Stapled Transanal Rectal Resection (STARR) for Rectocele

Patients with obstructed defecation complain of an inability to initiate rectal emptying, incomplete evacuation, pelvic pressure or excessive straining at stool. The pathophysiologic features of obstructed defecation include an increased anterior-posterior diameter of the rectum, decreased rectal compliance and an increased sensory threshold volume. Recently, there has been interest in the transanal resection of the rectum for obstructed defecation with the developement of endoanal staplers and techniques specifically for these purpose. Stapled transanal rectal resection (STARR), in the only large series reported, decreased the anterior-posterior diameter of the rectum, restored rectal compliance and decreased the rectal sensory threshold with an associated improvement in incomplete evacuation in 81.1%, digital assistance to defecate in 83.4%, pelvic pain in 43.3%, and the need for laxatives 43.3% of patients. Risks of the procedure included stenosis in 3.3%, urgency in 1.1% and incontinence of flatus in 1.1% of patients. These data suggest that the STARR procedure is an effective management option for obstructed defecation with an acceptable risk of complications.     

Intervention de STARR (Stapled Trans-Anal Rectal Resection)

STARR procedure is a safe approach for the treatment of obstructed defaecation syndrome. The anatomical correction of the rectocele and/or the intussusception can achieve a complete rectal vacuity during defaecation. This minimally invasive approach requires a high patient selection and respect of different surgical steps to offer the patients sustained improvement in obstructed defaecation.     

STARR手术治疗排便障碍综合征的临床疗效观察

目的探讨STARR手术治疗排便障碍综合征的临床效果和安全性。方法对23例排便障碍综合征患者采取STARR手术治疗的临床资料进行回顾性分析。结果术后20例患者临床症状缓解,其中19例患者直肠前突及直肠内脱垂得到改善,有效率87%。结论 STARR是一种安全有效的治疗排便障碍综合征的手术方法,术后并发症较少。     

Modified Stapled Transanal Rectal Resection (Starr) for Full Thickness Excision of Rectal Tumour

Introduction

Traditionally, adenomatous rectal lesions and unexpected malignant polyps that could not be removed endoscopically are referred to surgery. Local excision is the treatment of choice, and several techniques have been proposed. The choice of the approach requires that the tumour is excised intact, with a low recurrence rate and limited morbidity. Local excision can be a straight forward or conversely a demanding procedure due to the restricted space in which the surgeon must work and the difficulty of achieving a satisfactory exposure.

Methods

We describe a modified stapled transanal rectal resection for the excision of flat lesions with a diameter up to 2 cm and located between 5 and 12 cm from the anal verge.

Discussion and Conclusion

In our experience, it is quick, simple, and easy to teach but it has not previously been reported. It provides full thickness resection with adequate lateral margins. It overcomes some of the limits of the incomplete surgical field exposure and difficult manipulation, since after the confectioning of double half purse-string suture, the suture and sectioning is made by the stapler device.     

STARR手术治疗排便障碍综合征的临床研究

目的探讨STARR手术治疗排便障碍综合征（ODS）的临床疗效及并发症。方法将60例ODS患者随机分为治疗组、对照1组和对照2组,每组20名患者。治疗组采用STARR手术,对照1组采用PPH术,对照2组采用经阴道直肠前突修补术（荷包法）。观察、比较3组患者手术时间、出血量、住院时间、并发症、治疗效果等指标。结果治疗组与对照1组术后ODS评分、有效率、手术时间差异有统计学意义;治疗组手术时间、出血量少于对照2组的相关指标,差异有统计学意义。结论STARR手术治疗排便障碍综合征疗效肯定。     

吻合器经肛直肠切除术与经阴道手术治疗直肠前突的比较

目的经肛吻合器直肠切除术(STARR)与桥式缝合术分别是经肛门、经阴道治疗直肠前突较新的术式,本研究拟对这两种术式进行比较。方法回顾性分析2007年1月至2009年5月期间因直肠前突排便困难接受手术的住院患者的临床资料,根据不同手术途径分为STARR组(n=18)和桥式缝合组(n=13),对2组患者手术后症状改善情况、手术时间、出血量、住院时间、费用、并发症等进行比较。结果STARR组排便困难显著改善11例,明显改善5例,桥式缝合组显著改善4例,明显改善2例,STARR组总改善率(88.9%)高于桥式缝合组(46.2%),P=0.017。STARR组平均手术时间为24.6min,平均出血量为3.9ml,平均住院费用为10743元;桥式缝合组平均手术时间为33.2min,平均出血量为16.2ml,平均住院费用为3543元,STARR组的这3项指标小于(多于)桥式缝合组(P0.01)。2组住院时间相近,STARR组术后有2例出现轻度肛门失禁,3个月后自然恢复。结论STARR对改善排便困难疗效优于阴道后壁桥式缝合术,但也有缺点,如费用高,术后短期内有的患者发生轻度肛门失禁,但能够自行恢复。     

