Reinterventions after complicated or failed STARR procedure

Dynamic MRI defecography vs. entero-colpo-cysto-defecography in the evaluation of midline pelvic floor hernias in female pelvic floor disorders

PURPOSE

The aim of this study was to compare the diagnostic efficacy of dynamic MR defecography (MR-D) with entero-colpo-cysto-defecography (ECCD) in the assessment of midline pelvic floor hernias (MPH) in female pelvic floor disorders.

METHODS

From August 2004 to August 2010, 3,006 female patients who required ECCD for the evaluation of pelvic floor disorders were enrolled in this study. All the 1,160 patients with ECCD findings of MPH were asked to undergo MR-D; 1,142 accepted to undergo MR-D and constituted the object of analysis. This study was approved by the Institutional Ethical Committee. All the patients gave their written informed consent to take part in the study.

RESULTS

Overall, the prevalence of MPH at ECCD was higher if compared with that at MR-D. Concerning the hernia content, there were significantly more enteroceles and sigmoidoceles on ECCD than on MR-D, whereas, in relation to the hernia development modalities, the prevalence of elytroceles, edroceles, and Douglas' hernias at ECCD was significantly higher than that at MR-D. In spite of a 100% specificity, the sensibility of MR-D in the detection of an omentocele, sigmoidocele, and enterocele was, respectively, 95%, 82%, and 65%, showing an inferior diagnostic capacity if compared with that of ECCD.

CONCLUSION

MR-D shows lower sensitivity than ECCD in the detection of MPH development. The less-invasive MR-D may have a role in a better evaluation of the entire pelvic anatomy and pelvic organ interaction especially in patients with multicompartmental defects, planned for surgery.

Agraffectomy after low rectal stapling procedures for hemorrhoids and rectocele

BACKGROUND

Various sequelae which might lead to reintervention have been described after stapled rectal mucosectomy for hemorrhoids. One potential treatment modality for persistent complaints after stapled hemorrhoidopexy (SHP) or stapling for rectocele is the so-called agraffectomy (removal of the retained staples). This treatment option means a further procedure that can range from removal of the staples through the anoscope to removal of the entire staple line with the associated scar tissue.

METHODS

In order to review the published literature, we conducted a search on Medline, Pubmed, and Embase using different terms for "agraffectomy."

RESULTS

Overall, fourteen reports were found, dealing with agraffectomy for various conditions after low rectal stapling for hemorrhoids or rectocele. Agraffectomy is a rarely mentioned treatment option for conditions after SHP. In rectal stenosis with complete occlusion of the rectal lumen, the removal of the stenotic anastomosis and remaining staples seems to be reasonable. The same can be said of the removal of retained staples for rectal bleeding or in order to avoid penile injuries in anal intercourse. In contrast, the collected published reports on agraffectomy in this review only provide low-level evidence that this procedure provides relief for other problems such as incontinence or chronic pain.

CONCLUSIONS

There is no clear evidence that agraffectomy is indicated if not in case of rectal stenosis and hemorrhage caused by the staples.

Clinical outcomes of stapled transanal rectal resection (STARR) for obstructed defecation syndrome (ODS): a single institution experience in South Korea

PURPOSE

The purpose of this study was to assess both the short- and long-term functional outcomes of stapled transanal rectal resection (STARR) in ODS patients.

PATIENTS AND METHODS

We performed a retrospective review of data that were collected from January 2005 to October 2008. Between January 2005 to June 2006, 58 patients who underwent STARR were enrolled in this study. Follow-up was scheduled for 3 months and 1 year after surgery with the Cleveland Clinic Florida (CCF) constipation score and satisfaction grade. To evaluate the long-term functional outcome, we interviewed the patients by telephone using questionnaires for the CCF score and satisfaction grade on October 2008.

