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      Stapled Transanal Rectal Resection for the Surgical Treatment of Obstructed Defecation Syndrome Associated with Rectocele and Rectal Intussusception

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      1 , 2 , *
      ISRN Surgery
      International Scholarly Research Network

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          Abstract

          Obstructed defecation syndrome (ODS) is one of the most widespread clinical problems which frequently affects middle-aged females. There is a new surgical technique called stapled transanal rectal resection (STARR) that makes it possible to remove the anorectal mucosa circumferential and reinforce the anterior anorectal junction wall with the use of a circular stapler. This surgical technique developed by Antonio Longo was proposed as an effective alternative for the treatment of ODS. In this study we present our preliminary results with the STARR operation for the treatment of ODS. For this purpose, 40 consecutive female patients with ODS due to rectal intussusception (RI) and/or rectocele (RE) were recruited in this prospective clinical study, from May 2008 to October 2010. No major operative or postoperative complications were recorded, and after 12-month follow-up, significant improvement in the ODS score system was observed, and the symptoms of constipation improved in 90% of patients; 20% of patients judged their final clinical outcome as excellent, 55% as good, and 15% as moderate, with only 10% having poor results. After analyzing our results we can conclude that STARR is an effective and safe procedure for the treatment of obstructed defecation syndrome due to rectal intussusception and/or rectocele and can be performed safely without major morbidity.

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          Most cited references32

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          Results, outcome predictors, and complications after stapled transanal rectal resection for obstructed defecation.

          Obstructed defecation may be treated by stapled transanal rectal resection, but different complications and recurrence rates have been reported. The present study was designed to evaluate stapled transanal rectal resection results, outcome predictive factors, and nature of complications. Clinical and functional data of 123 patients were retrospectively analyzed. All patients had symptoms of obstructed defecation before surgery and had rectocele and/or intussusception. Of them, 85 were operated on by the authors and 38 were referred after stapled transanal rectal resection had been performed elsewhere. At a median follow-up of 17 (range, 3-44) months, 65 percent of the patients operated on by the authors had subjective improvement. Recurrent rectocele was present in 29 percent and recurrent intussusception was present in 28 percent of patients. At univariate analysis, results were worse in those with preoperative digitation (P<0.01), puborectalis dyssynergia (P<0.05), enterocele (P<0.05), larger size rectocele (P<0.05), lower bowel frequency (P<0.05), and sense of incomplete evacuation (P<0.05). Bleeding was the most common perioperative complication occurring in 12 percent of cases. Reoperations were needed in 16 patients (19 percent): 9 for recurrent disease. In the 38 patients referred after stapled transanal rectal resection, the most common problems were perineal pain (53 percent), constipation with recurrent rectocele and/or intussusception (50 percent), and incontinence (28 percent). Of these patients, 14 (37 percent) underwent reoperations: 7 for recurrence. Three patients presented with a rectovaginal fistula. One other patient died for necrotizing pelvic fasciitis. Stapled transanal rectal resection achieved acceptable results at the cost of a high reoperation rate. Patients with puborectalis dyssynergia and lower bowel frequency may do worse because surgery does not address the causes of their constipation. Patients with large rectoceles, enteroceles, digitation, and a sense of incomplete evacuation may have more advanced pelvic floor disease for which stapled transanal rectal resection, which simply removes redundant tissue, may not be adequate. This, together with the complications observed in patients referred after stapled transanal rectal resection, suggests that this procedure should be performed by colorectal surgeons and in carefully selected patients.
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            Stapled transanal rectal resection for outlet obstruction: a prospective, multicenter trial.

