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Pelvic Floor Dyssynergia 1

Stapled Transanal Rectal Resection (Starr)to Reverse the Anatomic Disorders of Pelvic Floor Dyssynergia

George Pechlivanides ?John Tsiaoussis ?

Elias Athanasakis ?Nikolaos Zervakis ?Nikolaos Gouvas ?George Zacharioudakis ?Evaghelos Xynos

Published online:25April 2007

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′te ′Internationale de Chirurgie 2007Abstract Anterior rectocele and rectoanal intussuscep-tion are anatomic disorders related to excessive straining during defecation that usually manifest with symptoms of obstructive defecation.Stapled transanal rectal resection (STARR),a newly described surgical method for correct-ing these disorders,is considered a good alternative to the traditional transrectal approaches.The aim of the present study was to assess the early postoperative functional re-sults of STARR.A total of 16patients (13female)were subjected to the STARR procedure during a period of 12months.The presence of anatomic disorders of the ano-rectum was veri?ed by dynamic defecography.Preopera-tive assessment also included colonic transit time,anal sphincter ultrasonography,and anorectal stationary manometry.Postoperative assessment included the same battery of tests.Altogether,12patients had rectoanal intussusception of >2cm and rectocele.In eight of them the anterior component of the rectocele was 2to 4cm,and in four it was >4cm.Four patients had a 1-to 2-cm internal intussusception and a rectocele of <2cm.All of them reported evacuation dif?culties,but none had sig-ni?cant incontinence.Preoperative endoscopy did not re-veal the presence of a solitary ulcer in any of the patients.

All females had had normal vaginal deliveries,and four of them were multiparous.No complications were encoun-tered postoperatively,and the need for analgesics was minimal.At defecography,rectoanal anatomy was seen to be restored in all patients.Obstructive defecation symp-toms remained rather unaffected in seven,disappeared in three,and improved signi?cantly in the remaining six pa-tients.The seven failures showed anismus at manometry and had biofeedback treatment with satisfactory results in ?ve of them.Failure of the operation and biofeedback sessions to treat symptoms in those two cases was attrib-uted to coexisting enterocele,which had been missed preoperatively.Immediately after surgery,most of the patients complained of urgency and frequent small motions that resolved spontaneously within 3to 5weeks in all but two cases.STARR is a safe,well tolerated surgical pro-cedure that effectively restores anatomy and function of the anorectum in patients with anterior mucosal prolapse and rectoanal intussusception.Additional biofeedback treat-ment is usually necessary for further functional improve-ment.Failure may be the result of other coexisting anatomic and functional abnormalities of the pelvic ?oor.Various transperineal,abdominal,or combined surgical procedures have been used to treat the anatomic abnor-malities that coexist with obstructed defecation.Following the successful introduction of stapled hemorrhoidectomy,the same device and its modi?ed version have been applied for the treatment of rectocele and internal intussusception.Successful in the short term,rectocele repair by stapled mucosectomy with a double purse-string technique alone [1]or combined with an anterior levatorplasty [2]have been reported in the recent literature.

Since 2004,though,when Longo announced a novel surgical treatment for obstructed defecation—the stapled

G.Pechlivanides

1st Department of General Surgery,Athens Naval Hospital,Athens,Greece

J.Tsiaoussis

Department of General Surgery,Metropolitan Hospital of Athens,Athens,Greece

E.Athanasakis áN.Zervakis áN.Gouvas áG.Zacharioudakis áE.Xynos (&)

Department of General Surgery,University Hospital of Heraklion,Heraklion,Crete,Greece GR-71110e-mail:exynos@med.uoc.gr

World J Surg (2007)31:1329–1335DOI

10.1007/s00268-007-9021-7

transanal rectal resection(STARR)procedure[3]—there have been a number of reports attesting to successful re-sults in the treatment of outlet obstruction,internal pro-lapse,and rectocele[4–11].On June2005,a consensus conference was held in Rome to evaluate the status and make conclusions and recommendations concerning the applicability of this new approach[12].All the experts agreed on its usefulness and the indications and contrain-dications for the technique.They also stated the compli-cations and the training required for a surgeon to perform the STARR procedure safely.

