Stapled trans-anal rectal resection (STARR) is a minimally invasive surgical procedure for conditions such as obstructed defecation syndrome, internal rectal prolapse, and rectocele. Circular surgical staplers are used to resect (remove) sections of the wall of the rectum via the anus. The defects are then closed with surgical staples. A modification of the technique is Contour Transtar. The average age of patients undergoing STARR is about 55 years, and 83% of procedures are carried out on females. The procedure is controversial. The results of many thousands of STARR procedures have been published in research. Proponents state that the procedure is simple, minimally invasive, safe, and effective. Skeptics argue that the complications may be significant (fecal urgency, urge fecal incontinence) or rarely even life-threatening. There is a general trend away from STARR towards ventral rectopexy for surgical treatment of obstructed defecation syndrome.
Indications Surgery may be indicated if there is no response to non-surgical treatments such as diet, laxatives, enemas, and pelvic floor physical therapy for more than 6 months. The main indications for STARR are internal rectal prolapse (internal intussusception) or rectocele in people with obstructed defecation syndrome. Obstructed defecation syndrome has no fixed definition, but encompasses symptoms such as straining during more than 25% of defecation attempts, digitation, sense of incomplete evacuation, laxative abuse, and dependence on enemas more than once per week. In rectocele, female patients might use digital pressure on the anterior perinueum or on the back wall of the lower vagina. This reduces the rectocele pouch and straightens the anorectum, facilitating defecation. In internal rectal prolapse, patients usually apply digital pressure inside the rectum. This involves inserting a finger into the rectum to assist with evacuation. This enables manual reduction of the intussuscepted or prolapsed rectal tissue and facilitates stool passage. Other potential symptoms of obstructed defecation which may be indications for STARR include frequent need to defecate again after evacuation, extended time spent in the toilet, pelvic pressure, rectal discomfort, and perineal pain. Internal rectal prolapse and rectocele often occur together, but not always. In rectocele, the rectal wall balloons out. In internal rectal prolapse, the rectal wall prolapses into the lumen of the rectum. The STARR is therefore able to treat these conditions by removing the redundant area of rectal wall and restoring normal anatomy. STARR has also been used to treat rectal mucosal prolapse, hemorrhoids (when associated with rectal internal mucosal prolapse), and solitary rectal ulcer syndrome (which often occurs with internal rectal prolapse). STARR has also been used for descending perineum syndrome. Up to 50% of people have some detectable degree of internal rectal prolapse when defecography is conducted on healthy volunteers with no symptoms. Rectoceles are detected in 80% of healthy female volunteers on defecography. Some consider defects like internal rectal prolapse and rectocele as consequences of obstructed defecation syndrome, rather than causes. Chronic straining / dyssynergic defecation may be the original and underlying pathology in obstructed defecation. Even if anatomic defects can be detected, they may not be the cause of symptoms. Therefore, simply detecting internal rectal prolapse or rectocele may not be a valid indication for surgery. Surgery may be considered if there is a combination of anatomic abnormalities with the characteristic symptoms of obstructed defecation, and after non surgical treatment has failed. Several optional investigations have been suggested in the assessment of patients for STARR, including clinical evaluation of sphincter function, proctoscopy / sigmoidoscopy, colonoscopy (or barium enema), defecography, small bowel series, colonic transit study, anal manometry (including assessment of rectal compliance and rectal capacity), electromyography, cystourethrogram, and assessment from a gynecologist or urologist.
Contra-indications Dyssynergic defecation (anismus). Enterocele, especially if detectable at rest. Fecal incontinence. Symptoms resulting from other problems such as slow transit constipation or irritable bowel syndrome. External rectal prolapse (complete / full thickness rectal prolapse). Infection in perineal region (e.g. anorectal abscess, anal fistula). Recto-vaginal fistula. Inflammatory bowel disease. Radiation proctitis. Anal stricture (which prevents insertion of stapler). Significant gynecological or urinary pathology which requires combined treatment. Surgical mesh or other foreign material adjacent to rectum. No detectable abnormality. Significant fibrosis in region of rectum. Prior surgical anastomosis in rectum. Psychiatric disorder. STARR is performed without direct vision. Therefore, any structure in the region of the recto-uterine pouch (pouch of Douglas) in females or the rectovesical pouch in males is at risk during the procedure. For example, an enterocele, which is a protrusion of peritoneum containing small intestine between the vagina and the rectum. Enteroceles are fairly common in people with pelvic floor disorders. Some have recommended to use laparoscopy while carrying out STARR for patients with an enterocele. MRI or defecography should demonstrate an enterocele.
… excerpt ends here. Continue reading the full article.
