BLAs 7-year experience STARR
A 7 yr prospectively collected electronic data base (2000 - 2007) of stapled transanal rectal resection (STARR) performed for either outlet obstruction 33%, solitary rectal ulcer) or symptomatic (bleeding 86%, prolapse 83%, urgency 81%, incomplete emptying 71%, pelvic pain 65%, faecal incontinence 62%) rectal anal intussusception has been audited. Digitation was reported in 18% of patients.
230 patients (187 - 81% were women, median age 58 years; range 19-90) have undergone double/triple STARR using 33-mm circular staplers.
Anatomical defects comprised: anterior prolapse 46%, occult prolapse 26%, prolapse to anal verge 15%, complete full thickness prolapse 8%, posterior prolapse 2%, lateral 3%A rectocele was present in 79% of the female patients. 32% had an associated mucosal prolapse 32%.
162 (70%) patients had undergone previous surgery; vaginal hysterectomy 31%, abdominal hysterectomy 8%, posterior colporrhaphy 8%, rubber band ligation 24%, excision haemorrhoidectomy 11% and PPH 1%.
Mean duration of surgery was 35 minutes (range 20-95). 159 (65%) were day cases of which 12 were admitted; 59 were planned overnight stays.
Significant complications were seen in 16 patients (7%). Staple line dehiscence required intraoperative suturing (2), reactive postoperative bleeding requiring a return to theatre (6). One of these latter patients required a temporary stoma. Secondary haemorrhage (1), acute urinary retention (4). Chronic pain (1). There were 9 readmissions - pain on day 3 (2), secondary bleed at 1 week (4) of which 2 returned to theatre 2, rectovaginal fistula developed on day 5 (1) & required a stoma 1, staple line stenosis (dilatation required) 2. One staple line dehisced when dilated.
Seven (8%) patients complaining of severe postoperative pain were managed in the community and one was admitted to hospital. Faecal impaction responding to an enema was seen in two (2.2%). A further patient suffered a staple line stenosis (responded to simple dilatation). One developed a recto-vaginal fistula (day 5) in response to a revtovaginal septum haematoma; the rectum was repaired and defunctioned for 3 months - outcome at 2 years is excellent.
100 patients (44%) had little if no postoperative pain, 14% had pain for up to two weeks and 3% pain for six months. One patient continues with chronic pain. Faecal urgency was reported in 107 patients (46%) which resolved within 3 weeks in 35% of patients. 24 patients (10%) reported faecal urgency lasting for 6 months. Three continued with urgency for between 6 and 15 months. Normal work was resumed at 7 - 140 days (median 10).
Patients were followed up at 2, 6 and 12 months. Symptomatic improvement was dramatic; incontinence improved in 96% of 142 incontinent patients (median pre-op wexner score 9 [2-20] fell to 4 [2-8] and got worse in 4%. Obstructed defecation improved in 58 of 75 patients (77%). No new case of obstructed defecation developed. At 6 months 77% were very pleased with the results of surgery and 152 (66%) would definitely recommend STARR to a friend; a further 45 (20%) would probably recommend STARR. 11 patients regretted having had surgery. Only three patients have represented with recurrent symptomatic prolapse at between 8 and 13 months.
Whilst STARR can be an effective and predictable treatment of symptomatic rectal intussusception, surgery is not without complication (7%)