We herein report our short-term results of the STARR procedure applied to patients with obstructed defecation syndrome(ODS)with associated rectal intussusception or rectocele(or both).

Patients and methods

During a period of12months,16patients(13female)with long-standing symptoms suggesting ODS were subjected to the STARR procedure according to the technique initially described by Longo[3]after giving an informed consent. The protocol of the study was approved by the ethics committee of Athens Naval and Veterans Hospital.Inclu-sion and exclusion criteria were in agreement with those proposed by a recent consensus conference[12].Symp-toms were recorded according to a standard questionnaire and included prolonged or repeated straining,a sense of incomplete evacuation,frequent calls to defecate,exces-sive time spent in toilet,assisted evacuation(digital,ene-mas,laxatives),perineal pressure,pain or discomfort,and incontinence[12–14].The severity of the symptoms and signs was scored as follows:0,absence of symptoms;1, symptoms of mild severity;2,symptoms of moderate severity;3,symptoms of distressing severity.Based on these criteria,the symptom score ranged from0to21.Most of the patients had one to three courses of biofeedback treatment.

The presence of anatomic disorders of the anorectum was veri?ed by standard dynamic defecography,with synchronous opaci?cation of the vagina and the ileal loops, as described elsewhere[14].Pelvic?oor mobility,anterior rectal mucosa prolapse,rectal intussusception,sigmoido-cele and enterocele at rest,and squeeze and straining were assessed according to standard de?nitions[13–15].Preop-erative assessment also included segmental colonic transit time studies and anal sphincter ultrasonography as de-scribed elsewhere[16].

Anorectal manometry was performed with a water-per-fused,eight-lumen polyethylene catheter with4mm external diameter,also bearing a central lumen,which ended to an in?atable balloon at the tip of the catheter.When in place,the balloon was situated in the mid-rectum. Each lumen was constantly perfused with distilled water at a rate of0.6ml/min by a low-compliance perfusion system (Andorfer Medical Specialties,Greendale,WI,USA).A pressure transducer,incorporated in each perfusion line was connected to a polygraph device-ampli?er(Synectics Medical,Stockholm,Sweden).The manometric tracings were shown on the screen of an online computer and were saved for retrospective analysis using dedicated software (Polygram version4.2,Upper GI Edition;Gastrosoft,Ir-ving,TX,USA).

The mean highest resting and squeeze pressures of the anus,rectoanal inhibitory re?ex(RAIR),minimum rectal volume to induce transient urge to defecate,minimum rectal volume to induce transient sensation,maximum tolerable rectal volume,and rectal compliance were as-sessed according to de?nitions previously described[13].

Patients were followed for at least9months.Clinical evaluation was performed after an interview on the?rst, third,sixth,and twelfth months postoperatively.Any changes in symptoms indicative of obstructed defecation were recorded,as were any newly presented symptoms, such as urgency to defecate and tenesmus.Satisfaction of the patient with the outcome was classi?ed as follows: grade1,excellent or very good with practically no defe-catory problems;grade2,good with occasional,nonsig-ni?cant defecatory problems;grade3,fair with several defecatory problems somehow affecting quality of life;and grade4,poor with severe defecatory problem,signi?cantly affecting quality of life.

Postoperative assessment also included anorectal manometry and dynamic defecography at6to9months postoperatively.Biofeedback treatment was given to those patients with anismus postoperatively according to a stan-dard protocol[17].

Values are expressed as the median and https://www.wendangku.net/doc/e29710949.html,-parisons of numerical defecographic and manometric parameters between pre-and postoperative states were made by applying either Student’s t-test or the Mann-Whitney U-test for paired values,as appropriate.Func-tional outcomes at various postoperative interviews were compared using Fisher’s exact test.Differences were con-sidered signi?cant at p<0.05.

