How stapled resection can treat rectal prolapse
Associate Director of Clinical ResearchFeza
Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, OH
The STARR procedure is gaining favor for the treatment of internal prolapse and rectocele.
First introduced in 2004 for treatment of obstructed defecation secondary to outlet dysfunction,1 stapled transanal rectal resection, also called STARR (Ethicon Endo-Surgery, Cincinnati, OH), has since been used for internal rectal prolapse and rectocele. Early results have been encouraging, but more evaluation is needed.
The procedure is mostly used in the management of outlet dysfunction after medical therapy has failed. This article reviews the state of the procedure—the indications and contraindications, and surgical technique.
When STARR is appropriate
Anatomical abnormalities such as rectal intussusception or prolapse, or rectocele with outlet dysfunction, provide a rationale for the procedure.
However, the patient may not always manifest an anatomical cause. In such a case, pain, a sensation of fullness, sense of incomplete defecation, bulging secondary to rectocele, and straining can comprise a symptom complex termed pelvic floor dyssynergia. The exact mechanism is poorly understood, so a number of techniques have been used in its management.
When a structural abnormality that could explain outlet dysfunction is detected, STARR may help in reducing maximum tolerable volume and rectal compliance. Surgical correction can interrupt the rectoanal inhibitory reflex the prolapsing bowel can cause.
How outlet dysfunction occurs
The patient may have an uncoordinated inhibitory pattern, progressing from the pubococcygeus to the puborectalis muscle or external sphincter, or both.2 This patient may benefit from biofeedback. When the internal intussusception extends to the anal canal, described as internal prolapse, sometimes combined with rectocele, surgery may provide a resolution.
Differentiating the type of rectal prolapse is important to ensure the appropriate treatment. The key types are:
Internal (hidden or occult) prolapse, or intussusception, occurs when the rectum intussuscepts but does not pass beyond the anal canal.
Mucosal prolapse results from loosening of the submucosal attachments to the muscularis propria of the distal rectum. It may present with hemorrhoidal disease.
Complete rectal prolapse, or procidentia, is a full-thickness protrusion of the wall of the rectum through the anal sphincters.
Internal mucosal prolapse. Various grades of severity exist,3 and circumferential prolapse may be a key cause of evacuatory difficulty.4,5 Its pathophysiologic relationship to full-thickness rectal prolapse and solitary rectal ulcer syndrome (SRUS), however, is controversial.
The surgeon’s options
Options for prolapse include abdominal procedures, such as rectopexy and resection rectopexy, Delorme’s excision (resection of the redundant mucosal sleeve via a perineal approach), and a perineal proctosigmoidectomy or Altemeier procedure. In the patient with internal rectal prolapse, the limited degree of tissue intussusception precludes perineal proctectomy.
STARR attempts to resect the full thickness of the rectal wall with the transanal application of two circular staplers.
Transanal, transperineal, and transvaginal approaches may also help manage rectocele. Psychological factors such as anxiety and depression can contribute to symptoms, so selecting a therapy for a specific patient can be difficult.6
STARR involves resection of the full thickness of the rectal wall with the transanal application of two circular staplers—one placed anteriorly, the other posteriorly.
Evaluating the patient
The preoperative examination for STARR includes evaluating sphincter function for rectocele, intussusception, perineal descent, and anal prolapse. Colonoscopy or barium enema would rule out other pathology.
Defecography can demonstrate associated anatomic abnormalities. Dynamic MRI is an alternative. Authors have questioned the use of defecography because it shows rectal intussusception is a common finding, even in normal patients,7 and can reveal insignificant abnormalities.8
Other options, depending on symptoms, can include vaginography, transit study, anal manometry (rectal compliance or capacity, electromyography [EMG], and voiding cystourethrogram), and gynecologic or urologic pelvic assessment.
Indications for STARR
The Consensus Conference on the Stapled Transanal Rectal Resection described these characteristic symptoms as potential indications for the procedure:9
Prolonged or repeated straining during evacuation.
Frequent calls to defecate before or after evacuation.
Digital means to effect evacuation.
Laxative or enema use, or both.
Sensation of incomplete evacuation.
Excessive time spent in the toilet.
Pelvic pressure, rectal discomfort, and perineal pain that have failed prior conservative treatment.
Contraindications include external full-thickness rectal prolapse (procidentia) and perineal infection (abscess or fistula).
Exclusion criteria for the procedure are:
External full-thickness rectal prolapse (procidentia).
Perineal infection (abscess, fistula).
Inflammatory bowel disease (including proctitis).
Anal incontinence (Wexner Score more than 7).9
Anal stenosis precluding insertion of the stapling device.
Enterocele at rest.
Significant gynecological or urinary pelvic floor abnormality requiring combined treatment.
Foreign material such as mesh adjacent the rectum.
Absence of anatomical or physiological abnormality associated with outlet dysfunction syndrome.
Intraoperative technical factors that preclude a safe operation.
Severe rectal or perirectal fibrosis.
Prior rectal anastomosis.
Before the procedure, the patient is given an enema and begins antibiotic prophylaxis. The patient is placed in the lithotomy position. The surgeon uses the specialized circular stapling device with a disposable circular anal dilator.
Introducing the dilator
The anal verge is progressively dilated with 2 fingers for 60 seconds and 4 radial stitches are placed on the perineal skin to gain better exposure. The lubricated obturator of the dilator is introduced then left in place for 60 seconds. Finally, the lubricated dilator is introduced into the anal canal and retained in place by securing the previously applied sutures (FIGURE 1).
FIGURE 1 Inserting the dilator
After the anal verge is dilated digitally, the lubricated dilator is introduced and retained in place by securing the previously applied sutures. (Figures reprinted with permission of Cleveland Clinic Center for Medical Art & Photography © 2008. All rights reserved.)
