Tech Coloproctol DOI 10.1007/s10151-014-1155-7
TECHNICAL NOTE
Partial prolapsectomy and fixation proctomucopexy: a novel minimally invasive procedure L. C. Pescatori • G. Busuito • M. Pescatori
Received: 23 November 2013 / Accepted: 12 April 2014 Ó Springer-Verlag Italia 2014
Abstract A novel minimally invasive procedure for the management of anterior external and posterior internal mucosal prolapse is described. The operation, carried out via a transanal route, consists of a partial prolapsectomy and a mucosal proctopexy. Out of six patients, one had severe postoperative bleeding and one had a recurrence of internal prolapse and obstructed defecation. Three patients had pelvic floor rehabilitation for associated dysfunctions. The advantage of the operation is that a circumferential anastomosis is avoided, thus decreasing the risk of dehiscence, and only a short sphincter dilation is required. Moreover, the procedure has very little effect on the rectal reservoir, thus preventing fecal urgency. No reintervention was needed, and almost all patients were cured after 2 years. Keywords Rectal mucosal prolapse Proctomucopexy Prolapsectomy
anal incontinence. Delorme and stapled transanal rectal resection (STARR) are among the most used procedures [2–4]. Other procedures have been also reported, i.e., manual mucosectomy without muscle plication, stapled circular mucosectomy or procedure for prolapse and hemorrhoids (PPH) and the Contour Transtar technique [5– 7]. All the above-mentioned procedures consist of rectal tissue excision, which may reduce the rectal reservoir thus leading to fecal urgency and incontinence, and of an anastomosis that may leak and cause anorectal stricture. The more tissue is excised, the higher is the risk of postoperative bleeding and the more the anal sphincter is stretched, the higher is the risk of soiling. In case of circumferential anastomosis, it is more likely that there will be severe stenosis following a major dehiscence. The operations with staplers are most costly. A novel minimally invasive procedure has been used at our unit, aimed at decreasing both costs and postoperative complications.
Introduction Rectal prolapse may be internal and external, mucosal and full thickness. It may also be mixed, usually with an anterior external portion and a posterior internal component, as posteriorly the mucosal descent is opposed by the bulk of the puborectalis muscle. Internal prolapse is frequently associated with obstructed defecation [1]. Surgery for rectal mucosal prolapse may be followed by troublesome complications such as bleeding, stricture and L. C. Pescatori (&) G. Busuito M. Pescatori Coloproctology Unit, Parioli Clinic, Via F. Giordano, 8–00197 Rome, Italy e-mail: [email protected]
Surgical technique (Fig. 1a–f) The operation, i.e., partial prolapsectomy and fixation proctomucopexy, is carried out by a transanal route and is indicated in case of anterior external and posterior internal mucosal prolapse B third degree according our classification, i.e., reaching the anal verge on straining [8]. After a fleet enema and antibiotic prophylaxis with i.v. metronidazole and a fifth generation cephalosporin, with the patient in the lithotomy position and under spinal anesthesia or local anesthesia and sedation, the anus is gently dilated and the anterior prolapse pulled out with forceps. After injecting adrenaline and saline 1:200,000 to achieve
123
Tech Coloproctol
Fig. 1 ‘‘Partial prolapsectomy and fixation proctectomy’’ procedure: a operative field, before the operation begins. Prolapse of the anal canal. The patient is in the lithotomy position. b Mild circumferential rectal mucosal prolapse. c First step diathermy incision just above the dentate line (arrow) to start the anterior mucosectomy. d Anterior
mucosal prolapsectomy. The mucosa is excised and the intact rectal muscle is left in situ (arrow). e Second step posterior mucopexy. Ustitch anchoring the distal part of the prolapsed mucosa to the upper rectal muscle. f At the end of the operation, due to the excision-pexy, the distal anal canal is not prolapsed any more