Disappointing Long-Term Outcomes After Stapled Transanal Rectal Resection for Obstructed Defecation

Background  

The aim of this study was to assess both short and long-term functional outcomes and the quality of life of patients treated with stapled transanal rectal resection (STARR) for obstructed defecation syndrome (ODS).     

Stapled Transanal Rectal Resection for Outlet Obstruction Syndrome: Results and Follow-up

BACKGROUND: The objective of the present study was to assess safety, effectiveness, and long-term outcomes of stapled transanal rectal resection (STARR) for the cure of outlet obstruction syndrome (OOS). METHODS: Data were collected over a 3-year period (2004-2007), at the Department of Surgery of the University of Genoa, from 25 consecutive subjects (19 of them females) undergoing STARR because of OOS that had not responded to medical treatment,. RESULTS: Preoperatively, patients were submitted to clinical examination, defecography, colonoscopy, manometry, and recto-anal reflexes determination. All patients had mucosal prolapse, 15 rectal intussusception, 15 rectocele. Postoperatively no deaths were observed; one patient had a hemorrhage requiring reintervention. Mean time to resumption of normal activity was 8.5 +/- 4.5 days. Patients were followed for a mean of 24.7 +/- 10.9 months (range: 6-42 months). Late specific complications included 3 cases of urge to defecate, 8 of incontinence to flatus. Functional outcome was positive for 22 patients (excellent in 4 cases, good in 15, fairly good in 3). Six months postoperatively (25 s), patients had improvement of the mean Constipation Score (p = 0.0002), less pain during evacuation (p = 0.0003), and reduced use of digital assistance to defecate (p < 0.0001). Continence Grading Scale and enema use remained stable after intervention. Patients had increase in basal sphincter pressure (p = 0.0078) and maximal squeeze pressure (p = 0.0051). Recto-anal reflex study showed increase in abdominal pain threshold (p < 0.0001); anal sphincter relaxation threshold and desire to defecate threshold did not change. CONCLUSIONS: According to the present study, STARR seemed to be a safe and effective treatment for OOS associated with symptomatic rectocele and intussusception.     

Rectovaginal Fistula: A New Approach By Stapled Transanal Rectal Resection

Many surgical procedures have been developed to repair rectovaginal fistulas even if no “procedure of choice” is reported. The authors report a case of relatively uncommon, complex, medium-high post-obstetric rectovaginal fistula without sphincteral lesions and treated with a novel tailored technique. Our innovative surgical management consisted of preparing the neck of the fistula inside the vagina and folding it into the rectum so as to enclose the fistula within two semicontinuous sutures (stapled transanal rectal resection); no fecal diversion was performed. Postoperative follow-up at 9 months showed no recurrence of the fistula.     

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

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.     

Decision-making algorithm for the STARR procedure in obstructed defecation syndrome: position statement of the group of STARR Pioneers

Internal rectal prolapse (rectal intussusception) and rectocele are frequent clinical findings in patients suffering from refractory constipation that may be best characterized as obstructive defecation syndrome. However, there is still no clear evidence whether the stapled transanal rectal resection (STARR) procedure provides a safe and effective surgical option for symptom resolution in patients with obstructive defecation syndrome, as evidence-based guidelines and functional long-term results are still missing. On the basis of the need for objective evaluation, a European group of experts was founded (Stapled Transanal Rectal Resection Pioneers). Derived from 2 meetings (October 26-28, 2006, Gouvieux, France and November 28-29, 2007, St Gallen, Switzerland) a concept for treatment options in patients suffering from obstructive defecation syndrome was developed, including a clear decision-making algorithm specifically focusing on the role of the stapled transanal rectal resection procedure based on clinical symptoms and dynamic imaging and inclusion and exclusion criteria for the stapled transanal rectal resection procedure.     