            This prospective, multicenter trial was designed to assess the safety and effectiveness of a novel technique in the treatment of outlet obstruction caused by the combination of intussusception and rectocele by using a double-transanal, 33-mm circular stapler. From January to October 2001, 90 patients with outlet obstruction were operated on and followed (mean, 16.3 +/- 2.9 months) by the validated Constipation Scoring and Continence Grading Systems, clinical examination, defecography, and anorectal manometry. Anal ultrasound also was performed in 58 multiparous patients. Operative time and hospital stay were short (mean, 43.3 +/- 8.7 minutes and 2.1 +/- 0.8 days, respectively), and postoperative pain was minimal. The mean time to resume normal activity was 10.2 +/- 4.5 days. Complications were 17.8 percent fecal urgency, 8.9 percent incontinence to flatus, 5.5 percent urinary retention, 4.4 percent bleeding, 3.3 percent anastomotic stenosis, and 1.1 percent pneumonia. All constipation symptoms significantly improved (P < 0.001) without worsening of anal continence. No patient complained of dyspareunia. At postoperative defecography, all patients had a double incisure of the lower rectal outline in the site of anastomosis, with the disappearance of both intussusception and rectocele. Anal pressure was not significantly modified, whereas rectal compliance was restored (P < 0.05). No lesions of anal sphincters caused by the operation were found in multiparous patients. The outcome at one year was excellent in 48 of 90 patients, good in 33, fairly good in 5, and poor in 4. This novel technique seems to be safe and effective in the treatment of outlet obstruction caused by the combination of intussusception and rectocele. Randomized trials are required to confirm these findings.
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              Stapled transanal rectal resection for obstructed defecation syndrome: one-year results of the European STARR Registry.

              Stapled transanal rectal resection is advocated for the treatment of obstructed defecation syndrome. Supporting evidence for its safety and effectiveness has been lacking. To address this, the European Stapled Transanal Rectal Resection Registry was initiated in January 2006. This study was designed to analyze 12-month postoperative outcomes of this procedure using data collected in the registry. On May 17, 2008, data were downloaded from the Stapled Transanal Resection Registry to perform an analysis of 12-month outcomes. Data had been collected prospectively on effectiveness (symptom severity and obstructed defecation scores), quality of life, incontinence, and safety profile at baseline, 6 weeks, 6 months, and 12 months. A total of 2,838 patients were entered into the registry, of whom 2,224 had reached 12 months of follow-up. Mean age was 54.7 years. A total of 2,363 patients (83.3%) were female. A significant improvement was seen in obstructive defecation and symptom severity scores and quality of life between baseline and 12 months (obstructed defecation score: 15.8 vs. 5.8, respectively, P < 0.001; symptom severity score: 15.1 vs. 3.6, respectively, P < 0.001). Complications were reported in 36.0% and included defecatory urgency (20.0%), bleeding (5.0%), septic events (4.4%), staple line complications (3.5%), and incontinence (1.8%). One case of rectal necrosis and one case of rectovaginal fistula were reported. Stapled transanal rectal resection produces improved function and better quality of life for patients with obstructed defecation that is maintained at 12 months of follow-up. Further investigation is required to optimize patient selection and reduce the potential complications of postoperative defecatory urgency and pain.
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                Author and article information

                Journal
                ISRN Surg
                ISRN Surg
                ISRN.SURGERY
                ISRN Surgery
                International Scholarly Research Network
                2090-5785
                2090-5793
                2012
                25 March 2012
                : 2012
                : 652345
                Affiliations
                1Department of General Surgery, Ain Shams University, Cairo, Egypt
                2Department of Obstetrics and Gynecology, AL-Azhar University, Cairo, Egypt
                Author notes

                Academic Editors: A. H. Al-Salem, A. Halevy, and A. Petroianu

                Article
                10.5402/2012/652345
                3346690
                22577584
                9d144b21-48d5-4b33-8bd3-ce61786e4fa1
                Copyright © 2012 H. M. Hasan and H. M. Hasan.

                This is an open access article distributed under the Creative Commons Attribution License, that permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 9 December 2011
                : 19 January 2012
                Categories
                Clinical Study

                Surgery
                Surgery

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