Perineale Rektumprolapsoperation: Gute Resultate bei geringem Aufwand! F.H. Hetzer

Transcription

1 Perineale Rektumprolapsoperation: Gute Resultate bei geringem Aufwand! F.H. Hetzer

2 STARR: Wunderwaffe beim Obstructed Defecation Syndrom (ODS) F.H. Hetzer

3 Stapled TransAnal Rectal Resection STARR PPH 01 Longo A (2003) Obstr cted defecation beca se of rectal Longo A. (2003) Obstructed defecation because of rectal pathologies. Novel surgical treatment: stapled transanal resection (STARR). Proceedings of the 14th Annual International Colorectal Disease Symposium, Ft Lauderdale, Florida, February 13-15

4 STARR Study Year Patients Follow-up (months) ODS score Pre-STARR Post-STARR Conclusion Bin Zhang Safe without major morbidity O. Schwandner % new incontinence, urgency 25% O. Zehler % good results VM. Leal % good results, TRREMS CB. Patel % good, 16% adequate, AC. Goede y Recurrent symptoms in 4.9% A. Stuto Good results, urgency 4.5%, bleeding 3.6%, perineal sepsis 3.4%, rectovaginal fistula 0.05% KH. Song * 9.6* 63% good results, safe, *CCF A.Stuto Good results 90%, low morbidity and recurrence rate H.M. Hasan Good results 90%, low morbidity and recurrence rate K.Köhler Good result deteriorate with the time

5 Stapled TransAnal Rectal Resection STARR Transtar PPH 01 Contour Transtar Longo A. (2003) Obstructed defecation because of rectal pathologies. Novel surgical treatment: stapled transanal resection (STARR). Proceedings of the 14th Annual International Colorectal Disease Symposium, Ft Lauderdale, Florida, February Lenisa L, Colorectal Dis. 2008

6 Transtar Study Year Patients Follow-up ODS Score Conclusion (months) Pre-Transtar Post-Transtar A. Renzi Success rate 86%, low morbidity L. Lenisa Success rate 77%, safe and low morbidity K. Wolff Improves QoL S. Bock y 12 7 Transtar stable over time H. Wadhawan STARR vs Transtar 25 STARR: similar outcome C. Isbert STARR vs Transtar 68 STARR: similar outcome A. Renzi RCT STARR vs Transtar Transtar more stable over time P. Boccasanta /50 36 RCT STARR vs Transtar Transtar less urgency and recurrence, higher costs

7 Complications Numbre Management Complications after STARR Rectal bleeding % Reoperation in 2.7 % Anorectal stricture t 1236% % Dilatation ti Anorectal pain % Agraphectomy? Rectal diverticulum Case report Urgency 23% Pelvic floor rehabilitation Faecal incontinence 3-19% Sacral nerve stimulation Rectovaginal fistula 3 Patients Pelvic sepsis Case report antibiotic prophylaxis p Pescatori, Tech Coloproctol (2008) 12:7 19

8 The Iceberg Diagram Pescatori Int J Colorectal Dis (2009) 24:87 95

9 The Iceberg Diagram

10 Pedictive factors: Rectocle and Intussusception ti Intussusception and Enterocele Symptoms of ODS Small rectal diameter Low squeeze pressure Symptoms of ODS Increased pelvic floor descent at rest Isbert et al. Br J Surg 2012: 99:416-22

11 Background - Idea *STARR with Contour Transtar TM internal rectal prolapse Perineal Stapled Prolapse resection (PSP) for external rectal prolapse *Lenisa L et al, STARR with Contour TranstarTM: Prospective Multicentre European Study. Colorectal Dis. 2008

12 Methods - Surgical technique Hetzer et al. Dis Colon Rectum. 2008: 48:307-16

13 Methods - Surgical technique Opening of prolapse (e.g. ILA 100) Hetzer et al. Dis Colon Rectum. 2008: 48:307-16

14 Methods - Surgical technique Opening of prolapse (e.g. ILA 100) Hetzer et al. Dis Colon Rectum. 2008: 48:307-16

15 Methods - Surgical technique Insert the Contour Transtar TM stapler in the prolapse Hetzer et al. Dis Colon Rectum. 2008: 48:307-16

16 Methods - Surgical technique Stepwise resection of the anterior part Hetzer et al. Dis Colon Rectum. 2008: 48:307-16

17 Methods - Surgical technique Stepwise resection of the anterior part Hetzer et al. Dis Colon Rectum. 2008: 48:307-16

18 Methods - Surgical technique Stepwise resection of the posterior part

19 Methods - Surgical technique Stepwise resection of the posterior part Hetzer et al. Dis Colon Rectum. 2008: 48:307-16

20 Methods - Surgical technique Oversew the staple line Oversew the staple line Hetzer et al. Dis Colon Rectum. 2008: 48:307-16

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22 Results No intraoperative complications Median operation time 31 min (range 15-60) Hospital stay 6 days (range 2-29) No mortality Median follow-up 9 months (range 1-17) No recuurence

23 Results - Morbidity 4/28 (14 %) Complications 2 Patients 1st Degree (no treatment) 1 Patient 2 nd Degree (medical treatment) 1 Patient 3th Degree (interventional treatment) Dindo et al, Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004

24 Hetzer et al. Dis Colon Rectum. 2012: accepted

25 Discussion - Versus Altemeier Shorter operation time 1 (31vs. 92 min) Wider anastomosis as stapled Altemeier 2 (11 vs. 7.5 cm circumference) More easily, less invasive 3 Costs! (staplers: 1850 US$) 1. Boccasanta P et al. Impact of new technologies on outcome of Altemeier(RCT). Dis Colon Rectum Hetzer F et al. Laparoscopic sigmoid resection: a comparative.. J Laparoendosc Adv Surg Tech A Altemeier WA et al. 19 years experience with perineal repair of rectal prolapse. Ann Surg 1971

26 PSP: Evidence IV/B Study Year Patients Follow-up Wexner Score Conclusion (months) Pre-Transtar Post-Transtar R. Scherer Faesibility sudy G. Rommano Easy and fast FH. Hetzer Safe and good functional outcome

27 Conclusion Safe and easy Patient t selection ect Costs? Longo STARR Transtar - PSP