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STARR for outlet obstruction (ODS) and symptomatic intussusception

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Bristol Laparoscopic Associates introduced STARR in 2002 for treatment of obstructed defecation secondary to outlet dysfunction, symptomatic internal rectal prolapse and rectocele. Early and intermediate (median follow-up 4 years) results have been very encouraging.


Anatomical abnormalities e.g., rectal intussusception (RI), occult prolapse, or rectocele with outlet dysfunction are indications to consider  STARR.

Patients present with pain, a sensation of fullness, sense of incomplete defecation, bulging into the vagina secondary to rectocele, prolonged straining and repeated call to stool comprise a symptom complex termed "pelvic floor dyssynergia".  

When a structural abnormality that could explain outlet dysfunction is detected, STARR may help in reducing maximum tolerable volume and rectal compliance.  Surgical correction also interrupts the rectoanal inhibitory reflex caused by the prolapsing bowel.


The patient may have an uncoordinated inhibitory pattern, progressing from the pubococcygeus to the puborectalis muscle or external sphincter, or both.2 This patient may benefit from biofeedback. When the internal intussusception extends to the anal canal, described as internal prolapse, sometimes combined with rectocele, surgery can provide a resolution.

  • Internal (hidden or occult) prolapse, or intussusception, occurs when the rectum intussuscepts but does not pass beyond the anal canal.

  • Mucosal prolapse results from loosening of the submucosal attachments to the muscularis propria of the distal rectum. It may present with hemorrhoidal disease.

  • Complete rectal prolapse, or procidentia, is a full-thickness protrusion of the wall of the rectum through the anal sphincters.

  • Internal mucosal prolapse. Various grades of severity exist,3 and circumferential prolapse may be a key cause of evacuatory difficulty.4,5 Its pathophysiologic relationship to full-thickness rectal prolapse and solitary rectal ulcer syndrome (SRUS), however, is controversial.


The traditional options for prolapse include abdominal procedures e.g., posterior rectopexy and resection rectopexy, Delorme’s rectal mucosectomy/muscle plication (resection of the redundant mucosal sleeve via a perineal approach), and a perineal proctosigmoidectomy or Altemeier procedure. In the patient with internal rectal prolapse, the limited degree of tissue intussusception precludes perineal proctectomy.

STARR involves full thickness resection of the rectal wall using the transanal application of two circular staplers—one placed anteriorly, the other posteriorly. Transanal, transperineal, and transvaginal approaches may also help in managing the symptoms of rectocele.  Psychological factors including anxiety and depression can contribute to symptoms, so selecting a therapy for a specific patient can be difficult.6


The pre-operative examination for STARR includes evaluating sphincter function and looking  a for rectocele, intussusception, perineal descent and anal prolapse. Colonoscopy or barium enema would rule out other pathology.

Defecography can demonstrate associated anatomic abnormalities. Dynamic MRI is an alternative. Some authors have questioned the use of defecography because it shows rectal intussusception is a common finding, even in normal patients,7,8 and can reveal insignificant abnormalities.  These studies however are flawed and have been misinterpreted; high grade intussusceptions were excluded from the analysis as they were operated-upon! 

Other options, depending on symptoms, can include vaginography, transit study, anal manometry (rectal compliance or capacity, electromyography [EMG], and voiding cystourethrogram), and gynecologic or urologic pelvic assessment.


The Consensus Conference on STARR described these characteristic symptoms as potential indications for the procedure:9

  • Prolonged or repeated straining during evacuation.

  • Frequent calls to defecate before or after evacuation.

  • Digital means to effect evacuation.

  • Laxative or enema use, or both.

  • Sensation of incomplete evacuation.

  • Excessive time spent in the toilet.

  • Pelvic pressure, rectal discomfort, and perineal pain that have failed prior conservative treatment.

  • 4th degree haemorrhoids

  • fissure that fails to heal (some people)


  • External full-thickness rectal prolapse (procidentia).

  • Perineal infection (abscess, fistula).

  • Rectovaginal fistula.

  • Inflammatory bowel disease (including proctitis).

  • Radiation proctitis.

  • Anal incontinence (Wexner Score more than 7).9

  • Anal stenosis precluding insertion of the stapling device.

  • Enterocele at rest.

  • Significant gynecological or urinary pelvic floor abnormality requiring combined treatment.

  • Foreign material such as mesh adjacent the rectum.

  • Absence of anatomical or physiological abnormality associated with outlet dysfunction syndrome.

  • Intraoperative technical factors that preclude a safe operation.

  • Severe rectal or perirectal fibrosis.

  • Prior rectal anastomosis.


