Postoperative complication
Incidence (%)
Reference
Author
Year
Rectal bleeding
4.4
[31]
Stuto et al.
2007
3.1
[32]
Lehur
2008
4.0
[7]
Boccasanta et al.
2011
Anorectal stricture
3.0
[33]
Pechlivanides et al.
2007
3.7
[34]
Ellis
2007
1.2
[31]
Stuto et al.
2007
1.5
[32]
Lehur
2008
Anal and pelvic pain
20.0
[8]
Boccasanta et al.
2004
9.5
[31]
Stuto et al.
2007
11.0
[19]
Gagliardi et al.
2007
23.0
[17]
Meurette et al.
2011
Urgency
22.0
[35]
Nicolas et al.
2004
23.0
[31]
Stuto et al.
2007
44.0
[6]
Wadhavan et al.
2010
34.0
[8]
Boccasanta et al.
2011
Anal incontinence
14.0
[35]
Nicolas et al.
2004
3.0
[8]
Boccasanta et al.
2004
16.0
[33]
Pechlivanides et al.
2007
27.0
[28]
Jongen et al.
2010
Reinterventions After Complicated and Failed STARR Procedures
The reintervention rate for some of the postoperative complications (rectal bleeding and anorectal stricture) after the STARR procedure are presented in Table 27.2.
In the US, where the procedure was introduced later than in Europe and other countries, the US Food and Drug Administration has reported a number of rectal perforations, in some cases due to the malfunction of the stapler used for the STARR operation [37]. Table 27.3 updates previously reported results [25] concerning reintervention after STARR-related complications (Fig. 27.1a–c).
Table 27.3
Indications and outcome after reintervention for stapled transanal rectal resection –related complicationsa
Case indication | Reintervention | Outcome |
|---|---|---|
Severe rectal bleeding | Transanal suture of the staple line | OD after 8 years |
Proctalgia, incontinence, anxiety/depression | Anterior levatorplasty | Unchanged |
RVF, constipation, anxiety/depression | Mucosectomy, RVF repair, colostomy | OD after 4 years |
Proctalgia, anxiety/depression | Agraphectomy | Unchanged |
Rectal diverticulum, proctalgia | Lay open | Improved |
Failure (recurrence of OD) | ||
Rectosigmoid stricture, diverticular disease | Sigmoid resection | Improved |
Enterocele | Pouch of Douglas mesh repair | Improved |
Rectorectal intussusception, anxiety/depression | Resection rectopexy | Unchanged |
Rectal diverticulum, proctalgia | Rectoplasty, agraphectomy | Cured |
Tenesmus, proctalgia, anxiety/depression | Rectal cauterization-plication | Unchanged |
Urgency, proctalgia | Agraphectomy | Improved |
Rectal procidentia, proctalgia | Altemeier procedure, agraphectomy | Cured |
Fecal incontinence | Injection of bulking agents | Cured |
Fecal incontinence, proctalgia, anxiety/depression | Anterior levatorplasty | Unchanged |
Enterocele, anismus | Pouch of Douglas repair, biofeedback | Improved |
Rectal stricture, anxiety/depressionb | Agraphectomy, anal dilation | Lost to follow-up |
Fig. 27.1
(a) Schematic representation of a complicated case after stapled transanal rectal resection (STARR). The complicated and unfortunate case of a 33-year-old patient (the last patient in Table 27.3), who had five unsuccessful reoperations in 1 year after a STARR procedure, complicated by dehiscence of the staple line. The target of transanal stapling was an internal rectal prolapse, but the patient was anxious, slightly constipated, and affected by irritable bowel syndrome, with a history of anorexia. The surgeon was dedicated to transanal stapling and the patient heard about him and the novel procedure while watching television. (1–3) A laparoscopic sigmoid resection also was carried out with the STARR to remove a dolichosigmoid that was thought to be a cause of the symptoms, without a preoperative intestinal transit time study. A dehiscence of the STARR anastomosis caused peritonitis, but the patient had to move to another hospital to have a diverting stoma, which was subsequently closed. (4, 5) Meanwhile, the patient had developed a rectal stricture at the site of the dehiscence and complained of abdominal pain and obstructed defecation. A course of anorectal dilatations had been scheduled, but the first surgeon strongly suggested that the patient to come and see him for a colonoscopy, during which a perforation occurred (6). A second diverting stoma was then carried out, which was closed after 3 months. The patient still had severe abdominal pain, caused by adhesions, plus obstructed defecation secondary to the rectal stricture and was becoming clinically depressed. She went to see a colorectal surgeon who found a recurrent internal mucosal prolapse and performed an internal Delorme’s procedure. After a while, the patient started to suffer from the same symptoms and came to the Coloproctology Unit of Ars Medica Hospital. She was anxious, considerably underweight, and had a poor quality of life. A severe stricture was found in the lower rectum 7 cm above the anal verge (shown by computed tomography in b, c), and two staples were removed during the first anal dilatation under local anesthesia in the office (7). Another dilatation, up to 23 mm, was carried out after a week in the operating theatre under general anesthesia. The patient did not come to have the third dilatation performed and then was lost to follow-up. (b) Sagittal and (c) axial scans of this patient show the staple line of the STARR procedure with a low rectal stricture