better hemostasis and dissection of planes, a semicircular anterior excision is carried out just above the dentate line to preserve the sensitive epithelium of the distal anal canal and the anterior mucosectomy is performed up to the borderline between the lower and the mid-rectum avoiding injuries of the rectal muscle (Fig. 1c, d). A small Farabeuf retractor is sufficient to lift up the anal verge, and no anal dilator is needed, so stretching of the sphincters is avoided. Once the mucosectomy is completed, the upper rectal mucosa is sutured to the lower anal canal with interrupted Vicryl 3/0 stitches. The segment of denuded anorectum is usually not more than 5 cm in length, and, since the rectal mucosa redundant in these patients, the anastomosis is unlikely to be under tension. A disposable fenestrated anal retractor (Sapi Med SpA, Alessandria, Italy) is used to visualize the posterior aspect of the rectum and deal with the bulk of the internal prolapse. One to three U stitches are used for the proctomucopexy, aimed at lifting up the prolapse as seen in Fig. 1e. The upper stitches of the sutures have to transfix the full thickness of rectal muscularis propria, whereas the lower stitches are passed just through the mucosa and the submucosa of the inferior edge of the internal prolapse. Once the pexy is completed, one to three fixation transverse sutures are used to make it stable. These sutures further anchor the uplifted prolapse to the rectal wall making the prolapsed mucosa ischemic and ultimately fibrotic, causing the redundant posterior wall to shrink
further. The hemostasis is carefully checked; once the retractor is removed, the sutures will disappear in the anal canal, protected by the lower edges of both internal and external sphincter, without any mucosal ectropion. The patient may be discharged on the same day or after an overnight stay. Plenty of fluids and high residue diet are prescribed as well as an oral analgesic, usually ketorolac, for at least 72 h. An elastomer may be used to administrate morphine hydrochloride 20 mg i.v. for the first 24 h, when the patient is not discharged on the same day. A digital rectal examination is performed within a week to check the integrity of the sutures.
123
Results and discussion We operated on six patients (4 females), with a median age of 56 years, (range 38–72 years), between January 2008 and February 2011. Informed consent was obtained from all patients prior to surgery. They represent 27 % of the patients operated on for rectal prolapse in the same period at the authors’ unit. The number of patients treated was small because the indications were restricted to those with anterior external and posterior internal mucosal prolapse. All patients but one had obstructed defecation. Two also had weekly incontinence to liquid stool grade B2, score 4 according to our classification [9], and underwent a
Tech Coloproctol
sphincter reconstruction during the same operation. Two of them had undergone previous anal surgery. In two females, the anterior external prolapse was just 1 cm in size, and a proctomucopexy was considered sufficient also on the anterior aspect. All patients were followed up for a median of 24 months (range 14–38 months) at our clinic. Operative mortality was nil, and none of the patients had intraoperative complications. One was discharged on the same day. Two stayed overnight, and three were discharged after 3 days. Postoperative pain was \4 during the first 48 h in all cases, as recorded with the 1–10 visual analog scale (VAS). One patient had postoperative bleeding, requiring readmission. He was a 72-year-old male and had fecal impaction. Straining and hard feces might have favored bleeding. The hemorrhage ceased with postoperative i.v. fluids and coagulant drugs. At proctoscopy, 1 week later, multiple erosions of the anterior lower rectum were found. One patient, a 66-year-old diabetic, had a partial breakdown of the recto-anal anastomosis, with no subsequent stricture. The other four patients had no complications. The two patients with incontinence improved and had only occasional nightly soiling, grade B1, score 3. Obstructed defecation was cured in, all but one patient whose internal prolapse recurred. One patient was lost to follow-up. None of the five remaining patients had recurrent external prolapse. Three of the patients had transanal electrostimulation and echo-enhanced bio-feedback training 2 months after surgery, aimed at treating rectal hyposensation and nonrelaxing puborectalis muscle on straining. The novel procedure may be considered minimally invasive as the amount of excised tissue is small, recto-anal anastomosis is partial, there is almost no intraoperative blood loss, the procedure lasts\40 min (excluding the time spent for the sphincter reconstruction), hospital stay is short and the level of postoperative pain is low. However, it should be noted that an adequate dosage of analgesics is needed to control pain in these patients. The posterior U suture may well cause pain, as the rectal muscle has to be transfixed when performing the proctomucopexy and the suture may involve the richly innervated underlying levator ani. One limitation of the study is the lack of a control group, e.g., with a Delorme procedure. However, the present paper is mainly aimed at reporting the novel technique. Moreover, it is better to avoid a Delorme procedure in these patients with small lesions, as it is associated with a high incontinence rate, due both to the reduced rectal reservoir and to prolonged sphincter stretching [3]. The double stapled rectotomy of STARR reduces the rectal capacity and is likely to impair the rectal adaptation reflex, which allows evacuation to be postponed. STARR is followed by fecal