Stapled transanal rectal resection (STARR): a new option in the treatment of obstructive defecation syndrome

Background Rectocele and distal intussusception are organic causes of outlet obstruction. A new surgical option called the stapled transanal rectal resection (STARR) is described within a prospective study. Patients and methods Fourteen patients with symptomatic rectocele (four females), rectocele with coexistent intussusception (eight females), and intussusception (two males) underwent STARR procedure. The symptoms were measured by means of a defecation score (0–20 points). Results Complications included local bleeding postoperatively in two cases, and temporary ischuria in four cases. The subjective sense of pain was low; from day 1 postoperatively five patients did not need any analgetics. Only one female patient had prolonged pelvic pain, without any organic reason. All patients showed improvement in rectal evacuation. The mean score of defecation (0–20 points) decreased from 13±3 to 4±3 after 1 month (p<0.05) and remained low. The overall follow-up was 19±9 months. Only one male patient with intussusception had defecation disorder again 6 months after surgery. Three patients had temporary urge incontinence. Conclusion STARR is an effective therapy for obstructive defecation disorder due to a symptomatic rectocele and/or a distal intussusception.     

STARR手术治疗排便梗阻综合征临床疗效分析

目的评价经肛吻合器直肠切除术(STARR)治疗排便梗阻综合征(ODS)的临床疗效。方法回顾性分析行STARR手术治疗ODS 18例的临床资料。结果本组患者平均随访时间38个月(4~68个月),术前ODS评分从14.5±4.9到术后3个月降至5.9±5.0。随访期间,术后便秘症状改善61.1%(11例),无效16.7%(3例),术后复发22.2%(4例),其中2例再次行手术治疗,1例再次行STARR手术治疗,1例行结肠切除回直肠吻合,术后便秘症状改善。术后并发症:急便感11.1%(2例),肛门坠胀11.1%(2例),无术后出血、感染、直肠阴道瘘、直肠狭窄等重大并发症。随访期间未见肛门失禁。术后治疗满意度72.2%。结论 STARR手术治疗ODS安全有效,创伤小,恢复快,并发症少。     

Transanal Inside-Out Rectal Resection for Ultra-Low Rectal Cancer

ABSTRACT

Two major issues encountered in the surgical resection of low rectal cancers (tumor located <6 cm from anal verge) are tumor-free surgical resection margin and adequate fields of colo-anal pull-through anastomosis. The clinical consequences of ensuring gross tumor-free surgical resection margin by transanal inside-out rectal resection technique were assessed for ultra-low rectal cancer patients. From February 2009 to September 2011, ultra-low anterior resection with a new method of eversion of the rectum through the anal canal after resecting the distal rectum and colo-anal anastomosis extracorporally performed in 30 patients (age range, 41–80 years) was reviewed. All patients received preoperative neoadjuvant concurrent chemoradiotherapy (CCRT) before the surgical resection. The median operating time was 265 min (range, 220–400 min), and the median intraoperative blood loss was 325 ml (range, 80–855 ml). No in-hospital mortality was noted among these patients. R0 resection (tumor-free margin range, 0.9–2.5 cm) was confirmed in all patients by pathologic reports, except one patient with 0.5 cm tumor-free margin. The new surgical technique of transanal inside-out rectal resection and colo-anal pull-through anastomosis for selected patients with ultra-low rectal cancers seems to be a safe and alternative procedure.     

Repair of rectocele using the Stapled TransAnal Rectal Resection (STARR) technique: intermediate results from a multicenter French study

BACKGROUND: Stapled transanal rectal resection is a new alternative for the treatment of outlet obstruction syndrome. The aim of this study was to assess its feasibility and safety in a multicenter context. MATERIALS AND METHOD: The study had a retrospective design and included 102 patients who were operated in 5 centers. All patients complained of symptomatic outlet obstruction. Surgical technique involved a double hemi-circumferential rectal stapling according to the technique described by Longo. Mean follow-up was 17.2 months. RESULTS: The STARR procedure was done in 100 patients (2 patients had a non relaxing sphincter preventing anal dilatation). Immediate postoperative morbidity included bleeding in 4 cases (4%) and rectal stenosis in 3 cases (3%). The main postoperative medium-term complaints were urge to defecate (34%) which was regressive in most patients and de novo incontinence to flatus (9%). Nevertheless, results were considered favorable in 85% of patients. CONCLUSION: This multicenter study, reporting the results of the largest published series, suggests that the STARR technique is feasible and safe in the medium term for the treatment of rectocele. Occurrence of adverse events such as incontinence to flatus should be better evaluated by future studies with longer follow up in order to assess the actual place of STARR in the treatment of rectocele or outlet obstruction.