RESULTS

The median follow-up period was 34 months (range, 27-46 months). The mean age and sex ratio were 54 years (range, 19-85 years) and 8:50 (M/F). The mean CCF constipation scores were 17.6 before the surgery, 9.5 at 3 months, 9.6 at 12 months, and 10.3 at the time of the latest interview. The satisfaction grade, which was rated as excellent and good by 63.4% of the patients at the time of the latest interview, was worse than that at 3 months (37.8%). Among the cases of the excellent group (19 cases) at postoperative 3 months, 13 cases (68.4%) were classified as excellent or good at the time of the latest interview.

CONCLUSION

The STARR is a safe and effective surgical procedure for restoring the anatomy and function in ODS patients. Strict selection of patients is needed in enhancing and maintaining the patients' satisfaction after the procedure.

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.

Stapled trans-anal rectal resection (STARR) in the surgical treatment of the obstructed defecation syndrome: results of STARR Italian Registry

PURPOSE

This study was designed to evaluate the safety and efficacy of stapled trans-anal rectal resection (STARR) in the treatment of obstructed defecation syndrome ODS by the analysis of the data collected in the STARR Italian Registry (SIR) with a special emphasis on the analysis of symptoms and quality of life.

METHODS

Collected data included, preoperative tests findings, and the evaluation of symptoms; the latter was obtained by using dedicated tools such as the Obstructed Defecation Syndrome Score (ODS-S), the Severity Symptom Score (SSS), and the Continence Grading Scale (CGS). Data on the quality of life were collected by Patient Assessment of Constipation Quality of Life (PAC-QoL) and the Euro Quality of Life-5 Domains Visual Analogue Scale (EQ-5D VAS). The evaluation of the symptoms and the quality of life was repeated 6 and 12 months after surgery.

RESULTS

The SIR had collected data on 2171 patients (1653 females, 76.1%; mean age 56.2 years; range 20-96 years). A significant improvement (P < .0001) was seen between preoperative and 12-month follow-up in all scores: ODS-S (16.7 vs. 5.0), SSS (15.6 vs. 2.6), CGS (2.0 vs. 0.7), PAC-QoL (51.0 vs. 22.1), and EQ-5D VAS (57.5 vs. 85.7). Complications included defecatory urgency (4.5% at 12 months), bleeding (3.6%), perineal sepsis (3.4%), and one case of rectovaginal fistula (0.05%).

CONCLUSION

The analysis of SIR data seems to confirm that STARR is a safe and effective procedure in the treatment of ODS. However, further studies are required to evaluate the long-term stability of results.

Conversion in transanal stapling techniques for haemorrhoids and anorectal prolapse

AIM

It was the aim of this single-surgeon series to assess the role of conversion in transanal stapling to techniques and to identify potential factors predictive of conversion.

METHOD

The details of all consecutive patients who were planned for a stapled approach were prospectively recorded in a PC database. Stapling techniques (PPH03, PPH01 and ContourTranstar) were indicated for haemorrhoidal disease and internal rectal prolapse. 'Conversion' from a stapled approach was defined as an unplanned change of the surgical method to a nonstapled, traditional technique, related to indication, anatomy and technical factors. The primary outcomes were whether the procedure was performed using a stapling device only, or whether the procedure was converted. Logistic regression analysis was performed to evaluate multiple variables as potential risk factors for conversion.

RESULTS

In a 2-year period (May 2006-May 2008), 258 patients met the inclusion criteria and underwent transanal surgery scheduled as a stapled approach. In these 258 patients, 246 procedures were completed as a stapled procedure [that stapled haemorrhoidopexy, n = 148; stapled mucosectomy, n = 52; stapled transanal rectal resection (STARR) with PPH01, n = 38; and STARR with ContourTranstar, n = 8], giving a completion rate of 95.4%. However, 12 procedures were converted to conventional surgery (including traditional haemorrhoidectomy and the Delorme procedure), giving a conversion rate of 4.6%. The reasons for conversion were related to anatomy and to clinical findings (nonreducible haemorrhoidal prolapse), to new clinical findings not detected preoperatively (proctitis, anal fistula) and to a technical inability to insert the circular anal dilatator because of a deep anal canal. Neither univariate nor multivariate analysis identified any factor to be specifically associated with the risk of conversion.

