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Article review: Constipation and continence after transanal rectal resection


Background. Although stapled transanal rectal resection (STARR) has become an important surgical option in the treatment of obstructive defecation syndrome, objective data about parameters that predict its success or failure are not yet available.

Methods. Medical history, clinical and radiomorphological data were obtained prospectively from a multi-institutional STARR registry. Predictive factors for postoperative constipation (Cleveland Clinic Constipation Score, CCS) and incontinence (Cleveland Clinic Incontinence Score, CCIS) were identified using univariable and multivariable analysis.

Results. Data were obtained for 181 of 201 patients in the STARR registry, with completed median follow‐up of 19.4 (range 12–41) months. Although the CCS decreased significantly overall [from mean (SD) 16.3 (4.9) to 6.7 (4.1); P < 0.001], 31 patients (17.1%) complained about persisting constipation. CCIS levels remained unchanged overall, but 16 patients (8.8% ) had new‐onset faecal incontinence. Multivariable analysis revealed that rectocele (β = −0.302, P < 0.001) and intussusception (β = −0.392, P < 0.001) were independent predictors of low CCS, and intussusception (β = −0.216, P = 0.001) and enterocele (β = −0.171, P = 0.012) were independent predictors of low CCIS. In contrast, small rectal diameter (β = −0.293, P < 0.001), low squeeze pressure (β = −0.188, P = 0.005) and increased pelvic floor descent at rest (β = 0.264, P < 0.001) predicted high CCIS.

Conclusion. Factors for a favourable outcome after STARR included rectocele, intussusception and enterocele, whereas small rectal diameter, low sphincter pressure and increased pelvic floor descent were unfavourable. These findings should be integrated into the therapy algorithm for STARR.


Since the introduction of the stapled transanal rectal resection (STARR), its use has become widely accepted in the treatment of obstructive defecation syndrome (ODS).1,2 Patients suffering from ODS experience a normal desire to defecate but are unable to evacuate the rectum. In these patients a defecogram may detect an anatomical abnormality such as rectal intussusception or rectocele. Although the STARR procedure has been shown to correct the anatomical abnormalities, the subsequent complications have divided surgeons in their use of this technique.3,4 The question facing surgeons is how can we avoid or prevent these complications following surgery? The commonly faced postoperative problems of urgency and incontinence may be short-lived but can also remain as a real deterioration in quality of life for the patient.

A study has already been done to prepare a decision-making algorithm for STARR in patients with ODS.5 When we look back there have already been observations noting which patients will have a poor outcome post STARR.6 Pescatori and Gagliardi4 suggested that patients with anismus, enterocele and weak sphincter should not undergo the STARR procedure.

Until now, there have been no real objective parameters to predict the success or failure of STARR. This paper uses clear parameters to help in the decision-making algorithm. This way surgeons who want to offer the best treatment can look at the selection criteria in order to determine whether or not their patient is likely to have a good outcome.

Here the authors have measured multiple parameters preoperatively and followed up their ODS patients with the Cleveland Clinic Constipation Score (CCS) and the Cleveland Clinic Incontinence Score (CCIS). They were able to demonstrate that patients with intussusception had better CCS score postoperatively and even better scores when they had intussusception combined with a rectocele larger than 20 mm.

Those patients having postoperative CCSI over 8, indicating moderate to severe incontinence, had a rectal diameter smaller than 40 mm. New-onset faecal incontinence occurred in patients having rectal diameters smaller than the rest of the patients (38.5 vs. 44.8 mm).

This paper helps surgeons to carefully select ODS patients suitable for the STARR procedure.

Independent predictive factors for postoperative continence


  1. Intussusception
  2. Enterocele.


  1. Small rectal diameter < 40 mm
  2. Low anal squeeze pressure
  3. Increased pelvic floor descent at rest.

Independent predictive factors favourable for postoperative constipation

  1. Enlarged rectocele
  2. Intussusception
  3. Combination of rectocele > 20 mm and intussusception has significantly less postoperative constipation.


  1. Lenisa L, Schwandner O, Stuto A, et al. STARR with Contour Transtar: prospective multicentre European study. Colorectal Dis 2009; 11:821–7.
  2. Naldini G, Cerullo G, Menconi C, et al. Resected specimen evaluation, anorectal manometry, endoanal ultrasonography and clinical follow-up after STARR procedures. World J Gastroenterol 2011; 17:2411–16.
  3. Pechlivanides G, Tsiaoussis J, Athanasakis E, et al. Stapled transanal rectal resection (STARR) to reverse the anatomic disorders of pelvic floor dyssynergia. World J Surg 2007; 31:1329–35.
  4. Pescatori M, Gagliardi G. Postoperative complications after procedure for prolapsed hemorrhoids (PPH) and stapled transanal rectal resection (STARR) procedures. Tech Coloproctol 2008;12:7–19.
  5. Schwandner O, Stuto A, Jayne D, et al. Decision-making algorithm for the STARR procedure in obstructed defecation syndrome: position statement of the group of STARR Pioneers. Surg Innov 2008; 15:105–9.
  6. Gagliardi G, Pescatori M, Altomare DF, et al.; Italian Society of Colo-Rectal Surgery (SICCR). Results, outcome predictors, and complications after stapled transanal rectal resection for obstructed defecation. Dis Colon Rectum 2008; 51:186–95.

Joan Robert-Yap

Pelvic Floor & Proctology Unit, Department of Surgery University Hospital Geneva

Rue Gabrielle Perret-Gentil 4, 1211 Geneva 14, Switzerland


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