urgency in one-third of cases [10], may cause rectovaginal fistulae [11] and can lead to reintervention for severe postoperative bleeding in up to 4.8 % of cases [12]. It may result in painful defecation in 20 % of patients [13] and the persistence of obstructed defecation in 50 % of patients [14]. Moreover, the procedure is contraindicated when dealing with an external prolapse [15]. The novel alternative, the Contour Transtar technique, recently proposed for the treatment of external prolapse, is associated with reinterventions for severe bleeding in 15 % of patients [16] and a cost of 1,600 euros [6]. Instead, the cost of partial prolapsectomy and proctomucopexy is minimal. Two other non-excisional procedures have been described for the management of rectal prolapse. Both are modified Delorme operations. One, the cauterization-plication procedure, has been proposed by El Sibai and Shafik [17] and is aimed at correcting the external prolapse, plicating the rectal muscle over diathermy strips. The other, the transanal purse-string suture, more recently described by Chinese authors [18], has been proposed for the management of internal mucosal prolapse. Both have been reported to achieve a satisfactory outcome. In conclusion, partial mucosal prolapsectomy and fixation proctomucopexy may have both clinical and functional advantages over other excisional procedures. Larger series with longer follow-up are needed to confirm its safety and efficacy and its role in the tailored surgery of rectal prolapse. What is important, in our opinion, is that the often hidden functional and organic lesions present in patients with rectal prolapse are also treated using an adequate diagnostic and therapeutic approach based on the ‘‘iceberg diagram,’’ which demonstrates that internal mucosal prolapse is just the ‘‘tip of the iceberg’’ in patients with obstructed defecation [1]. Associated dysfunctions, such as anismus and rectal hyposensation, which were present in half of our patients, have to be cured. If neglected, they may well worsen the outcome of surgery. Acknowledgments the manuscript.
Thanks are due to C. De Bono, who helped with
Conflict of interest
None.
References 1. Pescatori M, Spyrou M, Pulvirenti D’Urso A (2006) A prospective evaluation of occult disorders in obstructed defecation using the ‘‘iceberg diagram’’. Colorectal Dis 8:785–789 2. Berman IR, Harris MS, Rabeler MB (1990) Delorme’s transrectal excision for internal rectal prolapse. patient selection, technique, and three-year follow-up. Dis Colon Rectum 33:573–580 3. Liberman H, Hughes C, Dippolito A (2000) Evaluation and outcome of the Delorme procedure in the treatment of rectal outlet obstruction. Dis Colon Rectum 43:188–192
123
Tech Coloproctol 4. Pescatori M, Gagliardi G (2008) Postoperative complications after procedure for prolapsed hemorrhoids (PPH) and stapled transanal rectal resection (STARR) procedures. Tech Coloproctol 12:7–19 5. Pescatori M, Favetta U, Dedola S, Orsini S (1997) Stapled transanal excision of rectal mucosal prolapse. Tech Coloproctol 1:96–98 6. Lenisa L, Schwandner O, Stuto A et al (2009) STARR with Contour Transtar: prospective multicentre European study. Colorectal Dis 11:821–827 7. Blas-Franco M, Valenzuela-Salazar C, De la Concha-Blankenagel E et al (2014) Stapled transanal longitudinal posterior proctectomy (STALPP) in total rectal prolapse: a 7-year experience. Tech Coloproctol 18:173–178 8. Pescatori M, Quondamcarlo C (1999) A new grading of rectal internal mucosal prolapse and its correlation with diagnosis and treatment. Int J Colorectal Dis 14:245–249 9. Pescatori M, Anastasio G, Bottini C, Mentasti A (1992) New grading and scoring for anal incontinence. evaluation of 335 patients. Dis Colon Rectum 35:482–487 10. Boccasanta P, Venturi M, Roviaro G (2011) What is the benefit of a new stapler device in the surgical treatment of obstructed defecation? Three-year outcomes from a randomized controlled trial. Dis Colon Rectum 54:77–84 11. Bassi R, Rademacher J, Savoia A (2006) Rectovaginal fistula after STARR procedure complicated by haematoma of the
123
12.
