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STARR Surgery for ODS | Defecography in Pune | Healing Hands Clinic Pune


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Healing Hands Clinic is a unique and speciality clinic for constipation,piles, hernia & prevention of Lifetstyle diseases. Apart from its heart of the city location, expert consultation, state of the art technology and well qualified staff are few of its assets. It is the first clinic in the city to deliver facility of Defecography for constipation. Our focus, dedication and inner feeling of curing or treating the patients with care have given us many satisfied patients.

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STARR Surgery for ODS | Defecography in Pune | Healing Hands Clinic Pune

  1. 1. Obstructed Defecation Syndrome: Diagnosis & Surgical Treatment By Dr Ashwin Porwal Consultant Procto-Surgeon Apollo Jehangir Hospital Poona Hospital & Inamdar Hospital
  2. 2. Obstructed Defecation Syndrome (ODS) Constipation due to difficulty in passing stools once it has reached rectum as a result of Recto rectal Intussusceptions (Internal Rectal Prolapse) or Rectocele  ODS has been shown to be the result of an abnormal function of the muscles involved in defecation or an anatomical abnormality of the pelvic organs  ODS is a complex and multifactorial condition which is often referred to as an Iceberg Syndrome
  3. 3. Prevalence of Constipation  Constipation prevalence in the general population is estimated at around 5-15% .  reports suggesting significantly higher levels in the elderly, especially above the age of 65.  reports of females being affected more then males, male to female ratio of 1: 2.2.  ODS is estimated to be prevalent in 7% of the adult population and is judged to be the cause of one third of all cases of constipation
  4. 4. NICE guidelines for STARR Surgery for ODS 1)Failure of conservative treatment for ODS 2)Underlying structural abnormality like Rectocele & Recto-Rectal Intussusceptions on MRI Defecography Efficacy of STARR in ODS In multiple studies reviewed by NICE , It was observed that there was significant improvement in pre operative constipation symptoms at a mean follow up of 2 years. Post op Defecography also demonstrated correction of Rectocele and intussusceptions in one study. Quality of life following STARR was assessed in few studies , excellent or good outcome was reported by 70-80% of the patients.
  5. 5. Rectocele in females – A Rectovaginal Defect Definition • A rectocele is an out pouching of the anterior rectal wall and posterior vaginal wall into the lumen of the vagina Gradation • high rectoceles  due to stretching or disruption of the upper third of the vaginal wall and uterosacral ligaments • mid level rectoceles  most common and are associated with loss of pelvic floor support • low-level rectoceles  can be caused by obstetric trauma
  6. 6. Rectocele: Prevalence Prevalence in young nulliparous women : 12% • Source: Australia & NZ Journal of Obst. & Gynec. 2005 Oct;45(5):391-4 Prevalence in multifarious women with uterus : 18.6 % without uterus : 18.3% • Source: American Journal of Obst & Gynec  Prevalence of Rectocele in male patients who have a history of chronic constipation and are symptomatic for ODS is as high as 60% in my routine clinical observation
  7. 7. Rectocele & ODS Symptoms of Rectocele include: – Pain or pressure in the vagina – Pain during sexual intercourse – Pain or pressure in the rectum – Feeling of tissue bulging out of vagina – Constipation: ODS (Obstructed Defecation Syndrome) • Difficult passage of stool • Needing to apply pressure on vagina to pass stool • Feelings of incomplete stool passage
  8. 8. Diagnostic Approach for ODS Before patient sees surgeon • Colonoscopy to rule out tumors + IBD • Conservative treatment with laxatives /enemas / diet failed Patient sees the surgeon – Patient Interview • • • • Clinical Examination • Perinea Examination • Proctoscopy resting / straining • Urogenital Examination Clinical Evaluation Patient history Dr Longo’s Score (ODS Score) assessment Incontinence / Urogenital assessment to rule out other complications Quality of life / Patient motivation assessment • Conventional Defecography / MRI Defecography • Anal- manometry and Endo-anal ultrasound – only if incontinence or suspicion of sphincter damage – otherwise not mandatory • Colon transit – suspicion of slow bowel movement
  9. 9. Patients of ODS: Symptoms and Signs • • • • • • • • • • Pain at defecation Haemorrhoidal prolapse (!) Extended time at the toilet Perineal pain / discomfort when standing Use of laxatives or enemas Fecal Incontinence Extreme straining to defecate Feeling of incomplete evacuation Fragmented defecation Vaginal, Perineal or Rectal digitations
  10. 10. History Taking for Constipation Obstructive • Excessive Straining • Poor response to Laxatives over a period of time • Either 2-3 visits/day or 2-3 visits in a week to toilet • Inadequate Defecation • Feeling of stools obstructed in Rectum • Rectal and or Vaginal Digitations for Evacuation Functional / IBS • Straining + • No feeling of stools obstructed in rectum • Usually responds to laxatives • Inadequate Defecation + • Multiple visits to toilet + • Usually no history of digitation
  11. 11. Dr Longo’s ODS Score
  12. 12. Defecography • Salient phases of Conventional / MRI Defecography  Image captured – During rest with filled anal bulb – During maximum contraction of anal sphincter and pelvic floor muscles – During straining without evacuation – During evacuation – During rest when evacuation is completed
