Obstructed Defecation Syndrome: Diagnosis and Therapeutic Options, with Special Focus on the STARR Procedure Ada Rosen MD

EDITORIALS IMAJ • VOL 12 • FEBRUARY 2010

Department of Surgery A, Wolfson Medical Center, Holon and Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel

of constipation caused by obstructed nerves) [3]. Treatment can be conser- Key words: obstructed defecation syndrome, defecation: functional and mechanical. vative, such as the use of stool soft- STARR procedure, constipation, The functional type causes idiopathic eners, sphincter exercises and avoid- rectocele megarectum, anismus, descending ance of straining. Treatment may also IMAJ 2010; 12: 104–106 perineal syndrome, and solitary rectal be surgical, namely, post-anal repair, ulcer syndrome [3]. which corrects the anorectal angle. • Megarectum is an enlarged rectal • Solitary rectal ulcer 4–10 cm from diameter up to 6 cm at the level of the the anal verge usually occurs on the hronic constipation is a common pelvic brim, or total rectal capacity of anterior wall (68%). In these cases C self-reported bowel symptom that over 450 ml of air on manometry. In we often encounter a hyperactive affects 2–30% of people in the western special cases in children, megarec- puborectalis muscle with paradoxical world. It has a considerable impact on tum is due to a damaged mienteric contractions. It is frequently associ- health costs and quality of life. About plexus and abnormal motor func- ated with straining and prolapse (par- 30–50% of constipated patients have tion of the rectum [3]. Treatment is tial or complete). Treatment consists obstructed defecation [1,2]. surgical – anorectal myectomy or the of administration of local steroids The classical symptoms are pain at Duhamel procedure. and stool softeners (to prevent strain- defecation, extreme straining to def- • Anismus, also known as spastic pel- ing), as well as biofeedback [4,5]. If ecate, extended time on the toilet, long vic floor and pelvic floor dyssynergia, prolapse is present, it should be sur- interval between two evacuations (5–10 is a malfunction of the external anal gically repaired. days), perineal pain/discomfort when sphincter and puborectalis muscle standing, feeling of incomplete evacua- during defecation. This is a paradoxical Mechanical causes of obstructed defecation, and fragmented defecation [1]. contraction: failure to relax the pelvic tion are stricture, neoplasm, enterocele, Once a patient with these com- floor and anal muscles during defeca- intussusception, rectal prolapse, and plaints enters a pelvic floor clinic, a very tion [3]. The treatment for anismus rectocele. detailed diagnostic workup is necessary is difficult since patients with func- • Stricture usually follows surgery or to assess the exact cause of obstruction tional defecation disorders are often trauma. Treatment can be conservative and to tailor the most appropriate treat- unresponsive to conservative medical (use of stool softeners and enemas), ment. The diagnostic workup starts with management such as stool softeners invasive (use of dilators, YAG laser, a general investigation that includes: and niphedipine. Biofeedback train- or diathermy), or surgical (resection, history of symptoms, physical exami- ing has a success rate of 70–78% [4,5]. sphincterotomy or anoplasty). nation (digital anal examination and Treatment with botulinum toxin in- • Neoplasm, which should be ruled anoscopy), blood tests, barium enema or jection may provide temporary im- out by colonoscopy. colonoscopy, and rectal biopsy if need- provement, but it remains an investi- • Enterocele is the herniation of small ed. This is followed by specific anorectal gational treatment. Surgical division bowel into the pouch of Douglas. tests, such as anorectal manometry, bal- of the puborectalis muscle can also be Treatment is laparoscopic closure of loon expulsion test, rectal compliance, offered to these patients [6]. the enlarged pouch of Douglas. [7]. electromyography, nerve stimulation, • Descending perineum syndrome • Rectal prolapse/intussusception is transit studies, defecography, and endo- is caused by excessive straining and a partial (mucosal) or complete pro- anal ultrasound. weakened perineal muscles (possible trusion of the entire thickness of the We distinguish between two types stretching damage to the pudendal rectal wall through the anal sphincter.