A spatulated retractor placed through the lower opening of the anal dilator into the anal canal protects the posterior wall of the rectum (FIGURE 2). Inserting gauze facilitates prolapse of the rectal mucosa. The gauze is then withdrawn gradually.
FIGURE 2 Placing purse-string sutures
A spatulated retractor protects the posterior wall as purse-string sutures are placed at the 10, 12, and 2 o’clock positions. (Illustration by Maura Flynn)
Applying the sutures
Three 2-0 prolene purse-string sutures are placed at the apex of the prolapse at 10, 12, and 2 o’clock traversing the mucosa, submucosa, and rectal muscle wall over half the rectal circumference. The circular stapler is then introduced into the rectum and the open head is positioned above the most proximal suture.
Traction applied to the sutures prolapses the rectal wall into the stapler, which is then discharged to incorporate the shelf the previously placed sutures created (FIGURE 3). Before firing, fingers placed into the vagina help prevent entrapment of the posterior vaginal wall into the stapler. Including the posterior rectal wall into the staple line is also carefully avoided. The stapler is then gently withdrawn.
FIGURE 3 Suturing the prolapse
After the head of the circular stapler is inserted, traction applied to the sutures prolapses the rectal wall into the stapler, which is discharged to incorporate the previously created shelf.
The procedure is then repeated on the posterior rectal wall (FIGURE 4) with the retractor placed in the upper opening of the dilator and the 3 sutures in the residual prolapse of the posterior circumference.
FIGURE 4 The posterior application
The procedure is repeated on the posterior rectal wall. The retractor is placed in the upper opening of the dilator and three sutures are placed in the residual prolapse.
Hemostatic sutures are placed incorporating the staple line anteriorly and posteriorly. When firing the stapler, the surgeon must take care to avoid tissue overload, which can divide the tissue without placing the staples. This would result in a full-thickness injury to the rectal wall.
Modifications of the procedure
Authors have described the use of the circular stapling device for the patient with incomplete rectal prolapse.10,11 The enteroentero anastomosis circular stapler may be especially useful in the patient with a deep gluteal cleft and narrow distance between the ischial tuberosities. The circular stapler may also achieve combined perineal and endorectal repair of rectocele.12
Complications of STARR
Complications have included urinary retention, rectal bleeding, anal pain, fecal incontinence, rectovaginal fistula, and recurrence of rectocele.
Reports have documented postoperative problems such as urinary retention, rectal bleeding, anal pain, fecal incontinence, rectovaginal fistula, recurrence of the rectocele, intussusception, and symptoms of obstructed defecation.13,14 Urgency and frequency and persistent discomfort from residual staples have also been reported.
Because the resection is a full-thickness approach and involves the anorectal area, the risk exists of dehiscence of the staple line, peritonitis, pelvic and retroperitoneal sepsis, and necrotizing fasciitis.
Results so far
Problems due to heterogeneity of patient population and disassociation between symptom constellation, findings, and cause have made it difficult to interpret outcomes with various therapies.
In the only report of long-term follow-up, none of the 8 patients had recurrence of mucosal rectal prolapse.
One prospective multicenter trial15 evaluating STARR for outlet obstruction reported a significant improvement of all symptoms of constipation with improved constipation scores, minimal postoperative pain at 1 week, high patient satisfaction with improvement over 1 year of follow-up, and no dyspareunia.
However, these results were obtained in patient groups carefully selected by clinical and radiologic criteria, and who had failed with medical therapy, including diet and biofeedback, for 2 months. The complications in this group included:
Fecal urgency, 17.8%.
Incontinence to flatus, 8.9%.
Urinary retention, 5.5%.
Anastomotic stenosis, 3.3%.
A randomized controlled trial comparing STARR16 with stapled transanal prolapsectomy combined with perineal levatorplasty showed that both procedures were effective in the treatment of outlet dysfunction. STARR was associated with lower pain, dyspareunia, reduced rectal sensitivity threshold volume, and residual rectocele at defecography.
Evaluating the evidence for STARR
For patients with symptoms of obstructive defecation an adequate trial of conservative treatment is essential. Level of evidence: 3b—based on individual case-control study.
In the absence of contraindications, stapled transanal rectal resection can be offered to patients with obstructive defecation and a demonstrable rectal prolapse. Level of evidence—3b.
The procedure has had early and mid-term results comparable to conventional surgical techniques with less postoperative pain and shorter length of hospital stay. Level of evidence: 2b—based on individual cohort study.—RPK, FHR
STARR for prolapse
A retrospective study comparing the circular transanal stapled procedure with the conventional excisional technique for partial mucosal prolapse reported shorter surgery times, reduced analgesia use, shorter hospital stays for the stapled group despite similar incidence of early and late complications, and early functional outcome.10
Another randomized controlled trial comparing STARR with stapled hemorrhoidopexy in patients with association of prolapsed hemorrhoids and rectal prolapse reported STARR provided a more complete resection of prolapsed tissue with equal morbidity and significantly lower incidence of residual disease and skin-tags.17
Among patients with rectal internal mucosal prolapse having the procedure, 45% had postoperative complications, 32.5% required a reoperation, 52% had recurrent constipation, 65% had recurrent rectal internal mucosal prolapse, and 5% complained of fecal incontinence.18
However, most reports of the procedure have had short follow-up. In the only report that described the long-term result of the STARR procedure for rectal prolapse, after a median follow-up of 67 months in 8 patients, no recurrence of mucosal rectal prolapse had been reported.19
The authors had no relationships to disclose.
Obstructed defecation because of rectal pathologies. Novel surgical treatment: stapled transanal resection (STARR).
Annual Cleveland Clinic Florida Colorectal Disease Symposium. January 2005; Ft. Lauderdale, FL.
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