Before the procedure, the patient is given an enema to show the prolapse at its worst (picture showes 4th degree haemorrhoids in a man).  

The anaesthetised and paralysed patient is placed in the lithotomy position.

The surgeon uses a specialized circular stapling device (PPH01 and/or PPH03) with a disposable circular anal dilator.


The anal verge is dilated with 2 fingers and 4 radial silk stitches are placed on the perineal skin to gain better exposure. The lubricated obturator of the dilator is then introduced and left in place for 30 seconds. Finally, the lubricated dilator is introduced into the anal canal and retained in place by securing the previously applied sutures.

A spatulated retractor placed through the lower opening of the anal dilator into the anal canal protects the posterior wall of the rectum (FIGURE 2). Inserting gauze facilitates prolapse of the rectal mucosa. The gauze is then withdrawn gradually.


Three  sutures are placed at the apex of the rectal prolapse anteriorly at 10, 12, and 2 o’clock; each traversing the full thickness of the rectal muscle wall.  The circular stapler is then introduced into the rectum and the open head is positioned above the prolapse.

Traction applied to the sutures prolapses the rectal wall into the stapler, which is then closed and then discharged. Before firing, fingers placed into the vagina help prevent entrapment of the posterior vaginal wall into the stapler. Including the posterior rectal wall into the staple line is also carefully avoided. The stapler is then gently withdrawn.


The procedure is then repeated on the posterior rectal wall with the retractor placed in the upper opening of the dilator and the 3 sutures in the residual prolapse of the posterior circumference.

Hemostatic sutures are placed incorporating the staple line anteriorly and posteriorly as necessary.

When firing the stapler, the surgeon takes care to avoid tissue overload, which can divide the tissue without closing the staples. This would result in a full-thickness injury to the rectal wall.  If it does occur, all he surgeon has to do is spot it and correct with interrupted sutures.

The final result is fairly spectacular with re-inversion of the anal canal and elevation of the perineum (shown here).  The final result at six weeks is a normal looking (and feeling) anal canal.  Function is good also.


Because the resection is full-thickness, there are potential risks: dehiscence of the staple line, peritonitis, pelvic and retroperitoneal sepsis and necrotizing fasciitis.  Less dangerous complications include urinary retention, bleeding, anal pain, fecal incontinence, rectovaginal fistula, recurrence of the rectocele, intussusception, and symptoms of obstructed defecation.13,14 Urgency and frequency and persistent discomfort from residual staples have also been reported.  These complications reflect surgical technique and experience/vigilance.


Problems due to heterogeneity of patient population and disassociation between symptom constellation, physical findings, and cause have made it difficult to interpret outcomes with various therapies. 

One prospective multicenter trial15 reported a significant improvement of all symptoms of constipation with improved constipation scores, minimal postoperative pain at 1 week, high patient satisfaction with improvement maintained over 1 year of follow-up, and no dyspareunia. Common complications include:

  • Fecal urgency, 17.8%.

  • Incontinence to flatus, 8.9%.

  • Urinary retention, 5.5%.

  • Bleeding, 4.4%.

  • Anastomotic stenosis, 3.3%.

  • Pneumonia, 1.1%.

A randomized controlled trial comparing STARR16 with stapled transanal prolapsectomy combined with perineal levatorplasty showed that both procedures were effective in the treatment of outlet dysfunction. STARR was associated with lower pain, dyspareunia, reduced rectal sensitivity threshold volume, and residual rectocele at defecography.

Evaluating the evidence for STARR

  • For patients with symptoms of obstructive defecation an adequate trial of conservative treatment is essential. Level of evidence: 3b—based on individual case-control study.

  • In the absence of contraindications, stapled transanal rectal resection can be offered to patients with obstructive defecation and a demonstrable rectal prolapse. Level of evidence—3b.

  • The procedure has had early and mid-term results comparable to conventional surgical techniques with less postoperative pain and shorter length of hospital stay. Level of evidence: 2b—based on individual cohort study.—RPK, FHR


A retrospective study comparing the circular transanal stapled procedure with the conventional excisional technique for partial mucosal prolapse reported shorter surgery times, reduced analgesia use, shorter hospital stays for the stapled group despite similar incidence of early and late complications, and early functional outcome.10

Another RCT comparing STARR with stapled hemorrhoidopexy in patients with association of prolapsed hemorrhoids and rectal prolapse reported STARR provided a more complete resection of prolapsed tissue with equal morbidity and significantly lower incidence of residual disease and skin-tags.17

Among patients with rectal internal mucosal prolapse having the procedure, 45% had postoperative complications, 32.5% required a reoperation, 52% had recurrent constipation, 65% had recurrent rectal internal mucosal prolapse, and 5% complained of fecal incontinence.18

However, most reports of the procedure have had short follow-up. In the only report that described the long-term result of the STARR procedure for rectal prolapse, after a median follow-up of 67 months in 8 patients, no recurrence of mucosal rectal prolapse had been reported.19


  1. Longo A.  Obstructed defecation because of rectal pathologies. Novel surgical treatment: stapled transanal resection (STARR). Annual Cleveland Clinic Florida Colorectal Disease Symposium. January 2005; Ft. Lauderdale, FL.

