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Andreoli R, Zampieri N, Orlandi S, Geccherle A, Castellani RL. Long time consequences after STARR procedure: Report of 15 years experience and medico-legal perspective. Am J Surg 2024; 229:169-173. [PMID: 38042721 DOI: 10.1016/j.amjsurg.2023.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 10/28/2023] [Accepted: 11/11/2023] [Indexed: 12/04/2023]
Abstract
INTRODUCTION Stapled transanal rectal resection is the most surgical procedure used for obstructed defecation syndrome, rectal prolapse, rectocele and rectal intussusception worldwide. The aim of this study is to report our experience and long time consequences and to offer a new medico-legal perspective. MATERIALS AND METHODS We retrospective review medical charts of patients treated between 2006 and 2021 b y the same team directed by the same senior surgeon. We consider major complications and long time sequelaeses as main object for the discussion. Inclusion and exclusion criteria were created. IRB approved the study. After revision a medico-legal perspective was done based on major complications. RESULTS During the study period 1726 patients, ages between 18 and 71 years old, were treated with 1280 STARR procedures and 446 "Longo" [was stopped on 2012]; all procedures were performed by the senior surgeon and visited by the team at the same control visit at 7days, 30 days and 12 and 18 months after surgery. All patients had 100 % compliance at 30 days, while 85 % had long time visit (more than 18 months). During the study period 6 % (104 subjects) of patients had minor complications while 1 patient (42 yrs female) reported total fecal incontinence after 18 months (0,05 %). This patient had mental disorder treated with drugs unknown before surgery and long time mental disorder after surgery. We focused on this last case to discuss long time complication DISCUSSION: This survey reports some interesting clinical data; respect to standard complications minor complications such as pain, bleeding and anal discomfort represent less than 10 % of procedures that is a good results in this perineal surgery. For those working with rectal mucosal prolapse, obstructed defecation syndrome, rectocele or rectal intussusception is essential to distinguish these diagnosis to have a good counselling with patient before surgery (at least 1 month before). It is essential to check these patients with a close follow-up especially after surgery, to avoid any other mental discomfort related to fecal incontinence; long time fecal incontinence, without anatomical disorders as our case, could be associated and related to drugs consumption or mental disorder, or perineal insensitivity due to surgical procedure. In conclusion it is essential to have good clinical practice to suggest STARR procedure, having idea about different diseases, different surgical approaches and different long time complications.
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Affiliation(s)
- Remo Andreoli
- Recto-intestinal Operative Unit, Sacro Cuore-Don Calabria Hospital, Scientific Institute of Research and Care - Negrar di Valpolicella, Verona, Italy
| | - Nicola Zampieri
- Woman and Child Hospital, University of Verona, Pediatric Surgical Unit, Department of Engineering for Innovation Medicine, Verona, Italy; Recto-intestinal Operative Unit, Sacro Cuore-Don Calabria Hospital, Scientific Institute of Research and Care - Negrar di Valpolicella, Verona, Italy.
| | - Simone Orlandi
- Recto-intestinal Operative Unit, Sacro Cuore-Don Calabria Hospital, Scientific Institute of Research and Care - Negrar di Valpolicella, Verona, Italy
| | - Andrea Geccherle
- Recto-intestinal Operative Unit, Sacro Cuore-Don Calabria Hospital, Scientific Institute of Research and Care - Negrar di Valpolicella, Verona, Italy
| | - Roberto L Castellani
- Surgical and Emergency Departement, Pederzoli Hospital, Peschiera Del Garda, Verona, Italy; Recto-intestinal Operative Unit, Sacro Cuore-Don Calabria Hospital, Scientific Institute of Research and Care - Negrar di Valpolicella, Verona, Italy
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Abstract
Anorectal disorders encompass structural, neuromuscular, and functional disorders. They are common, often distressing, and in some cases debilitating, and significantly add to the health care burden. They present with multiple, overlapping symptoms that can often obscure the underlying pathology and can pose significant diagnostic and management dilemmas. A meticulous history and comprehensive digital rectal examination can provide clarity on the diagnosis, appropriate testing, and management of these conditions. Today, with the development of sophisticated diagnostic tools such as high-resolution and high-definition (3-D) anorectal manometry, 3-D anal ultrasonography, magnetic resonance defecography and imaging, and neurophysiological tests such as translumbosacral anorectal magnetic stimulation, it is possible to more accurately define and characterize the underlying structural and functional abnormalities. In this review, we present a succinct update on the latest knowledge with regards to the pathophysiology, diagnosis and management of anal fissure, hemorrhoids, rectal prolapse, intussusception, rectocele, solitary rectal ulcer syndrome, levator ani syndrome, dyssynergic defecation and fecal incontinence.
