Stapled Transanal Rectal Resection (Starr) to Reverse the Anatomic Disorders of Pelvic Floor Dyssynergia

Abstract

Anterior rectocele and rectoanal intussusception are anatomic disorders related to excessive straining during defecation that usually manifest with symptoms of obstructive defecation. Stapled transanal rectal resection (STARR), a newly described surgical method for correcting these disorders, is considered a good alternative to the traditional transrectal approaches. The aim of the present study was to assess the early postoperative functional results of STARR. A total of 16 patients (13 female) were subjected to the STARR procedure during a period of 12 months. The presence of anatomic disorders of the anorectum was verified by dynamic defecography. Preoperative assessment also included colonic transit time, anal sphincter ultrasonography, and anorectal stationary manometry. Postoperative assessment included the same battery of tests. Altogether, 12 patients had rectoanal intussusception of > 2 cm and rectocele. In eight of them the anterior component of the rectocele was 2 to 4 cm, and in four it was > 4 cm. Four patients had a 1- to 2-cm internal intussusception and a rectocele of < 2 cm. All of them reported evacuation difficulties, but none had significant incontinence. Preoperative endoscopy did not reveal the presence of a solitary ulcer in any of the patients. All females had had normal vaginal deliveries, and four of them were multiparous. No complications were encountered postoperatively, and the need for analgesics was minimal. At defecography, rectoanal anatomy was seen to be restored in all patients. Obstructive defecation symptoms remained rather unaffected in seven, disappeared in three, and improved significantly in the remaining six patients. The seven failures showed anismus at manometry and had biofeedback treatment with satisfactory results in five of them. Failure of the operation and biofeedback sessions to treat symptoms in those two cases was attributed to coexisting enterocele, which had been missed preoperatively. Immediately after surgery, most of the patients complained of urgency and frequent small motions that resolved spontaneously within 3 to 5 weeks in all but two cases. STARR is a safe, well tolerated surgical procedure that effectively restores anatomy and function of the anorectum in patients with anterior mucosal prolapse and rectoanal intussusception. Additional biofeedback treatment is usually necessary for further functional improvement. Failure may be the result of other coexisting anatomic and functional abnormalities of the pelvic floor.

The Impact of Stapled Transanal Rectal Resection on Anorectal Function in Patients with Obstructed Defecation Syndrome

“…22,[33][34] These conflicting observations are explained by the limited clinical use of STARR, as the literature accounts for fewer than 400 patients. These patients were recruited by different institutions that lack not only uniform inclusion/exclusion criteria but also expertise in stapler-assisted transanal surgery.…”

Long-Term Follow-Up of Simultaneous Abdominoperineal Repair of Enterorectocele and Internal Mucosal Prolapse

“…When surgery is aimed at treating either enterocele or rectocele as an isolated lesion, it is unlikely to cure constipation, even when the anatomical disorder is corrected. 5,6,13,24 Occult rectal prolapse on straining is detected in 50 percent of normal subjects 25 but is present in 96 percent of patients with obstructed defecation. 1 However, constipation is relieved in just half of the cases when only prolapse excision is carried out.…”

Short-term outcomes after anterior stapling rectotomy using a single stapler device for rectocele

“…In 2004, a study on STARR revealed that 90% of cases with ODS reported their overall satisfaction after STARR as good to excellent and only 4% of patients were described as poor [14]. In terms of efficacy, many studies showed an improvement of symptoms of obstruction after the procedure [12][13][14][15][16]. Results with STARR have been good.…”