Stapled transanal resection of the rectum (STARR) for obstructed defaecation syndrome

We read with interest the recent debate about STARR for obstructed defaecation syndrome. However, we disagree with several of the points made by Bhardwaj and Phillips. They start their argument with the issue of ‘abnormalities’ found on proctography of normal volunteers and quote the small proctographic study by Shorvon et al.1 of normal volunteers which analysed 25 men and 21 women. It is misleading to say that this study showed a rectocoele in 80% of asymptomatic women, as the rectocoele depth exceeded 2 cm (the upper limit of normal for most radiologists) in only one patient of the 46 studied. On the seven point grading of intussusception used in this study, 55% did have intussusception but in only 18% was this high grade (impinging on the anal canal). A more recent proctographic study of normal volunteers has shown that, whilst intussusception may be seen in asymptomatic patients, this is significantly less advanced and tends to be mucosal when compared to symptomatic patients.2 The relevance of proctographic studies in asymptomatic patients is in any case dubious; we do not see these patients in our pelvic floor clinics. We would argue that in many (but certainly not all) cases of obstructed defaecation, there is a relevant structural abnormality. The overlap of symptomatic and asymptomatic patients when studied proctographically does not necessarily contradict this but perhaps reflects the fact that proctography is an imperfect test. Some patients may need an examination under anaesthetic to aid their diagnosis and treatment. Bhardwaj and Phillips compare operating on obstructed defaecation syndrome patients to operating on patients with hypertension or asthma. Hypertension and asthma are well treated pharmacologically but are not amenable to surgery. By contrast, obstructed defaecation syndrome patients may be controlled by biofeedback and pharmacological manipulation, but many will not respond to these measures and move on to surgery. The issue of whether surgery is effective becomes the second major issue of the debate. We were disappointed that Bhardwaj and Phillips quote three papers that were each almost 20 years old as evidence that rectopexy does not cure obstructed defaecation syndrome.3–5 All three papers were reporting an open surgical technique that included a full posterior rectal mobilisation. This mobilisation would have caused rectal denervation affecting defaecatory function and continence.6–8 In our own experience of 75 patients treated for intussusception/obstructed defaecation syndrome by laparo-scopic ventral mesh rectopexy, there was no major morbidity and a median hospital stay of 2 days. Overall, 86% reported an improvement in obstructed defaecation syndrome symptoms and 85% an improvement in continence.9 Finally, in support of biofeedback, Bhardwaj and Phillips quote a single retrospective study10 of 34 patients before saying that the ‘evidence is poor’ for treating obstructed defaecation syndrome with STARR. We believe that surgery remains an option for patients who fail non-surgical treatments.