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Obstructed defecation - STARR & PPH

Evacuatory dysfunction in middle aged and older women is a common and often embarrassing condition.  Many are categorized as having constipation and irritable bowel syndrome.  It is estimated that 15% of women experience symptoms of constipation and/or obstructed defecation.  However, the true incidence is unknown due to the tendency for patients to self medicate rather than consult there GP.

Obstructed defecation syndrome ODS is the normal desire to defecate, but with an impaired ability to evacuate the rectum.  ODS is invariably associated with rectoceles, rectal intussusception, occult rectal prolapse, rectal mucosal prolapse and in some cases, concurrent genital prolapse.

Whilst it is most commonly seen in multiparous females, it is increasingly seen in nulliparous women and males.  The greatest single factor that has brought this undercurrent of patients to light has been the introduction of the two week wait fast track cancer referral system.  Middle aged women are health conscious and present to the GPs with urgency, obstructed defecation, incomplete emptying, prolonged toilet time, use of laxatives or loperimide, the need for perineal support or manual digitation to facilitate evacuation in addition to pelvic pain, rectal bleeding etc.  A TWW appointment is made and a change of bowel habit investigated.  Straight to test barium enema and colonoscopy will not pick up these patients.  The history is very classic and the sigmoidoscopic findings consistent.

Traditional management for ODS, including dietry manipulation, laxatives, enemas, pelvic floor physiotherapy, biofeedback and a variety of surgical repairs aimed at excisiong the rectocele (posterior colporraphy) and intussusception are largely unsuccessful.  In our opinion, tradittional gynaecological opperations make things worse and should only be considered cosmetic at best.

Stapled Trans Anal Rectal resection is a new treatment option that is being offered in the European Union, Australasis, USA and increasingly in the UK.  The procedure has arisen out the stapled haemorrhoidopexy which has been used in treating haemorrhoids. 

BLA quickly realised the potential in 2000 of using the equipment used in performing stapled haemorrhoidectomy to manage patients with ODS and symptomatic rectal intussusception.  We initially termed the procedure stapled rectal mucosectomy (cf., Delormes rectal mucosectomy).  It is our experience that the STARR procedure has high efficacy and that this is maintained over the short term (3 years).  The procedures efficacy is supported by its rapid uptake in the UK eg over 60 procedures have been performed in basingstoke and >150 in the SW in 2006.

What is STARR?

What the STARR procedure involves
NICE overview 2005
STARR - the surgery
Registered UK Colorectal Surgeons offering STARR procedure
BLAs 7-year experience STARR

PPH - stapled haemorrhoidopexy

Minimal access management of haemorrhoids (PPH)
2007 NICE guidance
BLAs experience of PPH

The view of other surgeons?

In April 2006 NICE issued their first guidance on STARR/ODS and recommended that surgeons performing STARR should enter patients into the STARR registry (established by NICE).  To date there are some 50 UK colorectal surgeons who have been trained (two day course in Vienna, Hamburg followed by proctorship here in the UK) and are registered on the NICE database.  42 NHS Trusts are performing regular STARR. 

Having been undertaking STARR (all be it using a different name) since 2000, BLA have one of the largest experiences in the world literature.  The second largest UK experience is Darren Gold in Basingstoke.  Other units regularly undertaking STARR include Bristol UBHT, Southampton, Taunton, Poole, Plymouth, Birmingham, Stoke, London, Leeds, Sheffield and Glasgow.

BLAs views?

We believe that  ODS is not an entirety in itself and forms a spectrum ranging between the two extremes of symptomatic haemorrhoids and a full thickness rectal prolapse and that symptomatic patients should be viewed in the context of their whole pelvic floor.  We believe that for large high take off intussusceptions, occult prolapse, concurrent genital prolapses, particularly in post hysterectomised patients - laparoscopic ventral rectopexy, posterior colporrhaphy and vaginal sacrocolpopexy offers a better solution.  Associated urinary stress incontinence responds to a Trans Vaginal Tape.

Those patients deemed unsuitable for a surgical approach (anismus) are offered alternative forms of medical management eg., biofeedback therapy.

The key investigation is clinical examination and rigid sigmoidoscopy.  Defaecating proctography can be of help in differentiating between the need for a laparoscopic approach.  Anorectal physiology is only realy useful when you suspect anismus.  Likewise, we believe that endo anal ultrasound adds little.

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SPIRE Hospital, Bristol. 
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Contact: Claire Trenberth - 0117 9804051