Results

All of the women had had normal vaginal deliveries,and 10of them were multiparous.Symptoms suggesting ob-structed defecation had been constantly present in all cases for2to7years.None of the patients reported signi?cant fecal incontinence,although three patients complained of occasional soiling(Table1).Prior to surgery,11women

T a b l e 1S y m p t o m s a n d s y m p t o m s c o r e p r e o p e r a t i v e l y a n d a t t h e 9-m o n t h p o s t o p e r a t i v e f o l l o w -u p i n a l l p a t i e n t s

P a t i e n t P r o l o n g e d s t r a i n i n g I n c o m p l e t e e v a c u a t i o n

F r e q u e n t c a l l s t o d e f e c a t e

E x c e s s i v e t i m e i n t o i l e t A s s i s t e d e v a c u a t i o n P e r i n e a l d i s c o m f o r t /p a i n I n c o n t i n e n c e S c o r e *

P r e P o s t P r e

P o s t

P r e P o s t P r e P o s t P r e P o s t P r e P o s t P r e P o s t P r e P o s t

1201

201010000070

2102

301000101191

3101

20110021007

4213

312132100014

5313

2021303110

6202

1110202101

7102

312010010

8101

101010100

9313

311031100

10003

211010200

11103

31223332

12303

21312020

13202

11100010

143131313230310118715003

2120001

16312

113233

2(0–3)0(0–1)2.5(1–3)1(0–3)2(1–3)1(0–1)1.5(1–3)0(0–2)1.5(0–3)0(0–3)1.5(0–3)

0.5(0–2)

0(0–1)0(0–1)9.5(6–18)3(0–11)

*S i g n i ?c a n t d i f f e r e n c e b e t w e e n p r e o p e r a t i v e a n d p o s t o p e r a t i v e s c o r e s (p <0.001)

and1man had biofeedback treatment with poor symp-tomatic response(six patients had one course,four had two courses,and one had three courses).

At dynamic defecography,12patients had rectoanal intussusception of>2cm and rectocele;in four of them the rectocele was>4cm,and in the remaining eight it was2to 4cm.Four patients had internal intussusception of1to2 cm and a rectocele that was<2cm.Perineal descent was present in all patients.In11the perineal descent was>6 cm(Table2).Preoperative endoscopy did not reveal the presence of an ulcer in any of the patients.At anorectal manometry,anal pressures were within the normal range although at the lower limits(Table3).

Postoperative recovery was uneventful in all but one patient,who bled from the anterior anastomotic line on the ?rst postoperative day.The bleeding was treated success-fully by placing two interrupted stitches under general anesthesia.The need for analgesics was minimal.At the ?rst postoperative interview at1month,although most of the symptoms suggesting ODS had diminished or disap-peared satisfaction with the outcome was graded as3and4 in all but two patients.The main complaints were frequent calls and urgency to defecate with the ability to defer stools <5minutes,small stools,and rectal discomfort.At the6-month postoperative follow-up,more than half of the pa-tients were satis?ed with the outcome of the procedure.In seven patients,obstructed defecation symptoms of mild severity,which manifested as moderate straining at stool and a feeling of incomplete evacuation,recurred,although urgency to defecate and frequent,small stools were not frequently reported.Those seven patients had biofeedback treatment,which was of signi?cant bene?t in all but two cases.At the9-month follow-up,all but two patients were satis?ed with the outcome.The symptom score was sig-ni?cantly lower than the preoperative score(Table1).The two dissatis?ed patients complained of a sensation of incomplete evacuation of moderate severity and frequent but not urgent calls for stool.They had the two highest scores postoperatively(Tables1,4).

