gms | German Medical Science

Introduction: Internal rectal prolapse (rectal intussusception) and rectocele are frequent clinical findings in patients suffering from refractory constipation that may be best characterized as Obstructive Defecation Syndrome (ODS). However, there is still no clear evidence whether the STARR procedure (Stapled TransAnal Rectal Resection) provides a safe and effective surgical option for symptom resolution in ODS patients.

Materials and methods: Based on the need for objective evaluation, a European group of 11 experts was founded (“STARR Pioneers”). Derived from their first meeting (October 26-28, 2006) in Gouvieux, France, a concept for treatment options in patients suffering from ODS was developed, specifically focussing on the role of the STARR procedure based on clinical symptoms and dynamic imaging. To provide a standardized decision-making algorithm, treatment options after dynamic imaging were differentiated in relation to the most common clinical findings (internal rectal prolapse +/- rectocele) in patients suffering from ODS.

Results: If internal rectal prolapse and rectocele are confirmed clinically and morphologically, and diagnostic assessment can rule out significant combined pathologies, the STARR procedure can be recommended as first option after conservative treatment failed. However, if internal rectal prolapse and rectocele are combined with other pelvic floor disease, such as enterocele, sigmoidocele, or urogenital prolapse, a treatment of these associated disorders (per local practice) should be recommended first. Specifically focussing on enterocele, enterocele should be treated prior to the STARR procedure, but can also be combined with the STARR procedure in experienced pelvic floor centers. If clinically and morphologically confirmed internal prolapse and rectocele are associated with pelvic dyssynergy, the primary treatment option should be conservative (biofeedback). If fecal incontinence is associated with internal rectal prolapse and rectocele, a tailored therapy with special reference to sphincter function and morphology should be initiated. The proposed decision-making algorithm with special reference to the STARR procedure is presented in figure 1 [Fig. 1].

Conclusion: As there is still no commonly accepted understanding of the definite role of the STARR procedure, this is the first algorithm on treatment options in ODS patients specifically focusing on the role of the STARR procedure.