International Journal of Colorectal Disease

, Volume 19, Issue 4, pp 359–369 | Cite as

New trends in the surgical treatment of outlet obstruction: clinical and functional results of two novel transanal stapled techniques from a randomised controlled trial

  • Paolo Boccasanta
  • Marco Venturi
  • Giovanni Salamina
  • Bruno Mario Cesana
  • Francesco Bernasconi
  • Giancarlo Roviaro
Original Article

Abstract

Background and aims

A randomised trial was undertaken to compare the clinical and functional results of two novel transanal stapled techniques in patients with outlet obstruction syndrome.

Materials and methods

Ninety-six females with outlet obstruction were treated with medical therapy and biofeedback for 2 months; 67 non-responders were evaluated by the Constipation Scoring and Continence Grading Systems, clinical examination, endoscopy, dynamic defecography, anorectal manometry, transanal ultrasound and anal EMG, and 50 of them, all affected with descending perineum, intussusception and rectocele, were randomly assigned to two groups and operated on: 25 patients (mean age 53.2±15.3 years) underwent a single Stapled Trans-Anal Prolapsectomy, associated with Perineal Levatorplasty (STAPL Group), and the other 25 (mean 54.6±14.2 years) underwent a double Stapled Trans-Anal Rectal Resection (STARR Group). Patients were followed-up for a mean period of 23.4±5.1 months in STAPL Group and 22.3±4.8 in STARR Group.

Results

STARR Group showed a significantly (p <0.0001) lower pattern of postoperative pain and a greater decrease (P =0.0117) of the rectal sensitivity threshold volume; otherwise, no differences were found in operative time, hospital stay, or time of inability to work. Complications included delayed healing of the perineal wound (ten), dyspareunia (five), urinary retention (two) and stenosis (one) in STAPL Group, and urge to defecate (four), transitory incontinence to flatus (two), urinary retention (two), bleeding (one) and stenosis (one) in STARR Group. All constipation symptoms significantly improved without worsening of anal continence and with excellent/good outcome at 20 months in 76 and 88% of patients of STAPL Group and STARR Group, respectively. Seven patients of STAPL Group had a little residual rectocele, while both intussusception and rectocele were corrected in all patients of STARR Group. Neither operation modified anal pressures or caused lesions of anal sphincters.

Conclusions

Both techniques are safe and effective in the treatment of outlet obstruction; nevertheless, the double Stapled Trans-Anal Rectal Resection seems to be preferable due to less pain, absence of dyspareunia, reduced rectal sensitivity threshold volume and absence of residual rectocele at defecography.

Keywords

Descending perineum Intussusception Outlet obstruction Rectocele Trans-anal stapled surgery 