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Giarratano G, Toscana C, Toscana E, Shalaby M, Sileri P. Stapled transanal rectal resection for the treatment of rectocele associated with obstructed defecation syndrome: a large series of 262 consecutive patients. Tech Coloproctol 2019; 23:231-237. [PMID: 30778786 DOI: 10.1007/s10151-019-01944-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 02/05/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND This study aims to investigate functional results and recurrence rate after stapled transanal rectal resection (STARR) for rectocele associated with obstructive defection syndrome (ODS). METHODS A study was conducted on patients with ODS symptoms associated with symptomatic rectocele ≥ 3 cm on dynamic defecography who had STARR at our institution between 01/2007 and 12/2015. Data were prospectively collected and analyzed. ODS was evaluated using the Wexner constipation score. Primary outcomes were functional results, determined by the improvement in 6-month postoperative Wexner constipation score, and 1-year recurrence. Secondary outcomes were operative time, time to return to work, pain intensity measured using the visual analogue scale (VAS), patient satisfaction, and overall postoperative morbidity and mortality at 30 days. RESULTS Two-hundred-sixty-two consecutive female patients [median age 54 years (range 20-78)] were enrolled in the study. The median duration of follow-up was 79 months (range 30-138). Sixty (23%) patients experienced postoperative complications, but only 9 patients required reinterventions for surgical hemostasis (n = 7), fecal diversion for anastomotic leakage (n = 1), and recto-vaginal fistula repair (n = 1). Only 1 intraoperative complication (stapler misfire) was reported, and there were no deaths. There was a statistically significant (p < 0.001) reduction in the median (range) Wexner constipation score from 19 (14-24) preoperatively to 9 (5-15) 6 months postoperatively. Only 10 (4%) patients experienced recurrence and only 3 of them required additional reintervention. Patient satisfaction at 1 year was excellent in 86%, good in 13%, and poor in 1% of patients. CONCLUSIONS STARR is a safe, effective, and minimally invasive technique for the treatment of rectocele associated with ODS.
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Affiliation(s)
- G Giarratano
- Department of General Surgery, Villa Tiberia Hospital, Via Emilio Praga, 26, 00100, Rome, Italy
| | - C Toscana
- Department of General Surgery, Villa Tiberia Hospital, Via Emilio Praga, 26, 00100, Rome, Italy
| | - E Toscana
- Department of General Surgery, Villa Tiberia Hospital, Via Emilio Praga, 26, 00100, Rome, Italy.
| | - M Shalaby
- Colorectal Surgery Unit, Department of General Surgery, Mansoura University, Mansoura, Dakahlia, Egypt.,Department of General Surgery, University of Rome Tor Vergata, Policlinico Tor Vergata, Rome, Italy
| | - P Sileri
- Department of General Surgery, University of Rome Tor Vergata, Policlinico Tor Vergata, Rome, Italy
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Giarratano G, Toscana E, Toscana C, Petrella G, Shalaby M, Sileri P. Transanal Hemorrhoidal Dearterialization Versus Stapled Hemorrhoidopexy: Long-Term Follow-up of a Prospective Randomized Study. Surg Innov 2018; 25:236-241. [DOI: 10.1177/1553350618761757] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Aim. This study aims to compare the early and late outcomes of transanal hemorrhoidal dearterialization (THD) versus stapled hemorrhoidopexy (SH) for the treatment of hemorrhoidal disease. Methods. From January 2013 to December 2014, 100 patients—50 patients on each arm—were randomly allocated to THD or SH groups. The inclusion criteria were grade III and IV hemorrhoids diagnosed by clinical examination and proctoscopy. The primary outcome was to compare the recurrence rate with a minimum follow-up of 2 years, and the secondary outcome was to compare complications rate, time to return to work postsurgery, procedure length, and patient’s satisfaction between the 2 techniques. Results. The mean follow-up period was 33.7 ± 7.6. The recurrence rate was 4% in the SH group and 16% in the THD group ( P = .04). There was no difference in the intraoperative and postoperative complications rate; the pain score was significantly higher in the THD group. The mean operative time was significantly shorter in the SH group compared with the THD group. Patients in the THD group returned to work or routine activities significantly later compared with patients in the SH group. The overall satisfaction rate was also higher in the SH group. Conclusion. Both procedures are simple and easy to perform for the treatment of grade III and IV hemorrhoids. SH showed better results in terms of lower rate of recurrence, lower postoperative pain, quicker return to work, and higher patient satisfaction.