  13. 13. Case: Internal Rectal Prolapse & Rectocele (Conventional Defecography)
  14. 14. Intussusception & Rectocele (1)
  15. 15. Intussusception & Rectocele (2)
  16. 16. Intussusception & Rectocele (3)
  17. 17. Intussusception & Rectocele (4)
  18. 18. MR Defecography
  19. 19. MRI Defecography Videos
  20. 20. ODS Cause Substantiated by Defecography Findings Rectal Intussusception  Internal Rectal Prolapse • closure of the anus by prolapse of the rectum into the anal canal Rectocele • accumulation of stool in ventral protrusion of the rectal anterior wall
  21. 21. Patient Inclusion Criteria for STARR Surgery Symptomatic  Dr Longo’s Score more than 15 • Evacuation by prolonged or repeated straining • Frequent calls to defecate prior to or following evacuation • Use of digital means to effect evacuation • Laxative and or Enema use required to defecate • Sense of incomplete evacuation • Excessive time spent on the toilet • Pelvic Pressure, Rectal discomfort, and Perinea pain Radiological & Clinical Findings • Recto rectal Intussusceptions • Reconcile Failure with medical management for 3-6 Months: By Means of Diet & Pelvic floor physiotherapy
  22. 22. Patient Exclusion Criteria for Surgery General Exclusion Criteria • • • • • Active anorectal infection Concurrent severe anorectal pathology Proctitis (Inflammatory Bowel Disease (IBD), Radiation) Enterocele at rest (low, stable) Chronic Diarrhea Relative Exclusion Criteria • Previous transanal surgery (Rectal anastomosis) • Presence of foreign material adjacent to the rectum (mesh) • Concurrent psychiatric disorder
  23. 23. Surgical Treatment for ODS – Stapled Transanal Rectal Resection(STARR)
  24. 24. Treatment for ODS STARR (Stapled Transanal Rectal Resection) • Transanal resection of the lower rectum • Full thickness resection of the anterior rectum wall by stapler after longitudinal stitches at 10, 12 and 2 o‘clock positions. Similar approach at the posterior wall with stitches at 4, 6 and 8 o‘clock positions. • Suturing of the overlaping dog ears at 3 and 9 o‘clock positions.
  25. 25. STARR Videos
  26. 26. Complications rectovaginal fistula (0,3%) bleeding (needing intervention) (3,7%) stenosis (1,1%) constant pain (4,0%) suture-insufficiency (0,3%) urgency (9,4%)
  27. 27. Conclusion STARR is a safe and effective procedure to treat ODS (Obstructd Defecation Syndrome) The surgery needs only 24hrs of hospitalisation & patient can resume his routine work from 3rd day The key to success is patient selection Problem could be the cost involved
  28. 28. Treating ODS - A Patient Case Study! History Taking Diagnosis STARR Surgery After Care & Follow up  Complain: Chronic Constipation since 3 years  Patient Profile: 26 year old nulliparous female  Patient History:  Chronic constipation for over 3 years  Symptoms: Need to go to the toilet 3-4 times in a day, Excessive straining, Extended time in toilet (15 min. minimum), Digitations, Fragmented defecation, Hard stool, Feeling of stool obstructed within the rectum  No relief with diet and pelvic floor physic for 6 months  Diagnosis:  P/R examination  Anterior Rectocele  Dr Longo’s ODS Score  24  MR Defecography findings  Moderate anterior Rectocele with severe descent of the Rectum  Advise  STARR Surgery
  29. 29. Patient Case Study continued... History Taking History Taking Diagnosis STARR Surgery STARR Surgery After Care & Follow up Follow up  Surgery  Stapled Transanal Rectal Resection (STARR)  3hrs after surgery  the patient complained of mild pain in the anal region, Was advised to discontinue NBM and take regular Maharashtrian dinner.  12hrs after surgery  bearable pain, passed motion with slight discomfort and observed a few drops of blood during defecation.  Discharged 24 hrs after hospitalization and subsequently the patient resumed work after 4 days.  Follow up  2 Weeks:  Less difficulty to pass motion, No h/o straining, No h/o digitation, Patient was on laxative but it helped her, Satisfactory defecation at least 70% of the time.  1 Month:  Motion was fine, evacuation was complete with lesser dose of laxatives.
  30. 30. Patient Case Study continued... History Taking Diagnosis STARR Surgery After Care & Follow up  Follow up  3 Months:  Patient was not on laxative but motion was sooth and without straining  Findings of MR Defecography repeated after 3 months  Normal with absence of Rectocle or any obstruction  Patient was advised to stop all medication and also advised to take a high fiber diet with plenty of water
  31. 31. My experience of 1st 100 STARRs… Patient inclusion criteria • Symptomatic with Dr Longo’s ODS score above 15 • Rectocele > 3cm & Recto rectal Intussusceptions Patient distribution • Male 43 , Female 57 • Age 37 < 40 yrs, 63 > 40 yrs • Nulliparous Female 33% • Rectocele  Males: 67 % Females: 90% • Recto rectal Intussusceptions  Males: 87% Females: 53% Follow up Schedule • 2 weeks, 1 Month, 3 Months, 6 Months & 1 Year Findings • Average Dr Longo’s ODS score pre operatively = 26 • Average Dr Longo’s ODS score 12 months post operatively =8
  32. 32. ODS Score for 1st 100 STARR Cases Mean Pre-op Score Mean 12 Months Post-op Score Defecation frequency 1 0 Straining Intensity 1 0 Extension of time in defecation Sensation of incomplete evacuation 2 1 3 1 Recto/perineal pain/discomfort 2 1 Activity reduction per week 4 2 Laxatives 5 3 Enemas 3 0 Digitation 5 0 Mean Dr Longo’s ODS Score 26 8 Symptoms
  33. 33. Thank You!