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

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

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

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

STARR Study Year Patients Follow-up (months) ODS score Pre-STARR Post-STARR Conclusion Bin Zhang 2010 50 12 17.54 5.92 Safe without major morbidity O. Schwandner 2010 379 12 11.14 6.45 2.9% new incontinence, urgency 25% O. Zehler 2010 20 66 1.6 72% good results VM. Leal 2010 35 12 10.6 2.9 88% good results, TRREMS CB. Patel 2011 37 11.1 4.6 72% good, 16% adequate, AC. Goede 2011 344 8y 14.6 1.6 Recurrent symptoms in 4.9% A. Stuto 2011 2171 12 16.7 5.0 Good results, urgency 4.5%, bleeding 3.6%, perineal sepsis 3.4%, rectovaginal fistula 0.05% KH. Song 2011 58 12 17.6* 9.6* 63% good results, safe, *CCF A.Stuto 2012 40 12 14.2 2.3 Good results 90%, low morbidity and recurrence rate H.M. Hasan 2012 40 12 14.2 2.3 Good results 90%, low morbidity and recurrence rate K.Köhler 2012 80 39 9.3 6.5 Good result deteriorate with the time

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 13-15 Lenisa L, Colorectal Dis. 2008

Transtar Study Year Patients Follow-up ODS Score Conclusion (months) Pre-Transtar Post-Transtar A. Renzi 2008 30 6 16 5 Success rate 86%, low morbidity L. Lenisa 2009 75 12 18 3 Success rate 77%, safe and low morbidity K. Wolff 2010 52 6 16 5 Improves QoL S. Bock 2012 70 2.7y 12 7 Transtar stable over time H. Wadhawan 2009 27 6 STARR vs Transtar 25 STARR: similar outcome C. Isbert 2009 82 12 STARR vs Transtar 68 STARR: similar outcome A. Renzi 2011 63 24 RCT STARR vs Transtar Transtar more stable over time P. Boccasanta 2011 50/50 36 RCT STARR vs Transtar Transtar less urgency and recurrence, higher costs

Complications Numbre Management Complications after STARR Rectal bleeding 4.4-11% Reoperation in 2.7 % Anorectal stricture t 1236% 1.2-3.6% Dilatation ti Anorectal pain 9.5-11% 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

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

The Iceberg Diagram

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

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

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

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

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

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

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

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

Methods - Surgical technique Stepwise resection of the posterior part

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

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

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

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

Hetzer et al. Dis Colon Rectum. 2012: accepted

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 2006 2. Hetzer F et al. Laparoscopic sigmoid resection: a comparative.. J Laparoendosc Adv Surg Tech A 1998 3. Altemeier WA et al. 19 years experience with perineal repair of rectal prolapse. Ann Surg 1971

PSP: Evidence IV/B Study Year Patients Follow-up Wexner Score Conclusion (months) Pre-Transtar Post-Transtar R. Scherer 2008 15 1.5 Faesibility sudy G. Rommano 2009 3 2-4 Easy and fast FH. Hetzer 2010 32 6 16 1 Safe and good functional outcome

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