Postoperative complications after procedure for prolapsed hemorrhoids (PPH) and stapled transanal rectal resection (STARR) procedures

Procedure for prolapsing hemorrhoids (PPH) and stapled transanal rectal resection for obstructed defecation (STARR) carry low postoperative pain, but may be followed by unusual and severe postoperative complications. This review deals with the pathogenesis, prevention and treatment of adverse events that may occasionally be life threatening. PPH and STARR carry the expected morbidity following anorectal surgery, such as bleeding, strictures and fecal incontinence. Complications that are particular to these stapled procedures are rectovaginal fistula, chronic proctalgia, total rectal obliteration, rectal wall hematoma and perforation with pelvic sepsis often requiring a diverting stoma. A higher complication rate and worse results are expected after PPH for fourth-degree piles. Enterocele and anismus are contraindications to PPH and STARR and both operations should be used with caution in patients with weak sphincters. In conclusion, complications after PPH and STARR are not infrequent and may be difficult to manage. However, if performed in selected cases by skilled specialists aware of the risks and associated diseases, some complications may be prevented

Obstructed defaecation syndrome: European consensus guidelines on the surgical management.

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Stapled transanal rectal resection versus stapled anopexy in the cure of hemorrhoids associated with rectal prolapse : a randomized controlled trial

Purpose A remarkable incidence of failures after stapled axopexy (SA) for hemorrhoids has been recently reported by several papers, with an incomplete resection of the prolapsed tissue, due to the limited volume of the stapler casing as possible cause. The stapled transanal rectal resection (STARR) was demonstrated to successfully cure the association of rectal prolapse and rectocele by using two staplers. The aim of this randomized study was to evaluate the incidence of residual disease after SA and STARR in patients affected by prolapsed hemorrhoids associated with rectal prolapse. Methods Sixty-eight patients were selected on the basis of validated constipation and continence scorings, clinical examination, colonoscopy, anorectal manometry, and defecography and randomized: 34 underwent a SA and 34 a STARR operation. The operated patients were followed-up with clinical examination, visual analog scale for postoperative pain, a satisfaction index, and defecography. Results At a mean follow-up of 8.1 +/ 12 2.0 and 7.9 +/ 12 1.8 months for the SA and STARR groups, respectively, the incidence of residual disease was significantly higher in the first group (29.4 vs 5.9 in the STARR group, p=0.007), while a significantly lower incidence of residual skin-tags was found after STARR (23.5% vs 58.8 after SA, p=0.03). All patients with residual disease showed prolapsed tissue over half the length of the anal dilator at the time of the operation. Operative time and incidence of transient fecal urgency were significantly higher in the STARR group (with p=0.001 and 0.08, respectively), while SA was followed by a significantly higher incidence of poor results at the overall patient satisfaction index (p=0.04). No significant differences were found in hospital stay, operative complications, postoperative pain, time to return to normal activity, continence, and constipation scores. All the defecographic parameters significantly improved after STARR, while SA was followed only by a trend to a reduction of rectal prolapse. Conclusions STARR provides a more complete resection of the prolapsed tissue than SA in patients with association of prolapsed hemorrhoids and rectal prolapse with equal morbidity and significantly lower incidence of residual disease and skin-tags. The anal dilator can be used for selecting the surgical techniqu

What is the benefit of a new stapler device in the surgical treatment of obstructed defecation? Three-year outcomes from a randomized controlled trial

PURPOSE: A randomized study was conducted to compare the clinical and functional outcomes of the stapled transanal rectal resection, using the traditional 2 circular staplers and a new, curved stapler device in patients with obstructed defecation caused by rectal intussusception and rectocele. Stapled transanal rectal resection gives good midterm results in patients with obstructed defecation syndrome, but the limited capacity of the casing of the circular stapler and the impossibility to control the positioning of the rectal wall and the firing of staples may result in incomplete removal of the prolapsed tissues, or serious complications. The new curved multifire stapler could avoid these drawbacks. METHODS: From January to December 2006, 100 women were selected, with clinical examination, constipation score, colonoscopy, anorectal manometry, and perineography, and randomly assigned to 2 groups: 50 patients underwent stapled transanal rectal resection with 2 traditional circular staplers (STARR group) and 50 had the same operation with a new, curved multifire stapler (TRANSTAR group). Patients were followed up with clinical examination, constipation score, and colpocystodefecography, with the recurrence rate as the primary outcome measure. RESULTS: Recurrence rates at 3 years were 12.0% in STARR group and 0 in the TRANSTAR group (P = .035). Operating time was significantly shorter in the STARR group (P = .008). Complications were 2 bleeds (4%) in the STARR group and 1 tear of the vagina in the TRANSTAR group. The incidence of fecal urgency was 34.0% in the STARR group and 14.0% in the TRANSTAR group (P = .035). All symptoms and defecographic parameters significantly improved after the operation (P < .001) without differences between groups. CONCLUSIONS: The curved Contour Transtar stapler device did not appear to offer significant advantages over the traditional PPH-01 device during the operation or in the clinical and functional outcomes. However, the lower incidence of fecal urgency and recurrences might justify the higher cost of the new stapler