13.
14.
15.
16.
17.
18.
posterior vaginal wall: report of a case. Tech Coloproctol 10:361–363 Stuto A, Renzi A, Carriero A et al (2011) Stapled trans-anal rectal resection (STARR) in the surgical treatment of the obstructed defecation syndrome: results of STARR Italian registry. Surg Innov 18:248–253 Boccasanta P, Venturi M, Stuto A (2004) Stapled transanal rectal resection for outlet obstruction: a prospective, multicenter trial. Dis Colon Rectum 47:1285–1296 Gagliardi G, Pescatori M, Altomare DF et al (2008) Italian Society of Colo-Rectal Surgery (SICCR). Results, outcome predictors, and complications after stapled transanal rectal resection for obstructed defecation. Dis Colon Rectum 51:186–195 Corman ML, Carriero A, Hager T et al (2006) Consensus conference on the stapled transanal rectal resection (STARR) for disordered defaecation. Colorectal Dis 8:98–101 Lieske B, Conaghan P, Farouk R (2010) Outcome after stapled perineal rectosigmoidectomy using tranSTARR. Dis Colon Rectum 53:581 El-Sibai O, Shafik AA (2002) Cauterization-plication operation in the treatment of complete rectal prolapse. Tech Coloproctol 6:51–54 Wang Y, Zhai C, Niu L, Tian L, Yang J, Hu Z (2010) A modified Delorme’s operation for the treatment f rectal mucosal prolapsed. Int J Colorectal Dis 25:607–611
TECHNICAL NOTE
Partial prolapsectomy and fixation proctomucopexy: a novel minimally invasive procedure L. C. Pescatori • G. Busuito • M. Pescatori
Received: 23 November 2013 / Accepted: 12 April 2014 Ó Springer-Verlag Italia 2014
Abstract A novel minimally invasive procedure for the management of anterior external and posterior internal mucosal prolapse is described. The operation, carried out via a transanal route, consists of a partial prolapsectomy and a mucosal proctopexy. Out of six patients, one had severe postoperative bleeding and one had a recurrence of internal prolapse and obstructed defecation. Three patients had pelvic floor rehabilitation for associated dysfunctions. The advantage of the operation is that a circumferential anastomosis is avoided, thus decreasing the risk of dehiscence, and only a short sphincter dilation is required. Moreover, the procedure has very little effect on the rectal reservoir, thus preventing fecal urgency. No reintervention was needed, and almost all patients were cured after 2 years. Keywords Rectal mucosal prolapse Proctomucopexy Prolapsectomy
anal incontinence. Delorme and stapled transanal rectal resection (STARR) are among the most used procedures [2–4]. Other procedures have been also reported, i.e., manual mucosectomy without muscle plication, stapled circular mucosectomy or procedure for prolapse and hemorrhoids (PPH) and the Contour Transtar technique [5– 7]. All the above-mentioned procedures consist of rectal tissue excision, which may reduce the rectal reservoir thus leading to fecal urgency and incontinence, and of an anastomosis that may leak and cause anorectal stricture. The more tissue is excised, the higher is the risk of postoperative bleeding and the more the anal sphincter is stretched, the higher is the risk of soiling. In case of circumferential anastomosis, it is more likely that there will be severe stenosis following a major dehiscence. The operations with staplers are most costly. A novel minimally invasive procedure has been used at our unit, aimed at decreasing both costs and postoperative complications.