At postoperative dynamic defecography,almost all of the anatomic deformities of the anorectum had either disappeared completely or were signi?cantly alleviated. In detail,rectoanal intussusception was absent in10and was<2cm in length in the remaining six patients (p<0.001).A small anterior rectocele was evident in only six patients(p=0.007),and perineal descent at straining was reduced signi?cantly(p=0.02)(Table2, Fig.1).Postoperative manometry revealed a signi?cant increase in the maximum resting anal pressure and a signi?cant decrease in rectal compliance(Table3).A satisfactory outcome was associated with the disappear-ance or improvement of the defecographic parameters. The two patients who experienced obstructed defecation symptoms even after the biofeedback treatment and continued to express dissatisfaction with the outcome of the operation had a large enterocele at rest,seen at the postoperative dynamic defecographic study but missed at the preoperative one.

Table2Dynamic defecography data

Anterior rectocele Intussusception(cm)Perineal descent at

straining(cm) Pre Post Pre Post Pre Post

(++)(–)3175 (+)(–)2066 (–)(–)1022 (++)(+)3155 (+++)(+)42118 (+)(–)3086 (++)(–)2175 (–)(–)1022 (+++)(+)4194 (++)(–)3063 (++)(+)3143 (+++)(+)5187 (++)(–)4166 (+++)(+)5188 (++)(–)4075 (++)(–)4132 3(1–5)1(0–2) 6.5(2–11)5(2–8)

p=0.007p<0.001p=0.02 (+),0–2cm;(++),2–4cm;(+++),>4cm

Table3Manometric variables before and after surgery Values are expressed as the

median and range

NS,not signi?cant;RAIR, rectoanal inhibitory re?ex Variable Preop Postop p

Maximum anal resting pressure(mmHg)60(40–90)70(40–110)0.002 Maximum anal squeeze pressure(mmHg)110(80–175)110(75–160)NS Minimum air volume for rectal sensation(ml)3(3–8)3(3–5)NS Maximum tolerable rectal air volume(ml)235(180–320)185(120–290)<0.001 Minimum rectal air volume to elicit RAIR(ml)30(20–60)30(20–50)NS Minimum rectal air volume for anal inhibition(ml)100(80–120)100(80–120)NS Rectal compliance(ml/mmHg)14(7–19)9.5(5–16)<0.001

Discussion

Patients with symptoms of ODS may demonstrate certain anatomic abnormalities on defecography,such as rectal intussusception,rectal prolapse,and rectocele.There also exists a functional aberration of the syndrome in which the anatomy is normal but evacuation is impaired;this is termed pelvic?oor dyssynergia[13,14].ODS symptoms range from pain,a sensation of prolapse,and toilet revis-iting mainly caused by rectal intussusception,bulging due to rectocele,and straining caused by both abnormalities.A symptom-based diagnosis is limited because of consider-able overlapping.In general,ODS symptoms are complex and dif?cult to describe,and the degree of severity cannot be precisely de?ned[12].The symptom scoring system used in the present study is tentative and not validated at present.

The16patients of the present series to whom an oper-ation was offered were selected from a large cohort of patients with symptoms of obstructed defecation.They had been evaluated by all diagnostic means and followed for a signi?cant period of time—of adequate duration to esti-mate their emotional and behavioral status.It is of great importance to ascertain that a disturbed psychological sit-uation,which may intensify ODS symptoms,is the result and not the cause of obstructive defecation symptoms. Most of the patients were offered one or more course of biofeedback treatment with no signi?cance response,pos-sibly because the method cannot address the anorectal

anatomic abnormalities.It is imperative to include a small bowel contrast outline in the preoperative defecographic testing to identify and exclude patients with enterocele because they are candidates for failure,as was the case with one of our patients.Those patients are better served by an abdominal resection rectopexy procedure[18,19].

The anatomic and physiologic derangements underlying ODS are complex and poorly understood.As a conse-quence,a plethora of surgical techniques have been de-scribed,with no one method achieving overall superiority. None of these techniques has addressed the underlying structural abnormalities of the syndrome in quite the same way as STARR.Indeed,the?ndings of the present series con?rmed the results reported by others[4–11];the anat-omy of the anorectum was restored in all patients,and symptoms had settled in most.Furthermore,there was a signi?cant increase in the anal resting pressure as a con-sequence of interrupting the inhibitory rectoanal re?ux, which is continuously triggered by the prolapsing bowel [20].Maximum tolerable volume and rectal compliance were also decreased as a result of the reduced capacity of the rectum owing to its wall

excision.

