Quo vadis STARR? A prospective long-term follow-up of stapled transanal rectal resection for obstructed defecation syndrome

Stapled Transanal Rectal Resection (Starr) in the Treatment of Obstructed Defecation: A Systematic Review

Obstructed defecation syndrome (ODS) is a form of constipation that influences the quality of life in most patients and is an important health care issue. In 2004 Longo introduced a minimal invasive trans-anal approach known as Stapled Trans-Anal Rectal Resection (STARR) in order to correct mechanical disorders such as rectocele or rectal intussusception, two conditions present in more than 90% of patients with ODS. Considering the lack of a common view around ODS and STARR procedure. the aim of our study is to review the literature about preoperative assessment, operative features and outcomes of the STARR technique for the treatment of ODS. We performed a systematic search of literature, between January 2008 and December 2020 and 24 studies were included in this review. The total number of patients treated with STARR procedure was 4,464. In conclusion STARR surgical procedure has been proven to be safe and effective in treating symptoms of ODS and improving patients Quality of Life (QoL) and should be taken in consideration in the context of a holistic and multi modal approach to this complex condition. International guidelines are needed in order to optimize the diagnostic and therapeutic process and to improve outcomes.

Post-operative clinical, manometric, and defecographic findings in patients undergoing unsuccessful STARR operation for obstructed defecation

AIM

To evaluate the reason for failure of STARR (stapled transanal rectal resection) operation for obstructed defecation.

METHODS

A retrospective study (June 2012-December 2017) was performed using a prospectively maintained database of patients who underwent STARR operation for ODS (obstructed defecation syndrome), complaining of persisting or de novo occurrence of pelvic floor dysfunctions. Postoperative St Mark's and ODS scores were evaluated. A VAS was used to score pelvic pain. Patients' satisfaction was estimated administering the CPGAS (clinical patient grading assessment scale) questionnaire. Objective evaluation was performed by dynamic proctography and anorectal manometry.

RESULTS

Ninety patients (83.3% females) operated for ODS using STARR technique were evaluated. Median ODS score was 19 while 20 patients (22%) reported de novo fecal urgency and 4 patients a worsening of their preoperative fecal incontinence. Dynamic proctography performed in 54/90 patients showed a significant (> 3.0 cm) rectocele in 19 patients, recto-rectal intussusception in 10 patients incomplete emptying in 24 patients. When compared with internal normal standards, anorectal manometry showed decreased rectal compliance and maximum tolerable volume in patients with urgency. Nine patients reported a persistent postoperative pelvic pain (median VAS score 6).

CONCLUSION

Failure of STARR to treat ODS, documented by persisting ODS symptoms, fecal urgency, or chronic pelvic pain, is often justified by the persistence or de novo onset of alteration of the anorectal anatomy at defecation. This occurs in about half of the patients, but in 40% of the cases who complained of incomplete emptying or incontinence, anatomical abnormalities were not recognized.

Clinical outcomes of stapled transanal rectal resection for obstructed defaecation syndrome at 10-year follow-up

AIM

The long-term efficacy of stapled transanal rectal resection (STARR) for surgical management of obstructed defaecation syndrome (ODS) has not been evaluated. Therefore, we investigated the long-term efficacy (> 10 years) of STARR for treatment of ODS related to rectocele or rectal intussusception and the factors that predict treatment outcome.

METHOD

This study was a retrospective cohort analysis conducted on prospectively collected data. Seventy-four consecutive patients who underwent STARR for ODS between January 2005 and December 2006 in two Italian hospitals were included.

RESULTS

Seventy-four patients [66 women; median age 61 (29-77) years] underwent STARR for ODS. No serious postoperative complications were recorded. Ten years postoperatively, 60 (81%) patients completed the expected follow-up. Twenty-three patients (38%) reported persistent perineal pain and 13 (22%) experienced the urge to defaecate. ODS symptoms recurred in 24 (40%) patients after 10 years. At the 10-year follow-up, 35% of patients were very satisfied and 28% would recommend STARR and undergo the same procedure again if necessary. In contrast, 21% of patients would not select STARR again. Previous uro-gynaecological or rectal surgery and high constipation scores were identified as risk factors for recurrence.

CONCLUSIONS

Stapled transanal rectal resection significantly improves the symptoms of ODS in the short term. In the long term STARR is less effective, however.

STARR with Contour Transtar for Obstructed Defecation Syndrome: Long-Term Results

INTRODUCTION

Obstructed defecation syndrome (ODS) is a widespread and disabling syndrome. With this study, we want to evaluate the long-term results of stapled transanal rectal resection (STARR) performed with Contour Transtar device in the treatment for ODS. A re-evaluation of 113 patients subjected to STARR from June 2007 to January 2010 was conducted.