Introduction Rectal prolapse may be internal and external, mucosal and full thickness. It may also be mixed, usually with an anterior external portion and a posterior internal component, as posteriorly the mucosal descent is opposed by the bulk of the puborectalis muscle. Internal prolapse is frequently associated with obstructed defecation [1]. Surgery for rectal mucosal prolapse may be followed by troublesome complications such as bleeding, stricture and L. C. Pescatori (&) G. Busuito M. Pescatori Coloproctology Unit, Parioli Clinic, Via F. Giordano, 8–00197 Rome, Italy e-mail: [email protected]
Surgical technique (Fig. 1a–f) The operation, i.e., partial prolapsectomy and fixation proctomucopexy, is carried out by a transanal route and is indicated in case of anterior external and posterior internal mucosal prolapse B third degree according our classification, i.e., reaching the anal verge on straining [8]. After a fleet enema and antibiotic prophylaxis with i.v. metronidazole and a fifth generation cephalosporin, with the patient in the lithotomy position and under spinal anesthesia or local anesthesia and sedation, the anus is gently dilated and the anterior prolapse pulled out with forceps. After injecting adrenaline and saline 1:200,000 to achieve
123
Tech Coloproctol
Fig. 1 ‘‘Partial prolapsectomy and fixation proctectomy’’ procedure: a operative field, before the operation begins. Prolapse of the anal canal. The patient is in the lithotomy position. b Mild circumferential rectal mucosal prolapse. c First step diathermy incision just above the dentate line (arrow) to start the anterior mucosectomy. d Anterior
mucosal prolapsectomy. The mucosa is excised and the intact rectal muscle is left in situ (arrow). e Second step posterior mucopexy. Ustitch anchoring the distal part of the prolapsed mucosa to the upper rectal muscle. f At the end of the operation, due to the excision-pexy, the distal anal canal is not prolapsed any more
better hemostasis and dissection of planes, a semicircular anterior excision is carried out just above the dentate line to preserve the sensitive epithelium of the distal anal canal and the anterior mucosectomy is performed up to the borderline between the lower and the mid-rectum avoiding injuries of the rectal muscle (Fig. 1c, d). A small Farabeuf retractor is sufficient to lift up the anal verge, and no anal dilator is needed, so stretching of the sphincters is avoided. Once the mucosectomy is completed, the upper rectal mucosa is sutured to the lower anal canal with interrupted Vicryl 3/0 stitches. The segment of denuded anorectum is usually not more than 5 cm in length, and, since the rectal mucosa redundant in these patients, the anastomosis is unlikely to be under tension. A disposable fenestrated anal retractor (Sapi Med SpA, Alessandria, Italy) is used to visualize the posterior aspect of the rectum and deal with the bulk of the internal prolapse. One to three U stitches are used for the proctomucopexy, aimed at lifting up the prolapse as seen in Fig. 1e. The upper stitches of the sutures have to transfix the full thickness of rectal muscularis propria, whereas the lower stitches are passed just through the mucosa and the submucosa of the inferior edge of the internal prolapse. Once the pexy is completed, one to three fixation transverse sutures are used to make it stable. These sutures further anchor the uplifted prolapse to the rectal wall making the prolapsed mucosa ischemic and ultimately fibrotic, causing the redundant posterior wall to shrink
further. The hemostasis is carefully checked; once the retractor is removed, the sutures will disappear in the anal canal, protected by the lower edges of both internal and external sphincter, without any mucosal ectropion. The patient may be discharged on the same day or after an overnight stay. Plenty of fluids and high residue diet are prescribed as well as an oral analgesic, usually ketorolac, for at least 72 h. An elastomer may be used to administrate morphine hydrochloride 20 mg i.v. for the first 24 h, when the patient is not discharged on the same day. A digital rectal examination is performed within a week to check the integrity of the sutures.