Fig.1A Defecographic study showing rectoanal intussusception with a large anterior rectocele.B Rectoanal intussusception and the large rectocele disappear after the stapled transanal rectal resection (STARR)procedure

Table4Grading patient satisfaction with the outcome of the pro-cedure at postoperative interviews

Grade Postop1

month Postop3

months

Postop6

months*

Postop9

months**

11345 21359 36651 48421

Results are the number of patients

*p<0.05vs.grade1–2cases at1month postoperatively **p=0.02vs.grade1–2cases at1month postoperatively

Dodi et al.[21]and Pescatori et al.[22]tried to dis-courage the rapidly increasing use of this technique for patients with obstructive defecation symptoms prior to any attempt at conservative treatment and even without the appropriate diagnostic tests.They reported14patients with either severe postoperative complications,such as rectal bleeding,anal pain,fecal incontinence,and rectovaginal ?stula or recurrence of rectocele,rectal intussusception, and obstructed defecation symptoms.Fortunately,none of the patients in the present study suffered a severe postop-erative complication.Urgency and frequent stools were the most frequent complaints and were attributed to rectal wall edema and reduced rectal compliance.Those symptoms resolved within a few weeks.

Recurrence of symptoms or the anatomic abnormalities are not discussed in the present study because of the short follow-up.Shovron et al.[16]and Mellgren et al.[23]stated that not all abnormalities found on defecography are of signi?cance.The patients in the present series who continued to complain of ODS symptoms had evidence of anismus on manometry or defecography but showed otherwise restored rectoanal anatomy on defecography.They were offered biofeedback treatment,after which they experienced con-siderable alleviation of their symptoms.A preoperative diagnosis of anismus is dif?cult,as it is usually masked by other,more striking symptoms and?ndings.The authors strongly believe that patients with the best chance for improvement with biofeedback treatment are those with re-stored rectoanal anatomy and that biofeedback treatment prior to restoration of the gross anatomy is doomed to fail. Conclusions

STARR is a safe,well tolerated surgical procedure that effectively restores the anatomy and function of the ano-rectum in well selected patients with rectoanal intussus-ception and anterior rectocele.As a result,obstructed defecation symptoms resolve or are diminished.Initial urgency and frequent stools in some cases resolve promptly as the rectal wall in?ammation disappears.Additional biofeedback treatment is usually necessary for further functional improvement,particularly in patients with an-ismus.Failure may be the result of other coexisting ana-tomic and functional abnormalities of the pelvic?oor that are not therapeutically addressed by the procedure. References

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A、生鲜系列 B、禽肉加工系列其它公司 C、外购系列产品 2.产品要求及贴标明细(以后期顾客实际需求调整产结构) 3.产品包装 (1)包装设计标准门店产品包装分为两个方面: A、方便顾客携带的手提袋(要求设计大方，实用，突出公司产品形像及品牌形像。 B，设计精美，档次高，卖得起价，包装吸引客户购买，增加销量，过年过节送的礼盒。(要求能突出产品档次，产品品牌形像、公司品牌形像) (2)公司产品包装单位(指门店运营过程中的计量单位) 4 .产品外购 (1)明确产品外购标准 A、市场有需求，但我司暂时未能生产的品种. B、我司产品有生产，但因未达到规模化效应或机器设备自动化程度不高，成本没有优势的产品， C、我司产能紧张，一些品种通过与生产沟通，在预算的时间内未能进行生产，为了确保货源不断货，需要对外进行采购的。四(渠道策略 1.渠道标准 1,拥有良好位置农贸市场周边店面，以便于提升我司产品的品牌形象。 2,具备较好的周边环境，方便公司物流配送. 3,具备较高的流动人口，保持门店的视觉印象和客户资源。

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