard to complications. Conclusion. Transtar is a more complex technique with more severe complications. A major resection is not always more effective.

The relationship between internal rectal prolapse and internal anal sphincter function

AIM

Faecal incontinence is commonly seen in patients with internal rectal prolapse (IRP), although the mechanism is not clear. This study assessed the relationship between IRP and anal sphincter function.

METHOD

Patients both with IRP diagnosed on proctography and those with external rectal prolapse (ERP) were identified from a prospective database generated from a tertiary referral pelvic floor clinic. The results of anorectal manometry were analysed, and the relationship between sphincter pressure and grade of prolapse was assessed.

RESULTS

A total of 515 patients were identified with clinical evidence of ERP or proctographic evidence of internal and external prolapse. There were 88 with grade 5 or external prolapse [mean maximal resting pressure (MRP) 28.5 (standard error 2.1) mmHg], 156 with grade 4 prolapse [44.0 (1.8) mmHg], 153 with grade 3 prolapse [49.2 (1.6) mmHg], 88 with grade 2 prolapse [56.2 (2.1) mmHg] and 29 patients with grade 1 rectal prolapse [56.8 (4.5) mmHg]. There was a significant reduction in the mean MRP with increasing grade of prolapse from grade 2 to 5. By contrast, there was no relationship between prolapse grade and mean maximal squeeze pressure, except in patients with ERP, in whom the squeeze pressure was significantly lower compared with patients with IRP.

CONCLUSION

This is the first large-scale study to show the relationship between internal prolapse and MRP. The observation that squeeze pressure is unchanged suggests that the effect of internal prolapse on continence occurs mainly through a reduction in internal anal sphincter tone.

Improved clinical outcomes with a new contour-curved stapler in the surgical treatment of obstructed defecation syndrome: a mid-term randomized controlled trial

BACKGROUND

Stapled transanal rectal resection has become the primary surgical procedure for surgical treatment of obstructed defecation syndrome caused by rectocele or rectal intussusception. The procedure is generally performed with 2 circular staplers. Recently, a dedicated contour-curved stapler was developed.

OBJECTIVE

This study was designed to compare the effects of these stapler types on relief of symptoms.

DESIGN AND SETTING

A randomized controlled trial was conducted at a regional referral center in Naples, Italy.

PATIENTS

Patients with obstructed defecation syndrome and rectocele or rectal intussusception, treated from November 2005 through September 2007.

INTERVENTIONS

Participants were randomly assigned to undergo stapled transanal rectal resection with 2 circular staplers or the contour-curved stapler.

MAIN OUTCOME MEASURES

The primary end point was success rate at 24 months, defined by symptom improvement on an obstructed defecation syndrome scale. Secondary end points included success rate at 12 months, Agachan-Wexner constipation score, and rates of early and late complications at 12 and 24 months.

RESULTS

Of 198 patients evaluated, 63 patients (31.8%) satisfied criteria. Follow-up data were available for 61 patients: 30 patients (28 women) in the circular stapler group (mean age, 53; range, 41-75 years) and 31 (29 women) in the contour-curved stapler group (mean age, 55; range, 38-69 years). At 24-month follow-up, success was achieved in 21 patients (70.0%) with the circular staplers and in 27 (87.0%) with the contour-curved stapler (P = .10). Symptom scores improved significantly in both groups from baseline to 12 months (P < .0001). Improvement was maintained in the contour-curved stapler group: mean score, 5.0 (SD, 1.6) at 12 months and 5.5 (1.5) at 24 months (P = .20). In the circular stapler group, symptom scores worsened from 4.5 (1.5) at 12 months to 9.0 (1.3) at 24 months (P < .0001). At 24 months, the groups differed significantly in symptom scores (P < .0001) and constipation scores (P = .03). No significant differences were seen in duration of postoperative hospital stay or rate of early or late complications.

CONCLUSIONS

Stapled transanal rectal resection with either circular or contour-curved staplers can achieve relief of symptoms in patients with obstructed defecation syndrome. The contour-curved stapler appears to result in more stable clinical results over time.

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.