123
Results and discussion We operated on six patients (4 females), with a median age of 56 years, (range 38–72 years), between January 2008 and February 2011. Informed consent was obtained from all patients prior to surgery. They represent 27 % of the patients operated on for rectal prolapse in the same period at the authors’ unit. The number of patients treated was small because the indications were restricted to those with anterior external and posterior internal mucosal prolapse. All patients but one had obstructed defecation. Two also had weekly incontinence to liquid stool grade B2, score 4 according to our classification [9], and underwent a
Tech Coloproctol
sphincter reconstruction during the same operation. Two of them had undergone previous anal surgery. In two females, the anterior external prolapse was just 1 cm in size, and a proctomucopexy was considered sufficient also on the anterior aspect. All patients were followed up for a median of 24 months (range 14–38 months) at our clinic. Operative mortality was nil, and none of the patients had intraoperative complications. One was discharged on the same day. Two stayed overnight, and three were discharged after 3 days. Postoperative pain was \4 during the first 48 h in all cases, as recorded with the 1–10 visual analog scale (VAS). One patient had postoperative bleeding, requiring readmission. He was a 72-year-old male and had fecal impaction. Straining and hard feces might have favored bleeding. The hemorrhage ceased with postoperative i.v. fluids and coagulant drugs. At proctoscopy, 1 week later, multiple erosions of the anterior lower rectum were found. One patient, a 66-year-old diabetic, had a partial breakdown of the recto-anal anastomosis, with no subsequent stricture. The other four patients had no complications. The two patients with incontinence improved and had only occasional nightly soiling, grade B1, score 3. Obstructed defecation was cured in, all but one patient whose internal prolapse recurred. One patient was lost to follow-up. None of the five remaining patients had recurrent external prolapse. Three of the patients had transanal electrostimulation and echo-enhanced bio-feedback training 2 months after surgery, aimed at treating rectal hyposensation and nonrelaxing puborectalis muscle on straining. The novel procedure may be considered minimally invasive as the amount of excised tissue is small, recto-anal anastomosis is partial, there is almost no intraoperative blood loss, the procedure lasts\40 min (excluding the time spent for the sphincter reconstruction), hospital stay is short and the level of postoperative pain is low. However, it should be noted that an adequate dosage of analgesics is needed to control pain in these patients. The posterior U suture may well cause pain, as the rectal muscle has to be transfixed when performing the proctomucopexy and the suture may involve the richly innervated underlying levator ani. One limitation of the study is the lack of a control group, e.g., with a Delorme procedure. However, the present paper is mainly aimed at reporting the novel technique. Moreover, it is better to avoid a Delorme procedure in these patients with small lesions, as it is associated with a high incontinence rate, due both to the reduced rectal reservoir and to prolonged sphincter stretching [3]. The double stapled rectotomy of STARR reduces the rectal capacity and is likely to impair the rectal adaptation reflex, which allows evacuation to be postponed. STARR is followed by fecal
urgency in one-third of cases [10], may cause rectovaginal fistulae [11] and can lead to reintervention for severe postoperative bleeding in up to 4.8 % of cases [12]. It may result in painful defecation in 20 % of patients [13] and the persistence of obstructed defecation in 50 % of patients [14]. Moreover, the procedure is contraindicated when dealing with an external prolapse [15]. The novel alternative, the Contour Transtar technique, recently proposed for the treatment of external prolapse, is associated with reinterventions for severe bleeding in 15 % of patients [16] and a cost of 1,600 euros [6]. Instead, the cost of partial prolapsectomy and proctomucopexy is minimal. Two other non-excisional procedures have been described for the management of rectal prolapse. Both are modified Delorme operations. One, the cauterization-plication procedure, has been proposed by El Sibai and Shafik [17] and is aimed at correcting the external prolapse, plicating the rectal muscle over diathermy strips. The other, the transanal purse-string suture, more recently described by Chinese authors [18], has been proposed for the management of internal mucosal prolapse. Both have been reported to achieve a satisfactory outcome. In conclusion, partial mucosal prolapsectomy and fixation proctomucopexy may have both clinical and functional advantages over other excisional procedures. Larger series with longer follow-up are needed to confirm its safety and efficacy and its role in the tailored surgery of rectal prolapse. What is important, in our opinion, is that the often hidden functional and organic lesions present in patients with rectal prolapse are also treated using an adequate diagnostic and therapeutic approach based on the ‘‘iceberg diagram,’’ which demonstrates that internal mucosal prolapse is just the ‘‘tip of the iceberg’’ in patients with obstructed defecation [1]. Associated dysfunctions, such as anismus and rectal hyposensation, which were present in half of our patients, have to be cured. If neglected, they may well worsen the outcome of surgery. Acknowledgments the manuscript.