  2. Fucini C, Ronchi O, Elbetti C.  Electromyography of the pelvic floor musculature in the assessment of obstructed defecation symptoms. Dis Colon Rectum. 2001;44:1168–1175.

  3. Pescatori M, Quondamcarlo C.  A new grading of rectal internal mucosal prolapse and its correlation with diagnosis and treatment. Int J Colorectal Dis. 1999;14:245–249.

  4. Karlbom U, Pahlman L, Nilsson S, Graf W.  Relationships between defecographic findings, rectal emptying, and colonic transit time in constipated patients. Gut. 1995;36:907–912.

  5. Pomerri F, Zuliani M, Mazza C, Villarejo F, Scopece A.  Defecographic measurements of rectal intussusception and prolapse in patients and in asymptomatic subjects. Am J Roentgenol. 2001;176:641–645.

  6. Pescatori M, Spyrou M, Pulvirenti d’Urso A.  A prospective evaluation of occult disorders in obstructed defecation using the “iceberg diagram”. Colorectal Dis. 2006;8:785–789.

  7. Dvorkin LS, Gladman MA, Epstein J, Scott SM, Williams NS, Lunniss PJ.  Rectal intussusception in symptomatic patients is different from that in asymptomatic volunteers. Br J Surg. 2005;92:866–872.

  8. Mellgren A, Anzen B, Nilsson BY, et al. Results of rectocele repair. A prospective study. Dis Colon Rectum. 1995;38:7–13.

  9. Corman ML, Carriero A, Hager T, et al. Consensus conference on the stapled transanal rectal resection (STARR) for disordered defaecation. Colorectal Dis. 2006;8:98–101.

  10. Araki Y, Ishibashi N, Kishimoto Y, Ogata Y, Shirouzu K.  Circular transanal stapled procedure for incomplete rectal prolapse associated with outlet obstruction versus conventional procedure. Min Inv Ther Allied Technol. 2001;10:235–238.

  11. Regadas FS, Regadas SM, Rodrigues LV, et al. Transanal repair of rectocele and full rectal mucosectomy with one circular stapler: a novel surgical technique. Tech Coloproctol. 2005;9:63–66.

  12. Altomare DF, Rinaldi M, Veglia A, Petrolino M, De Fazio M, Sallustio P.  Combined perineal and endorectal repair of rectocele by circular stapler: a novel surgical technique. Dis Colon Rectum. 2002;45:1549–1552.

  13. Pescatori M, Dodi G, Salafia C, Zbar AP.  Rectovaginal fistula after double-stapled transanal rectotomy (STARR) for obstructed defaecation. Int J Colorectal Dis. 2005;20:83–85.

  14. Dodi G, Pietroletti R, Milito G, Binda G, Pescatori M.  Bleeding, incontinence, pain and constipation after STARR transanal double stapling rectotomy for obstructed defecation. Tech Coloproctol. 2003;7:148–153.

  15. Boccasanta P, Venturi M, Stuto A, et al. Stapled transanal rectal resection for outlet obstruction: a prospective, multicenter trial. Dis Colon Rectum. 2004;47:1285–1297

  16. Boccasanta P, Venturi M, Salamina G, Cesana BM, Bernasconi F, Roviaro G.  New trends in the surgical treatment of outlet obstruction: clinical and functional results of two novel transanal stapled techniques from a randomized controlled trial. Int J Colorect Dis. 2004;9:359–369.

  17. Boccasanta P, Venturi M, Roviaro G.  Stapled transanal rectal resection versus stapled anopexy in the cure of hemorrhoids associated with rectal prolapse. A randomized controlled trial. Int J Colorectal Dis. 2007;22:245–251.

  18. Pescatori M, Boffi F, Russo A, Zbar AP.  Complications and recurrence after excision of rectal internal mucosal prolapse for obstructed defecation. Int J Colorectal Dis. 2006;21:160–165.

  19. Zacharaki E, Pramateftaki M.G, Kanel D.  Long-term results after transanal stapled excision of rectal internal mucosal prolapse. Tech Coloproctol. 2007;11:67–69.

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