104 IMAJ • VOL 12 • FEBRUARY 2010 EDITORIALS

It is classified as first degree when the ment option for obstructed defecation protrusion is invisible, second degree Figure 1. Stapled transanal rectal resection syndrome [14]. According to a Milan resection (STARR) [20] when it is visible on straining, and study reported in 2009, STARR is safe third degree when visible externally. and effective in the treatment of solitary It is caused by diastasis of the leva- rectal ulcer associated with internal rectal tors, deep Douglas pouch, redundant prolapse and has minimal complications rectosigmoid, patulous anus, or loss and no recurrence after 2 years [15]. of rectal horizontal position (due Recently, a new device – the CCS-30 to loose attachment to the sacrum). Contour Transtar – was developed by Treatment is surgical by the abdomi- the same Professor Longo. A multi- nal approach (Ribshtain procedure, STARR (stapled transanal rectal resec- center prospective study from Naples which is a fixation of the stretched tion) is a new surgical procedure that was confirms that the device is effective and rectum to the sacrum with or with- launched by Longo in 2001. It is a mini- safe and has functional results similar out a mesh), the perineal approach mally invasive transanal operation for rec- to those of the conventional STARR (Altemeier operation that involves a tocele and mucosal/rectal prolapse using [16]. This procedure (with both tech- sleeve resection of the prolapsed rec- a double circular stapler [Figure 1]. niques), according to most authors, tum and colon with a primary anas- In January 2006, the European is effective; the postoperative pain is tomosis performed transanally, or STARR registry was initiated. According mild, and the procedure is very much the Thiersch ring), or transanal (the to the results published in 2009 on 2838 accepted among colorectal surgeons for STARR procedure: namely, stapled patients, the improvement in rectal func- the treatment of rectocele as well as for transanal rectal resection). tion and quality of life was statistically internal rectal prolapse in patients with • Rectocele is defined as a herniation significant [13]. A multicenter study obstructed defecation. Yet, it should be of the rectal wall through a defect conducted in Spain between 2001 and emphasized that STARR is associated in the rectovaginal septum in the 2006 concluded that this procedure is with complications such as postop- direction of the vagina. It was tradi- associated with low morbidity and short erative bleeding, chronic proctalgia, tionally considered as a defect in the hospital stay and is an effective treat- rectovaginal fistula, stricture, and fecal rectovaginal septum, not the rectum. Possible causes are erect bipedal Figure 2. S.T.A.R.R. Written and agreed upon by the group of S.T.A.R.R. Pioneers Oct. 26-28, 2006 posture, vaginal childbirth, chronic increase in abdominal pressure (con- Diagnostic Approach Treatment Options after Dynamic Imaging

stipation, straining), or congenital or Before the patient sees the surgeon Clinically & morphologically confirmed S.T.A.R.R. inherited weakness in the pelvic sup- Colonoscopy to rule out tumors + inflammatory Internal prolapse +/- rectocele only bowel disease (IBD), etc. port system. Classical symptoms are Patient was treated, but conservative treatment with incomplete rectal emptying or bulge laxatives/enemas/diet failed Clinically & morphologically confirmed Treatment of Internal prolapse +/- rectocele associated disorders in the vagina. Evacuation is often associated with other morphological as per local practice digitally supported. The definitive When the patient sees the surgeon disorders objective diagnosis of rectocele is Patient interview • Enterocele (low and stable) Reassessment of ODS • Patient history • Sigmoidocele (low and stable) symptoms, if positive most commonly made by defec- • ODS assessment (score assessment) • Urogenital prolapse • Incontinence assessment (score assessment) • External rectal prolapse S.T.A.R.R. ography. This also assesses the size • Urogenital symptoms of the rectocele and the emptying • Quality of life / patient motivation assessment Clinically & morphologically confirmed Biofeedback capacity. The surgical indications for Inernal prolapse +/- rectocele Clinical examination associated with pelvic dyssynergia rectocele repair are controversial, but Reassessment of ODS • Perineal examination symptoms, if positive most surgeons advocate operative • Proctoscopy (rest/ straining) repair when a symptomatic recto- • Urogenital exam S.T.A.R.R. cele is large (> 3 cm), or if it fails to empty sufficiently on defecography. Clinical evaluation Clinically & morphologically confirmed With sphincter defect • Defecography/ perineography or dynamic MRI Internal prolapse +/- rectocele The treatment of rectocele is sur- • Anal manometry and endo-anal ultrasound – associated with fecal incontinence gery, the surgical approach can be only if incontinence or suspicion of sphincter Tailored therapy S.T.A.R.R. based on leading transvaginal [8], transperineal [9], damage; otherwise not mandatory symptoms and • Colon transit – if suspicion of slow transit No morphological Reassessment personal experience or transanal [10-12]. sphincter defect Biofeedback sacral The overall success rate of various surgi- nerve stimulation cal procedures is 80–95%.