METHODS

All the patients treated for symptomatic ODS with STARR with Contour Transtar were included in the study. We re-evaluate all patients treated in the study period with clinical examination and specific questionnaire to verify the stability of the functional results and the satisfaction at 5 years from surgery. Constipation was graded using the Agachan-Wexner constipation score; eventual use of aids to defecate and patient satisfaction were assessed preoperatively, 6 months and 5 years after surgery. Long-term complications were also investigated.

RESULTS

Constipation intensity decreased from the preoperative value of 15.8 (±4.9) to 5.2 (±3.9) (p < 0.0001) at 6 months and remained stable after 5 years (7.4 ± 4.1; p < 0.01). Patients who use laxatives and enema decrease from 74 (77%) and 27 (28%) to only 16 (17%; p < 0.001) and 5 (5%; p < 0.001), respectively, at 5-year follow-up. None continue to help themselves with digitations after surgery. Also the satisfaction rate remained stable (3.64 vs 3.81) during the 5 years of the study.

CONCLUSION

The long-term results have demonstrated the efficacy of the STARR with Contour Transtar in treating ODS and the stability over time of the defecatory improvements.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov NCT02971332.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

AIM

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

METHOD

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

RESULTS

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

CONCLUSION

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

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

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

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

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

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

[Transanal procedure for functional bowel diseases]

The transanal operative procedure for the treatment of obstructive defecation syndrome (ODS) can be secondarily applied in cases of failure or ineffectiveness of conservative treatment. Clinically established transanal procedures are rectocele resection (RR), mucosectomy for internal rectal prolapse according to the Rehn-Delorme procedure (MR) and stapled transanal rectal resection (STARR Contour Transtar). Only few studies have indicated the value of RR and MR in the treatment of obstructive diseases and in general study quality and evidence level are low. There might be an indication in rectocele-associated symptoms, such as incomplete evacuation, straining and digitation. In contrast the STARR procedure has been well characterized by a large number of high quality studies providing an elevated evidence level for the treatment of ODS. Functional results are available with a follow-up of 1 year up to 68 months postoperatively. Response rates of up to 90% were reported whereas recurrence rates were given as a maximum of 18% at 68 months follow-up. In summary the STARR procedure provides good functional results for conservative refractory outlet obstruction with minor morbidity and outcome seems to remain stable in the long-term follow-up.

A practical approach to diagnosis and management of functional constipation in adults

Chronic constipation is a frequently complained condition in clinical practice and may be primary (idiopathic) or due to secondary causes. The definition of the various forms of constipation is presently made according to the Rome III criteria, which recently incorporated also specific diagnostic algorithms. The diagnosis of constipation relies on the patient's history, including use of drugs, physical examination, and specific investigations (transit time, anorectal manometry, balloon expulsion test, defecography). These will often be useful to start a targeted therapeutic schedule that may include fibres, laxatives, biofeedback training and, in extreme cases, a surgical approach. This review will analyse the clinical and diagnostic aspects of chronic constipation in adult patients, with emphasis on recent therapeutic approaches.

Stapled transanal rectal resection (STARR) for obstructive defaecation syndrome: patients with previous pelvic floor surgery have poorer long-term outcome

AIM

Stapled transanal rectal resection (STARR) is used for patients with obstructive defaecation syndrome (ODS) not responding to conservative management. Reports indicate mixed results and there are no studies publishing the long-term outcome.

METHOD

Following full investigation, 37 patients with ODS underwent a STARR procedure by one of the authors (SP) between 2005 and 2010.

RESULTS

The median (range) patient age was 53.0 (28-79) years and all were female. Median (range) follow up was 13 (0-57) months, and nine (24.3%) patients were followed for longer than 24 months. Eighteen patients had undergone at least one (and often multiple) previous gynaecological procedures, including hysterectomy (n = 14), colposuspension (n = 3), vaginal rectocele repair (n = 4) and pelvic floor repair (n = 5). Four patients had had at least one previous rectal operation [stapled anopexy (n = 3) and Delorme's procedure (n = 2)]. One patient did not attend for postoperative follow up. Of the remaining 36 patients, 18 had resolution of obstructive symptoms. Of the 18 with residual symptoms, 17 eventually reported the same level of symptoms as before the STARR procedure. There was a significant correlation between the presence of residual symptoms and long-term ODS recurrence (P < 0.0005). For those with residual symptoms, the mean (95% CI) time to symptom recurrence was 3 (2.86-11.81) months. Twenty (56%) patients were satisfied with the outcome from the STARR procedure.

CONCLUSION

Residual symptoms are a strong indicator of long-term failure. STARR was effective for symptom resolution in 50% of patients. Those who had undergone pelvic floor or rectal prolapse surgery were significantly more likely to experience recurrent symptoms.

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.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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