Stapled Trans-Anal Rectal Resection has been proposed for the treatment of the ODS in the presence of internal rectal prolapse (rectal intussusception) and associated rectocele. This is the first report with medium-term results of this technique performed with the new Contour® Transtar™ Curved Cutter Stapler. The device has been developed to overcome the potential drawbacks of the original STARR using the haemorrhoidal stapler (PPH 01). This procedure is technically demanding and there is a learning curve period during which resection is difficult in about a tenth of cases. In the present trial, the procedure had a low postoperative morbidity (7%) and reduced obstructed defecation in all patients. More than 90% of our patients had an anterior rectocele while only 8% had an enterocele. Our main inclusion criterion was a full-thickness internal rectal prolapse associated with ODS.
The new device effectively allows a full-thickness resection of the entire rectal circumference. This was consistent with the mean size and weight of the specimens obtained, which were at least twice the weight of a standard double-stapler specimen. The length of rectal wall to be resected may be tailored to the patient’s anatomy and surgeon’s choice and is not limited by the device. It is not known whether resecting more tissue will improve the functional outcomes further but the technique with the Contour® Transtar™ instrument proved satisfactory in our hands. It was however found to be more demanding than the procedure with the conventional STARR PPH instrument. Dehiscence and spiralling of the staple line were detected intra-operatively in 9% of procedures, with the need for manual oversewing although this had no impact on the postoperative morbidity in any of the patients with obstructed defecation pathology.
Spiral resection may be a technical problem specifically related to this procedure. It is caused by the staple line ending inwards or outwards with respect to the beginning of the suture line; leaving an island of tissue in the gap between the two lines which may potentially cause anastomotic leakage. In the learning phase, this may have resulted from excessive or uneven traction on the parachute stitches at the edge of the prolapse or to excessive thickness of tissue incorporated into the jaws of the device. If this is so, the height and depth of the lateral stitch at 3 o’clock appears to be critical for determining the height of the staple line, as well as the amount of tissue to be resected. Immediate detection of possible staple-line leakage is crucial. The low postoperative complication rate of 7% contrasts with 16% (0 [10
]) reported for the conventional STARR procedure with the PPH instrument. Other than two cases of bleeding from the stapler line, there were no complications which required re-operation with anaesthesia. There were no cases of pelvic floor sepsis [11
], recto-vaginal fistula formation [20
], rectal diverticulum [14
] or persisting pelvic pain [13
], all of which have been described following the STARR procedure. The Transtar appears to be as safe as the PPH-STARR and the complication rate reported in this study is acceptable. Furthermore, more extensive resection does not appear to be associated with a higher rate of complications or an increased safety of the device.
Incontinence has been claimed to be a potential postoperative drawback of STARR [12
] and for some its presence may be a contraindication to trans-anal surgery for ODS [22
]. Impaired continence may however be part of the symptom aetiology of patients with internal rectal prolapse and an intact sphincter and not by itself a contra-indication to surgery. In this study, only 5% of the patients complained of new onset incontinence, while 41% of these with a degree of incontinence preoperatively that were improved at 1 year after operation. Faecal urgency is commonly considered to be part of continence disorder and is not accounted for separately in the Cleveland continence system. It is however an independent item of the SSS, which showed a new onset of urgency in 13% of patients. It is noteworthy however that 22% of the patients who had urgency preoperatively were relieved of this symptom by the operation.
Patients should be carefully selected for the STARR procedure. The present authors have previously developed an algorithm for patient selection for the STARR procedure [19
]. The strict adoption of the algorithm for the entry of patients into this study, combined with extensive experience with STARR using double PPH and training in the use of the new device may explain the results achieved in this study.
The Contour® Transtar™ device appears to facilitate more tailored surgery, including a real circumferential full-thickness resection with the potential of removing more tissue. This may lead to an improved functional outcome. Reports of function after the STARR with PPH have been encouraging [4
] and the Transtar procedure seems to produce results at least as good as that judged by constipation scoring systems. This might suggest that larger resections may perhaps not be the sole factor determining a good postoperative outcome, but it is our opinion that STARR with Transtar is a more satisfactory technique for trans-anal rectal resection.