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Mehrvarz S, Towliat SM, Mohebbi HA, Heydari S, Farahani M, Rasouli HR. Obstructed Defecation Syndrome After Delivery Trauma. Trauma Mon 2015; 20:e25611. [PMID: 26839863 PMCID: PMC4727471 DOI: 10.5812/traumamon.25611] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2014] [Revised: 06/06/2015] [Accepted: 07/07/2015] [Indexed: 12/13/2022] Open
Abstract
Background: Obstructed defecation syndrome (ODS) occurs in about 7% of adults; it seems that the etiology of pelvic floor disorders is multifactorial. Pregnancy and childbirth damage to the pelvic nerve and muscles are proposed causes for this condition. The precise role of vaginal delivery (VD) is not clearly defined, although in recent studies association of pelvic floor disorder with Operative vaginal delivery and episiotomy has been proposed. Objectives: In this prospective study, we assessed the outcome of stapled transanal rectal resection (STARR) in females with one of the two modes of delivery (VD or caesarean section (C/S). Patients and Methods: We used Longo’s ODS score for the assessment of the severity of pelvic floor malfunction. Stapled Trans Anal Rectal Resection (STARR) procedure was performed using two circular staplers. Follow-up was done 12 months after the discharge. To assess the role of episiotomy in patient with VD, we divided them into two subgroups; females who had VD with episiotomy (Vd + epi) and females who had VD alone. Data were analyzed using SPSS version 20 software. P values less than 0.05 were considered statistically significant. Results: In 30 consecutive females undergoing STARR for the treatment of ODS, who enrolled in this prospective study, 19 (63.3%) had Vaginal Delivery VD and 11 (36.7%) had Cesarean Section (C/S). The ODS score before the surgery was higher in females who had C/S, although there was no significant difference between VD and C/S groups in terms of the percentage of the ODS score improvement after the STARR surgery. Conclusions: Higher ODS score in females who had C/S showed that C/S could not protect the pelvic organ from pregnancy and delivery trauma. It seems that episiotomy has a protective effect during VD; it can reduce the severity of trauma in pelvic organs during childbearing.
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Affiliation(s)
- Shaban Mehrvarz
- Trauma Research Center, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
| | - Seyed Mohsem Towliat
- Department of Surgery, Faculty of Medicine, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
| | - Hassan Ali Mohebbi
- Department of Surgery, Faculty of Medicine, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
| | - Soleyman Heydari
- Department of Surgery, Faculty of Medicine, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
- Corresponding author: Soleyman Heydari, Department of Surgery, Faculty of Medicine, Baqiyatallah University of Medical Sciences, Tehran, IR Iran. Tel: +98-2181263550, Fax: +98-2188053766, E-mail:
| | - Mahdi Farahani
- Department of Surgery, Faculty of Medicine, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
| | - Hamid Reza Rasouli
- Trauma Research Center, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
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Prichard D, Bharucha AE. Management of pelvic floor disorders: biofeedback and more. ACTA ACUST UNITED AC 2014; 12:456-67. [PMID: 25267107 DOI: 10.1007/s11938-014-0033-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OPINION STATEMENT Defecatory disorders (DD) and fecal incontinence (FI) are common conditions. DD are primarily attributable to impaired rectoanal function during defecation or structural defects. FI is caused by one or more disturbances of anorectal continence mechanisms. Altered stool consistency may be the primary cause or may unmask anorectal deficits in both conditions. Diagnosis and management requires a systematic approach beginning with a thorough clinical assessment. Symptoms do not reliably differentiate a DD from other causes of constipation such as slow or normal transit constipation. Therefore, all constipated patients who do not adequately respond to medical therapy should be considered for anorectal testing to identify a DD. Preferably, two tests indicating impaired defecation are required to diagnose a DD. Patients with DD, or those for whom testing is not available and the clinical suspicion is high, should be referred for biofeedback-based pelvic floor physical therapy. Patients with FI should be managed with lifestyle modifications, pharmacotherapy for bowel disturbances, and management of local anorectal problems (e.g., hemorrhoids). When these measures are not beneficial, anorectal testing and pelvic floor retraining with biofeedback therapy should be considered. Sacral nerve stimulation or perianal bulking could be considered in patients who have persistent symptoms despite optimal management of bowel disturbances and pelvic floor retraining.
