Expert opinion: The benefits of the STARR approach for constipation

Dr Sabreena Malik looks at a new method of treating obstructed defaecation syndrome

Constipation in middle-aged and older women is a common and often embarrassing condition. It is thought that approximately 15 per cent of adult women experience symptoms of constipation; however, owing to the decision of many women to self-medicate with OTC products rather than discuss the problem during consultation, the true incidence remains unknown.  

The causes of constipation are slow colonic transit, obstructed defaecation or a concurrent combination.  

Slow transit constipation refers to the impaired ability of the colon to move faecal material around the bowel, which results in infrequent bowel motions. Obstructed defaecation syndrome (ODS) is the normal desire to defaecate, but an impaired ability to evacuate the rectum. Radiological evidence suggests ODS is often associated with rectoceles, rectal intussusception, and mucosal prolapse.  

An element of obstructed defaecation is believed to be present in about 30–40 per cent of women with constipation, with a preponderance in multiparous females. It is occasionally seen in nulliparous women and also rarely in males.  

Symptoms  

ODS is characterised by one or more of the following: increased straining at defaecation, excessive time spent on the toilet, the regular use of laxatives or enemas, fragmented or incomplete evacuation, and the need for perineal support or manual digitation to facilitate evacuation. 

Traditional management options for ODS — including dietary manipulation, laxatives, enemas, pelvic floor physiotherapy and a variety of surgical repairs aimed at rectoceles and intussusception – are largely unsuccessful in providing long-term benefits.  

Stapled transanal rectal resection (STARR) is a new treatment option being used to manage ODS-related constipation in the UK and other European countries as well as in the US. STARR is usually suitable for patients with rectoceles, rectal intussusception, mucosal prolapse or any combination of the above. The procedure is an extension of the stapled haemorrhoidopexy which has been used for the surgical treatment of haemorrhoids since 1996. 

Existing evidence of efficacy is limited to a small number of clinical trials. Evidence in favour of the procedure is rapidly accumulating; data suggest approximately 80 per cent of appropriately selected patients experience a significant clinical benefit from STARR.  

Colorectal surgeons who express an interest in performing the STARR procedure undergo training in Vienna and Hamburg followed by proctorship in the UK.  

NICE guidance  

In April 2006 NICE issued their first guidance on STARR/ODS and recommended that trained surgeons performing STARR should enter patients into the Association of Coloproctology of GB&I (ACPGBI) national registry.  

So far, 35 UK colorectal surgeons have been trained and are registered. They are based  throughout the country, at private and NHS hospitals in Leeds, Sheffield, Glasgow, Birmingham, Stoke, London, Basingstoke, Southampton, Poole, Taunton, and Plymouth.  

One of the surgeons currently undertaking the STARR procedure is Mr David Jayne, consultant colorectal surgeon at St James’s University Hospital, Leeds.  

Mr Jayne regularly assesses patients with ODS in a combined pelvic floor clinic run in conjunction with a consultant urogynaecologist. Not all pat-ients with constipation are suitable for the STARR procedure.  

Mr Jayne believes that ODS is not always an entity in itself and should be viewed in the context of the whole pelvic floor.  

The initial assessment is thorough and includes colonic imaging (colonoscopy or barium enema), colonic transit studies, a defaecating proctogram, anorectal physiology assessment and endoanal ultrasound.  

Those patients deemed unsuitable for STARR are offered alternative forms of medical management, such as biofeedback therapy.  

The costs of equipment for each STARR operation are £700, on to which are added the usual expenses of overnight hospitalisation. Figures from equipment sales indicate that over 5,000 STARR procedures will have been performed in Europe by the end of the year, and that, to date, there have been approximately 150 procedures performed in the UK.   

Referral  

GPs wishing to refer a patient for further assessment should write to their local colorectal surgeon enquiring about STARR. If registered, the surgeon will perform the pre-operative investigations and, if  the patient is suitable, the STARR procedure.  

If the surgeon is not registered, he or she is likely to arrange the work-up and then refer the patient on to a registered surgeon.  

Although discussing symptoms of constipation may not be easy for some women, an awareness of the recent advances in ODS among doctors has the potential to provide those seeking help with effective remedies for their complaints.  

Dr Malik is an A&E clinical assistant at St James’ University Hospital, Leeds 

What the STARR procedure involves  

STARR is usually suitable for patients with rectoceles, rectal intussusception, mucosal prolapse or any combination of the above.  

It is usually performed under general anaesthesia, with patients being fit for discharge the following day.  

Transanal insertion of a stapling instrument to resect the lower 4–5cm of rectum together with any associated rectocele, intussusception or mucosal prolapse.  

A simultaneous resection and anastomosis is secured with the resulting staple line placed high in the anorectum, avoiding any painful anodermal wounds.  

Potential complications include rectal bleeding and perineal sepsis.  

Some patients may experience defaecatory urgency early in the post-operative period, but this is usually self-limiting within three to six months.  

References  

Boccasanta P, Venturi M, Stuto A, et al. Stapled transanal resection for outlet obstruction: a prospective multicentre trial. Dis Colon Rectum 2004; 47: 1,285–97  

Boccasanta P, Venturi M, Salamina G, et al. New trends in the surgical treatment of outlet obstruction: clinical and functional results of two novel transanal stapled techniques from an RCT. Int J Colorectal Dis 2004; 19: 359–69  

Renzi A, Izzo D, Di Sarno G, et al. Stapled transanal rectal resection to treat obstructed defaecation caused by rectal intussusception and rectocele. Int J Colorectal Dis 2006; 1: 7 

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