105 EDITORIALS IMAJ • VOL 12 • FEBRUARY 2010

incontinence [17,18]. Some of these are and carry good results in patients with 707-11. "learning curve" complications and can obstructed defecation syndrome. 11. Khubchandani IT, Sheets JA, Stasik JJ, Hakki AR. Endorectal repair of rectocele. Dis Colon Rectum be avoided. In patients with enterocele 1983; 26: 792-6. and puborectalis dyssynergia, this pro- Correspondence: Dr. A. Rosen 12. Sehapayak S. Transrectal repair of rectocele: an cedure is contraindicated (unless the Dept. of Surgery A, Wolfson Medical Center, Holon extended armamentarium of colorectal surgeons. enterocele is repaired simultaneously 58100, Israel A report of 335 cases. Dis Colon Rectum 1985; 28: 422-33. on laparoscopy) [19]. All authors stress Phone: (972-3) 670-4480 Fax: (972-3) 670-4815 13. Jane DG, Schwandner O, Stuto A. Stapled trans- that if this procedure is performed in email: [email protected] anal rectal resection for obstructed defecation selected cases by skilled specialists, most syndrome: one year results of the European SRARR Registry. Dis Colon Rectum 2009; 52: complications can be avoided [18]. References 1205-12. In view of conflicting reports on the 1. Lembo A, Camilleri M. Chronic constipation. 14. Arroyo A, Gonzales-Argente FX, Garcia- safety and efficacy of the STARR proce- N Engl J Med 2003; 349: 1360-8. Domingo M, et al. Prospective multicenter dure, a European group of experts was 2. Surrenti E, Rath DM, Pemberton JH, Camilleri clinical trial of stapled transanal rectal resection M. Audit of constipation in a tertiary referral for obstructed defecation syndrome. Br J Surg founded in October 2006; and in June gastroenterology practice. Am J Gastroenterol 2008; 95: 1521-7. 2008, following a consensus conference 1995; 90: 1471-5. 15. Boccasanta P, Venturi M, Calabro G, Maccioco with evidence-based conclusions, they 3. Bharucha AE, Wald A, Enck P, Rao S. Functional M, Roviaro GC. Stapled transanal rectal resection anorectal disorders. Gastroenterology 2006; 130: in solitary rectal ulcer associated with prolapse published guidelines on inclusion and 1510-18. of the rectum: a prospective study. Dis Colon exclusion criteria as well as a diagnostic 4. Chiarioni G, Whitehead WE, Pezza V, Morelli A, Rectum 2008; 51: 348-54. and therapeutic algorithm for the STARR Bassotti G. Biofeedback is superior to laxatives 16. Renzi A, Talento P, Giardiello C, Angelone G, Izzo procedure in ODS [20] [Figure 2]. for normal transit constipation due to pelvic D, Di SamoG. Stapled transanal rectal resection floor dyssynergia. Gastroenterology 2006; 130: by a new dedicated device for the surgical These recommendations were based 657-64. treatment of obstructed defecation syndrome on the experience of 11 specialists in 5. Chiarioni G, Salandini L, Whitehead WE. caused by rectal intussusaption and rectocele: coloproctology and pelvic floor disease, Biofeedback benefits only patients with outlet early results of a multicenter prospective study. dysfunction, not patients with isolated slow transit Int J Colorectal Dis 2008; 23: 999-1005. pioneers in the STARR procedure, and constipation. Gastroenterology 2005; 129: 86-97. 17. Gagliardi G, Pescatori M, Altomare DF, et al. it was concluded after a 100% consen- 6. Kamm MA, Hawley PR, Lennard-Jones JE. Results, outcome, predictors and complications sus within the group [20]. They also Lateral division of the puborectalis muscle in after stapled transanal resection for obstructed the management of severe constipation. Br J Surg defecation. Dis Colon Rectum 2008; 51: 186-95. concluded that this procedure can be 1988; 75: 661-3. 18. Pescatori M, Gagliardi G. Postoperative com- performed with either of the devices, 7. Zacharin FR, Hamilton NT. Pulsion enterocele: plications after procedure for prolapsed hemor- depending on the size of the prolapse long-term results of an abdominoperineal rhoids (PPH) and stapled transanal rectal technique. Obstet Gynecol 1980; 2: 141-8. or rectocele and on the personal experi- resection (STARR) procedure. Tech Coloproctol 8. Porter WE, Steele A, Walsh P, Kohli N, Karram 2008; 12: 7-19. ence of the surgeon. Patient selection is MM. The anatomic and functional outcomes 19. Carriero A, Picchio M, Martellucci J, Talento P, crucial, as is the use of the standardized of defect-specific rectocele repairs. Am J Obstet Palimento D, Spaziani E. Laparoscopic correction diagnostic and therapeutic approach. Gynecol 1999; 181: 1353-8. of enterocele associated to stapled transanal rectal 9. van Laarhoven CJ, Kamm MA, Bartram CI, resection for obstructed defecation syndrome. From my personal experience with Halligan S, Hawley PR, Phillips RK. Relationship Int J Colorectal Dis 2009. [Epub ahead of print] STARR and TRANSTAR procedures, between anatomic and symptomatic long- 20. Schwandner O, Stuto A, Jayne D, et al. Decision- I maintain that when performed with term results after rectocele repair for impaired making algorithm for the STARR procedure defecation. Dis Colon Rectum 1999; 42: 204-11. in obstructed defecation syndrome. Position caution, after a very careful selection 10. Block JR. Transrectal repair of rectocele using statement of the group of STARR Pioneers. Surg of patients, both procedures are safe obliterative suture. Dis Colon Rectum 1986; 29: Innov 2008; 15: 105-9.

Capsule

Dendrite functions in fast-spiking hippocampal basket cells

Basket cells, a group of fast-spiking inhibitory interneurons, This is very different from what had been observed previously play an important part in the function of neuronal networks. in widely investigated pyramidal cell dendrites, probably due The mechanisms underlying the high temporal precision and to the high potassium to sodium conductance ratios in the short latency of basket cell activity are unclear. Hu and team dendrites of the interneurons. These dendritic mechanisms investigated dendrite functions in fast-spiking hippocampal can explain the high frequency firing and precise timing of basket cells and found that action potentials are initiated basket cells seen in network activity in vivo. in the axon and propagate back into the dendrites without Science 2010; 327: 52 activity dependence but with strongly reduced amplitude. Eitan Israeli

106