CONCLUSION

In the era of transanal stapling procedures for haemorrhoids and anorectal prolapse, the majority of procedures can be performed using stapled techniques if strict criteria of indication and patient selection are respected. However, the current study identified a 4.6% conversion rate to traditional treatment, which has an impact on informed consent and requires the surgeon to be familiar with conventional anorectal procedures.

Patient satisfaction and symptomatic outcomes following stapled transanal rectal resection for obstructed defecation syndrome

BACKGROUND

Obstructed defecation syndrome (ODS) is recognized as a functional (e.g., anismus) and anatomic (e.g., rectocele and rectal intussusception) defecatory disorder of the pelvic floor. This study was designed to evaluate outcomes and patient satisfaction following stapled transanal rectal resection (STARR) for the surgical treatment of ODS.

MATERIALS AND METHODS

Between May 2006 and July 2009, 37 patients underwent STARR for correction of ODS secondary to rectocele and internal intussusception. Demographic data and postoperative outcomes were tabulated. Symptomatic outcomes were assessed by comparing pre- and postoperative subsets of the Wexner constipation scoring system, and quality outcomes were evaluated with patient satisfaction surveys.

RESULTS

Thirty-seven female patients with a mean age of 52.9 ± 11.2 y underwent STARR. All patients had clinically significant rectocele as evidenced on defecography and 81.1% had concomitant internal rectal intussusception. Postoperative complications occurred in 13 patients (35.1%). Two of these patients required re-intervention: dilation of stricture and transanal excision of staple granuloma. Mean quality of life follow-up occurred at 20.3 ± 6.5 mo (median: 20 mo, range: 9-36 mo). Mean preoperative and postoperative constipation subset scores were 11.1 ± 3.6 and 4.6 ± 3.9, respectively (P < 0.00001). Overall outcome was reported as "excellent" or "good" in 71.9% of patients, "adequate" in 15.6%, and "poor" in 12.5%. When asked if they would undergo the procedure again, 81.3% responded affirmatively.

CONCLUSIONS

The STARR procedure results in improved symptomatic outcomes, high patient satisfaction, and an acceptable complication rate. In selected patients, this minimally invasive approach was an acceptable procedure for the surgical correction of ODS secondary to rectocele and intussusception.

Assessing the safety, effectiveness, and quality of life after the STARR procedure for obstructed defecation: results of the German STARR registry

BACKGROUND

Internal rectal prolapse and rectocele are frequent clinical findings in patients with obstructed defecation syndrome (ODS). However, there is still no evidence whether stapled transanal rectal resection (STARR) provides a safe and effective surgical option. Therefore, the German STARR registry was initiated to assess safety, effectiveness, and quality of life.

METHODS

The German STARR registry was designed as an interventional, prospective, multicenter audit. Primary outcomes include safety (morbidity and adverse events), effectiveness (ODS, symptom severity, and incontinence scores), and quality of life (PAC-QoL and EQ-5D) documented at baseline and at 6 and 12 months. Statistical evaluation was performed by an independent research organization of clinical epidemiology.

RESULTS

Complete data of 379 patients (78% females, mean age 57.8 years) were entered into the registry database. Mean operative time was 40 min, mean hospitalization was 5.5 days. A total of 103 complications and adverse events were reported in 80 patients (21.1%) including staple line complications (minor bleeding, infection, or partial dehiscence; 7.1%), major bleeding (2.9%), and postsurgical stenosis (2.1%). Comparisons of ODS and symptom severity scores (SSS) demonstrated a significant reduction in ODS score between baseline (mean 11.14) and 6 months (mean 6.43), which was maintained at 12 months (mean 6.45), and SSS at preoperative and at 6- and 12-month follow-up (13.02 vs. 7.34 vs. 6.59; paired t test, p < 0.001). Significant reduction in ODS symptoms was matched by an improvement in quality of life as judged by symptom-specific PAC-QoL and generic ED-5Q (utility and visual analog scale) scores and was not associated with an impairment of incontinence score following STARR (p > 0.05). However, 11 patients (2.9%) showed de novo incontinence, and new-onset symptoms of fecal urgency were observed in 25.3% of patients.

