Stefan Farke Department of Surgery Schlosspark-Klinik, Berlin, Germany The Stapled Trans-Anal Rectocele Resection (S T A R R) Technique and Results Stefan Farke Department of Surgery Schlosspark-Klinik, Berlin, Germany

Obstructed Defecation Syndrome Stapled TransAnal Rectocele Resection O D S Obstructed Defecation Syndrome S T A R R Stapled TransAnal Rectocele Resection

Obstructed Defecation

S.T.A.R.R Principle theory: Reconstruction of normal anatomy Resection of the distal rectum Resection of rectocele Resection of rectal wall prolaps Elevation of the pelvic floor

S.T.A.R.R. Operation in lithotomy position General- or Spinal-Anaesthesia PPH 01 Set, metal spatula

S.T.A.R.R. Insertion of the transparent proctoscope and fixation with sutures following gentle dilatation

S.T.A.R.R. Full thickness stitches of the rectal wall, three stitches at the edge of the prolaps or several semi-circular sutures above the dentate line Resection of the anterior rectal wall with the first stapler, protection of the posterior wall Careful examination of the posterior vaginal wall

S T A R R

S T A R R Resection of the posterior wall in the same manner Suturing of the overlaps of the stapling lines and control of hemostasis

S T A R R

Results First results very promising No longterm results Only few studies Mainly single center experiences

14 patients, mean follow up 19 month (1-30) 8 patients very satisfied Results S T A R R 14 patients, mean follow up 19 month (1-30) 8 patients very satisfied 6 patients satisfied Significant reduction of defecation-scores A. Ommer, K. Albrecht, F. Wenger, M.K. Walz: Stapled transanal rectal resection (STARR): a new option in the treatment of obstructive defecation syndrome, Langenbecks Arch Surg (2006) 391: 32 - 37

S T A R R – Results Disorders Symptoms n No complaints 8 Distinct improvement No digital evacuation no squeezing no rectal tenesmus 6 Slight improvement No digital evacuation severe squeezing rectal tenesmus laxatives No improvement 1

60 patients, mean follow up 16 month (3-49) Results S T A R R 60 patients, mean follow up 16 month (3-49) M. Sielaff, R. Scherer, H. Gögler, S. Farke: Die STARR-Operation Erfahrungen bei 60 Patienten, coloproctology 28 (2006), 4: 217-23

Results Author year n FU (Mo.) success Boccasanta 04 25 20 88 % Sielaff, Farke 04 60 16 68 % Ommer 06 14 19 100 % Boccasanta 07 34 8 94 % Guarnieri 08 20 85 % Slim 08 100 85 % Gagliardi 08 123 17 65 %

Standardized documentation German S T A R R Register Standardized documentation Evaluation of safety and efficacy of STARR procedure in patients with ODS Register startet 15.05.2006, first evaluation 2007 Results: n = 122 85,2 % without complications No mortality

Clinical symptoms Severe symptomatic outlet constipation „digitizing“ „overflow incontinence“ Failed improvement by enema / laxatives soiling pain

rest squeeze 103° defecation Defecography

S T A R R - Success Indications Failure of conservative therapy in obstructed defecation Rectocele, DPS, Intussusception Exclusion of slow transit constipation Exclusion of spastic outlet

Conclusion The STARR-Operation is a new procedure with promising first results It is a new approach to improve function in obstructed defecation The indication is most importment for a good result There are no long term results