ABSTRACT

Outlet obstruction syndrome (OOS) is related to anatomic alterations, such as rectocele, enterocele and distal intussusception which may be associated with functional disorders, such as paradoxical puborectalis contraction. Patients unresponsive to conservative treatment are eligible for surgical correction of the specific anatomic defect. Recently, new techniques of stapler-assisted trans-anal surgery have been proposed as an alternative to traditional trans-anal operations. This prospective study was undertaken with the aim of assessing the efficacy and postoperative morbidity of two trans-anal stapled techniques (stapled trans-anal prolapsectomy or stapled trans-anal rectal resection, STARR) which were selectively performed in patients with OOS, based on the specific clinical, manometric and defecographic findings. From January 2004 to December 2006, 31 female patients (median age = 58.2 years: range = 27-77 years) underwent surgery at the Division of General Surgery, Colo-Rectal Disease Unit of San Martino Hospital in Genoa. Patients had preoperative colonoscopy, anorectal manometry, defecography, and a complete standardized questionnaire was completed preoperatively and at every six-month follow-up visit aimed at assessing the obstructed defecation score (ODS), the degree of symptoms (Gravity Disease Score = GDS), as well as the quality of life (PAC-QoL), and the satisfaction index by means of a visual analogue scale (VAS: 0-10). A complete re-assessment was performed after one year, including anorectal manometry and defecography. Six patients underwent stapled trans-anal prolapsectomy and 25 underwent STARR (double-STARR in seven, and single anterior STARR in 18 patients). All patients had a regular postoperative course. They had follow-up visits for a median period of 12 months (range: 4-27 months); 23 patients completed clinical and instrumental follow-up at one year, with a significant improvement of post-operative scores of outlet obstruction; moreover, 3 of them (13%) judged their final clinical outcome as excellent, and 18 (80%) as good or moderate. As regards anorectal manometry, pre- and postoperative resting and squeeze pressures were not different thus excluding any postoperative damage to the anal sphincter; conversely, an improvement of rectal sensation was observed in 15 patients (79%) as suggested by the decrease of rectal sensitivity threshold volumes (P = 0.01) and maximum tolerable volume (P < 0.01); moreover, in 7 out of 19 patients (36.8%) the balloon expulsion test became positive. With regard to postoperative defecography, normal findings were observed in 11 patients (61,2%) with a significant reduction of rectocele (P < 0.001); persistent abnormal findings were observed in 7 patients (38,8%). The accurate preoperative assessment and the selective trans-anal correction of rectocele and/or intussusception determined a significant improvement of outlet obstruction scores coupled with a normalization of defecographic and manometric findings, which was most relevant in patients undergoing STARR, without any serious postoperative complication.