CONCLUSION

These data indicate that STARR is a safe and effective procedure. However, conclusions are limited due to the selection and reporting bias of a registry. The problem of fecal urgency needs cautious reassessment.

Functional outcome and quality of life after stapled transanal rectal resection for obstructed defecation syndrome

PURPOSE

Clinical studies have demonstrated that stapled transanal rectal resection with Contour Transtar (Transtar procedure) is a safe and effective treatment for patients with obstructive defecation syndrome. The aim of this study was to determine functional outcome and quality of life after the procedure.

METHODS

Female patients with obstructive defecation syndrome were enrolled prospectively for the Transtar procedure. Intussusception and anterior rectocele were confirmed by clinical investigation and by magnetic resonance defecography. Functional outcome was measured by obstructed defecation syndrome score, severity of symptoms score, and Wexner score preoperatively and postoperatively. Quality of life was assessed by the Cleveland Clinic constipation score, the fecal incontinence quality of life scale, and the SF-36v2 health survey.

RESULTS

Between January 2007 and November 2008, 52 consecutive patients (median age: 64 years) were included in the study. Before the surgery, 12 patients experienced fecal incontinence. Functional scores improved significantly: 6 weeks after surgery, the obstructed defecation syndrome score decreased from a median of 16 (range, 9-22) to 5 (range, 2-10) and the severity of symptoms score, from 16 (range, 9-21) to 4 (range, 0-9) (each P < .0001). After 6 weeks, 10 patients had fecal incontinence and 12 patients experienced fecal urgency. At 3 months, 6 patients were still incontinent, 3 of whom were treated successfully with sacral neuromodulation. Fecal urgency resolved in all cases after 6 months. Quality of life improved, particularly in the mental components.

CONCLUSION

Despite the described postoperative symptoms, most of which can be treated conservatively, the Transtar procedure is an effective treatment for patients with obstructive defecation syndrome and improves quality of life significantly.

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.

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.

Dynamic magnetic resonance imaging and transperineal sonography in the assessment of patients presenting primarily with evacuatory difficulty: a short position paper

Patients presenting with primary evacuatory difficulty have a multiplicity of pelvic floor and perineal soft tissue anomalies. The radiological assessment of these patients requires modalities which monitor the dynamic interaction of pelvic organs during provocative manoeuvres such as straining and simulated defaecation. The advantages and disadvantages of these complementary modalities, (dynamic magnetic resonance imaging, dynamic transperineal sonography and dynamic 2- and 3-dimensional endoanal sonography) are provided in this position paper.

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.

Constipation and evacuation disorders

Constipation and evacuation difficulty symptoms are common in the general populace. The ROME III criteria define the latter as a subset of the former. Constipation and defaecatory symptoms rarely occur in isolation and can often form part of a global pelvic floor problem, involving bladder voiding difficulties, sexual dysfunction and pain syndromes. While there is often a functional cause for symptoms, there are a number of organic causes particularly in the elderly that should not be missed. Novel physiological and imaging insights are improving our understanding, and potentially treatment, of these symptoms. Conservative therapies focus on a holistic approach in tandem with evolving drug therapies that target intestinal secretion and transit. The role of the biofeedback specialist is continually being re-defined to an all-encompassing one of physiotherapist, behavioural psychologist and moderator for alternative therapies such as rectal irrigation. Sacral neuromodulation for constipation is an emerging minimally invasive surgical option, although the criteria for patient selection are still to be elucidated. Colectomy for functional constipation is associated with a high morbidity, and gut symptoms often persist, suggesting a global GI phenomenon. Surgical correction of rectocele and intussusception for evacuation difficulty will benefit those with anatomical symptoms; for those with predominantly functional features, surgery is best avoided to prevent a vicious cycle of multiple re-operations.