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Affiliation(s)
- David Prichard
- Clinical Enteric Neuroscience Translational and Epidemiological Research Program, Division of Gastroenterology and Hepatology, Mayo Clinic, 200 1st Street, Rochester, MN, 55905, USA,
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Abstract
Rectal prolapse continues to be problematic for both patients and surgeons alike, in part because of increased recurrence rates despite several well-described operations. Patients should be aware that although the prolapse will resolve with operative therapy, functional results may continue to be problematic. This article describes the recommended evaluation, role of adjunctive testing, and outcomes associated with both perineal and abdominal approaches.
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BHARUCHA ADILE, PEMBERTON JOHNH, LOCKE GRICHARD. American Gastroenterological Association technical review on constipation. Gastroenterology 2013; 144:218-38. [PMID: 23261065 PMCID: PMC3531555 DOI: 10.1053/j.gastro.2012.10.028] [Citation(s) in RCA: 505] [Impact Index Per Article: 45.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- ADIL E. BHARUCHA
- Division of Gastroenterology and Hepatology Mayo Clinic and Mayo Medical School Rochester, Minnesota
| | - JOHN H. PEMBERTON
- Division of Colon and Rectal Surgery Mayo Clinic and Mayo Medical School Rochester, Minnesota
| | - G. RICHARD LOCKE
- Division of Gastroenterology and Hepatology Mayo Clinic and Mayo Medical School Rochester, Minnesota
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Pescatori M. Obstructed Defecation (OD) and Related Diseases. PREVENTION AND TREATMENT OF COMPLICATIONS IN PROCTOLOGICAL SURGERY 2012:135-163. [DOI: 10.1007/978-88-470-2077-1_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Bharucha AE. Difficult defecation: difficult problem assessment and management; what really helps? Gastroenterol Clin North Am 2011; 40:837-44. [PMID: 22100121 DOI: 10.1016/j.gtc.2011.09.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Difficult defecation is a common and perhaps underrecognized cause of chronic constipation. While the history and a careful digital rectal examination are very useful for diagnosing defecatory disorders, the diagnosis needs to be confirmed by anorectal tests. Anorectal manometry and a rectal balloon expulsion test generally suffice to diagnose defecatory disorders; barium or MR defecography may necessary in selected cases. Colonic transit is normal or slow in patients with defecatory disorders. Pelvic floor retraining by biofeedback therapy is superior to laxatives for managing defecatory disorders.
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Affiliation(s)
- Adil E Bharucha
- Clinical Enteric Neurosciences Translational and Epidemiological Research Program, Division of Gastroenterology and Hepatology, Mayo Clinic and Mayo Foundation, Rochester, MN 55905, USA.
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Goede AC, Glancy D, Carter H, Mills A, Mabey K, Dixon AR. Medium-term results of stapled transanal rectal resection (STARR) for obstructed defecation and symptomatic rectal-anal intussusception. Colorectal Dis 2011; 13:1052-7. [PMID: 20813023 DOI: 10.1111/j.1463-1318.2010.02405.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- A C Goede
- Department of Colorectal Surgery, Frenchay Hospital, Bristol, UK
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Pescatori M. Ostruita defecazione (OD) e patologie correlate: rettocele, prolasso mucoso interno e intussuscezione rettale,discinesia addomino-pelvica, ulcera solitaria del retto. PREVENZIONE E TRATTAMENTO DELLE COMPLICANZE IN CHIRURGIA PROCTOLOGICA 2011:135-163. [DOI: 10.1007/978-88-470-2062-7_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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