References

  1. 1.
    Fucini C, Ronchi O, Elbetti C (2001) Electromyography of the pelvic floor musculature in the assessment of obstructed defecation symptoms. Dis Colon Rectum 44:1168–1175PubMedGoogle Scholar
  2. 2.
    Mellgren A, Bremmer S, Johansson C, Dolk A, Uden R, Ahlback SO, Holmstrom B (1994) Defecography, results of investigation in 2816 patients. Dis Colon Rectum 37:1133–1141PubMedGoogle Scholar
  3. 3.
    Choi JS, Hwang YH, Salum MR, Weiss EG, Pikarsky AJ, Nogueras JJ, Wexner SD (2001) Outcome and management of patients with large rectoanal intussusception. Am J Gastroenterol 96:740–744CrossRefPubMedGoogle Scholar
  4. 4.
    Singh K, Cortes E, Reid WM (2003) Evaluation of the fascial technique for surgical repair of isolated posterior vaginal wall prolapse. Obstet Gynecol 101:320–324CrossRefPubMedGoogle Scholar
  5. 5.
    Watson SJ, Loder PB, Halligan S, Bartram CI, Kamm MA, Phillips RK (1996) Transperineal repair of symptomatic rectocele with Marlex mesh: a clinical, physiological and radiological assessment of treatment. J Am Coll Surg 183:257–261PubMedGoogle Scholar
  6. 6.
    Holmstrom B, Broden G, Dolk A (1986) Results of the Ripstein operation in the treatment of rectal prolapse and internal rectal procidentia. Dis Colon Rectum 29:845–848PubMedGoogle Scholar
  7. 7.
    Bruch HP, Herold A, Schiedeck T, Schwandner O (1999) Laparoscopic surgery for rectal prolapse and outlet obstruction. Dis Colon Rectum 42:1189–1195PubMedGoogle Scholar
  8. 8.
    Orrom WJ, Bartolo DC, Miller R, Mortensen NJ, Roe AM (1991) Rectopexy is ineffective treatment of obstructed defecation. Dis Colon Rectum 34:41–46PubMedGoogle Scholar
  9. 9.
    Boccasanta P, Rosati R, Venturi M, Cioffi U, De Simone M, Montorsi M, Peracchia A (1999) Surgical treatment of complete rectal prolapse: results of abdominal and perineal procedures. J Laparoendosc Adv Surg Tech A 9:235–238PubMedGoogle Scholar
  10. 10.
    Lieberman H, Hughes C, Dippolito A (2000) Evaluation and outcome of the Delorme procedure in the treatment of rectal outlet obstruction. Dis Colon Rectum 43:188–192PubMedGoogle Scholar
  11. 11.
    Zacharin FR, Hamilton NT (1980) Pulsion enterocele: long-term results of an abdominoperineal technique. Obstet Gynecol 2:141–148Google Scholar
  12. 12.
    Longo A (1998) Treatment of haemorrhoidal disease by reduction of mucosa and haemorrhoidal prolapse with a circular stapling device: a new procedure. 6th World Congress of Endoscopic Surgery. Monduzzi, Bologna, pp 777–784Google Scholar
  13. 13.
    Pescatori M, Favetta U, Dedola S, Orsini S (1997) Transanal stapled excision of rectal mucosal prolapse. Tech Coloproctol 1:96–98Google Scholar
  14. 14.
    Altomare DF, Rinaldi M, Veglia A, Petrolino M,De Fazio M, Sallustio PL (2002) Combined perineal and endorectal repair of rectocele by circularstapler: a novel surgical technique. Dis Colon Rectum 45:1549–1552PubMedGoogle Scholar
  15. 15.
    Stuto A, Boccasanta P, Venturi M, Bottini C, Caviglia A, Carriero A, Mascagni D, Mauri R, Sofo L, Landolfi V (2003) Stapled Transanal Rectal Resection (STARR) for obstructed defecation. A prospective multicentric trial. Annual Meeting Abstracts of American Society of Colon and Rectal Surgeons. Dis Colon Rectum 46:A21Google Scholar
  16. 16.
    Agachan F, Chen T, Pfeifer J, Reisman P, Wexner SD (1996) A constipation scoring system to simplify evaluation and management of constipated patients. Dis Colon Rectum 39:681–685Google Scholar
  17. 17.
    Oliveira J, Pfeiffer J, Wexner SD (1996) Physiological and clinical outcome of anterior sphincteroplasty. Br J Surg 83:502–505Google Scholar
  18. 18.
    Mahieu P, Pringot J, Bodart P (1984) Defecography. II. Contribution to the diagnosis of defecation disorders. Gastrointest Radiol 9:253–261PubMedGoogle Scholar
  19. 19.
    Costalat G, Garrigues JM, Drawed F, Noel P, Veyrac M, Vernhet J (1989) Rectopexie antero-posterieure pour troubles de la statique rectale: résultats cliniques et radiologiques. Interet de la rectographie dinamique numerisée. A propos de trente cas. Ann Chir 43:733–743PubMedGoogle Scholar
  20. 20.
    Choi JS, Salum MR, Moreira H Jr, Weiss EG, Nogueras JJ, Wexner SD (2000) Physiologic and clinical assessment of patients with rectoanal intussusception. Tech Coloproctol 4:29–33CrossRefGoogle Scholar
  21. 21.
    Marti MC, Deleaval J, Roche B (1999) Rectoceles: value of videodefecography in selection of treatment policy. Colorect Dis 1:324–329CrossRefGoogle Scholar
  22. 22.