In another series, a reintervention rate of 19% at 18 months was reported after the STARR operation; most reinterventions were performed for postoperative complications, disabling and persisting/recurrent OD symptoms, or both [19]. In the series by Miliacca et al. [38], only half of the patients undergoing reintervention were either improved or cured. It is of great importance to note that almost all of those patients who failed reintervention had significant anxiety and depression, which was diagnosed by a psychologist or defined by means of the draw-the-family test, and most of these patients were using antidepressants and tranquilizers. As previously reported, altered mental pattern is a negative predictor for outcome after surgery for OD [39], and it is thus essential that such patients be assessed by a neuropsychologist with an interest and experience in gastrointestinal somatization disorders before their initial surgery for OD symptoms. It is likely that such screening before contemplation of the STARR procedure will significantly reduce the incidence of disabling symptomatology after STARR; however, despite these warnings only a few authors of studies of the STARR procedure have ever reported psychological evaluation of their patients before surgery [40]. This issue is complex, and there is currently limited data on this aspect of OD patients presenting to coloproctologists; however, it is intuitive that such screening should be selectively part of the surgical indication and contraindication process [41].
Etiology of Postoperative Complications and of Symptom Recurrence After the STARR Procedure
Both the STARR and the trans-STARR operations are two rather appealing procedures with a sound rationale as far as the excision of the redundant and invaginated rectal folds is concerned, allowing for potential satisfactory evacuation in patients presenting with OD. Unfortunately, the STARR procedure does not seem to be effective in cases of a wide-neck rectocele [19], possibly because it does not reinforce the weakened rectovaginal septum, which is thought to be the main cause of symptoms because it is addressed by other techniques employing mesh or levatorplasty. Moreover, the STARR operation requires two rectal resections without a clear view of some crucial structures, including the mesorectum and the pouch of Douglas, rendering the procedure more prone to complications. Finally, because not all surgeries for OD (except perhaps Farid’s bilateral partial division of the nonrelaxing puborectalis muscle) [42] correct the neuromuscular causation of some of these cases, there are some concerns regarding a potential worsening of preexisting anismus by the stapled technology; it has been shown that the puborectalis may be partially incorporated in a peristaple fibrotic process, through which it becomes more rigid and less prone to relax during straining [26, 43] and that is accompanied on occasion by intractable pain that can be unaffected in some patients by staple excision (so-called aggraphectomy). The medicolegal issues pertaining to reoperative and reconstructive surgery of the anal canal are covered in the last section of this book; however, there is a medicolegal imperative to inform patients of the consequences and outcomes of complications after the stapled technology and that an understanding of these problems directs investigations before STARR and trans-STARR that are designed to exclude patients who are less likely to benefit from such a surgical approach. Herein also lies the dual dialog referred to earlier, where the inherent indications and contraindications to surgery in the OD population (and hence the utilization of the stapled procedures for its amelioration) will provide clues to the conflicting reports of postoperative success for these mixed functional disorders.
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