Thanks are due to C. De Bono, who helped with
Conflict of interest
None.
References 1. Pescatori M, Spyrou M, Pulvirenti D’Urso A (2006) A prospective evaluation of occult disorders in obstructed defecation using the ‘‘iceberg diagram’’. Colorectal Dis 8:785–789 2. Berman IR, Harris MS, Rabeler MB (1990) Delorme’s transrectal excision for internal rectal prolapse. patient selection, technique, and three-year follow-up. Dis Colon Rectum 33:573–580 3. Liberman H, Hughes C, Dippolito A (2000) Evaluation and outcome of the Delorme procedure in the treatment of rectal outlet obstruction. Dis Colon Rectum 43:188–192
123
Tech Coloproctol 4. Pescatori M, Gagliardi G (2008) Postoperative complications after procedure for prolapsed hemorrhoids (PPH) and stapled transanal rectal resection (STARR) procedures. Tech Coloproctol 12:7–19 5. Pescatori M, Favetta U, Dedola S, Orsini S (1997) Stapled transanal excision of rectal mucosal prolapse. Tech Coloproctol 1:96–98 6. Lenisa L, Schwandner O, Stuto A et al (2009) STARR with Contour Transtar: prospective multicentre European study. Colorectal Dis 11:821–827 7. Blas-Franco M, Valenzuela-Salazar C, De la Concha-Blankenagel E et al (2014) Stapled transanal longitudinal posterior proctectomy (STALPP) in total rectal prolapse: a 7-year experience. Tech Coloproctol 18:173–178 8. Pescatori M, Quondamcarlo C (1999) A new grading of rectal internal mucosal prolapse and its correlation with diagnosis and treatment. Int J Colorectal Dis 14:245–249 9. Pescatori M, Anastasio G, Bottini C, Mentasti A (1992) New grading and scoring for anal incontinence. evaluation of 335 patients. Dis Colon Rectum 35:482–487 10. Boccasanta P, Venturi M, Roviaro G (2011) What is the benefit of a new stapler device in the surgical treatment of obstructed defecation? Three-year outcomes from a randomized controlled trial. Dis Colon Rectum 54:77–84 11. Bassi R, Rademacher J, Savoia A (2006) Rectovaginal fistula after STARR procedure complicated by haematoma of the
123
12.
13.
14.
15.
16.
17.
18.
posterior vaginal wall: report of a case. Tech Coloproctol 10:361–363 Stuto A, Renzi A, Carriero A et al (2011) Stapled trans-anal rectal resection (STARR) in the surgical treatment of the obstructed defecation syndrome: results of STARR Italian registry. Surg Innov 18:248–253 Boccasanta P, Venturi M, Stuto A (2004) Stapled transanal rectal resection for outlet obstruction: a prospective, multicenter trial. Dis Colon Rectum 47:1285–1296 Gagliardi G, Pescatori M, Altomare DF et al (2008) Italian Society of Colo-Rectal Surgery (SICCR). Results, outcome predictors, and complications after stapled transanal rectal resection for obstructed defecation. Dis Colon Rectum 51:186–195 Corman ML, Carriero A, Hager T et al (2006) Consensus conference on the stapled transanal rectal resection (STARR) for disordered defaecation. Colorectal Dis 8:98–101 Lieske B, Conaghan P, Farouk R (2010) Outcome after stapled perineal rectosigmoidectomy using tranSTARR. Dis Colon Rectum 53:581 El-Sibai O, Shafik AA (2002) Cauterization-plication operation in the treatment of complete rectal prolapse. Tech Coloproctol 6:51–54 Wang Y, Zhai C, Niu L, Tian L, Yang J, Hu Z (2010) A modified Delorme’s operation for the treatment f rectal mucosal prolapsed. Int J Colorectal Dis 25:607–611