    Basilisco G, Velio P, Bianchi PA (1997) Oesophageal manometry in the evaluation of megacolon with onset in adult life. Gut 40:188–191PubMedGoogle Scholar
  23. 23.
    Sorensen M, Rasmussen O, Tetzschner T, Christiansen J (1992) Physiological variation in rectal compliance. Br J Surg 79:1106–1108PubMedGoogle Scholar
  24. 24.
    Frudinger A, Bartram CI, Halligan S, Kamm M (1998) Examination techniques for endosonography of the anal canal. Abdom Imaging 23:301–303CrossRefPubMedGoogle Scholar
  25. 25.
    Keighley MR, Fielding JW, Alexander-Williams J (1983) Results of Marlex mesh abdominal rectopexy for rectal prolapse in 100 consecutive patients. Br J Surg 70:229–232PubMedGoogle Scholar
  26. 26.
    Duthie GS, Bartolo DC (1992) Abdominal rectopexy for rectal prolapse: a comparison of technique. Br J Surg 79:107–113PubMedGoogle Scholar
  27. 27.
    Sielezneff I, Malouf A, Cesari J, Brunet C, Sarles JC, Sastre B (1999) Selection criteria for internal rectal prolapse repair by Delorme’s transrectal excision. Dis Colon Rectum 42:367–373PubMedGoogle Scholar
  28. 28.
    Brieger GM, Kordan AR, Houghton CR (1996) Abdominoperineal repair of pulsion rectocele. J Obstet Gynaecol Res 22:151–156PubMedGoogle Scholar
  29. 29.
    Boccasanta P, Venturi M, Calabrò G, Trompetto M, Ganio E, Tessera G, Bottini C, Pulvirenti d’Urso A, Ayabaca SM, Pescatori M (2001) Which surgical approach for rectocele? A multicentric report from Italian Coloproctologists. Tech Coloproct 5:147–154Google Scholar
  30. 30.
    Roos P (2000) Haemorrhoid surgery revised (letter). Lancet 355:1648Google Scholar
  31. 31.
    Molloy RG, Kingsmore D (2000) Life-threatening pelvic sepsis after stapled haemorrhoidectomy. Lancet 355:810PubMedGoogle Scholar
  32. 32.
    Herold A, Kirsh JJ (2000) Pain after stapled haemorrhoidectomy (letter). Lancet 356:2187CrossRefGoogle Scholar
  33. 33.
    Murphy KJ (1978) Tetanus after rubber-band ligation of haemorrhoids. BMJ 1:1590–1591Google Scholar
  34. 34.
    O’Hara VS (1980) Fatal clostridial infection following hemorrhoidal banding. Dis Colon Rectum 23:570–571PubMedGoogle Scholar
  35. 35.
    Scarpa FJ, Hillis W, Sabetta JR (1988) Pelvis cellulitis: is a life-threatening complication of hemorrhoidal banding. Surgery 103:383–385PubMedGoogle Scholar
  36. 36.
    Barwell J, Watkins RM, Lloyd-Davies E, Wilkins DC (1999) Life-threatening retroperitoneal sepsis after hemorrhoid injection sclerotherapy. Dis Colon Rectum 42:421–423PubMedGoogle Scholar
  37. 37.
    Maw A, Eu KW, Seow-Chen F (2002) Retroperitoneal sepsis complicating stapled hemorrhoidectomy. Dis Colon Rectum 45:826–828PubMedGoogle Scholar
  38. 38.
    Felt-Bersma RJ, Poen AC, Cuesta MA, Meuwissen SG (1997) Anal sensitivity test: what does it measure and do we need it? Cause or derivative of anorectal complaints. Dis Colon Rectum 40:811–816PubMedGoogle Scholar
  39. 39.
    Ho YH, Ang M, Nyam D, Tan M, Seow-Choen F (1998) Transanal approach to rectocele repair may compromise anal sphincter pressures. Dis Colon Rectum 41:354–358PubMedGoogle Scholar
  40. 40.
    Gosselink MJ, Hop WCJ, Schouten WR (2001) Rectal compliance in females with obstructed defecation. Dis Colon Rectum 44:971–977PubMedGoogle Scholar
  41. 41.
    Piloni V, Pomerri F, Platania E, Pieri I, Pinto F, Gasparini G, Genovesi N, Di Giandomenico E, Grassi R, Salzano A (1994) The National Workshop on Defecography: anorectal deformities with a functional origin (prolapse, intussusception, rectocele). Radiol Med 87:789–795Google Scholar
  42. 42.
    van Laarhoven CJ, Kamm MA, Bartram CI, Halligan S, Hawley PR, Phillips RK (1999) Relationship between anatomic and symptomatic long-term results after rectocele repair for impaired defecation. Dis Colon Rectum 42:204–211Google Scholar
  43. 43.
    Fleshman JW, Dreznick Z, Meyer K, Fry RD, Carney R, Kodner IJ (1992) Outpatient protocol for biofeedback therapy of pelvic floor outlet obstruction. Dis Colon Rectum 35:351–357Google Scholar

Copyright information

© Springer-Verlag 2004

Authors and Affiliations

  • Paolo Boccasanta
    • 1
  • Marco Venturi
    • 1
  • Giovanni Salamina
    • 1
  • Bruno Mario Cesana
    • 2
  • Francesco Bernasconi
    • 3
  • Giancarlo Roviaro
    • 1
  1. 1.1st Department of General Surgery, Ospedale Maggiore di MilanoI.R.C.C.S. University of MilanMilanItaly
  2. 2.Epidemiologic Unit, Ospedale Maggiore di MilanoI.R.C.C.S. University of MilanMilanItaly
  3. 3.Uro-Gynecological DepartmentOspedale Civile di DesioMilanItaly

Personalised recommendations