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.
STARR Surgery for ODS | Defecography in Pune | Healing Hands Clinic Pune
1. Obstructed Defecation Syndrome:
Diagnosis & Surgical Treatment
By
Dr Ashwin Porwal
Consultant Procto-Surgeon
Apollo Jehangir Hospital
Poona Hospital &
Inamdar Hospital
2.
3. 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
๏ต 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
๏ต ODS is a complex and multifactorial condition which is often
referred to as an Iceberg Syndrome
4. Prevalence of Constipation
๏ฑ 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
5. 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.
6. Rectocele in females โ A Rectovaginal Defect
Definition
โข A rectocele is an out pouching of
the anterior rectal wall and
posterior vaginal wall into the
lumen of the vagina
Gradation
โข high rectoceles ๏ due to stretching or
disruption of the upper third of the vaginal
wall and uterosacral ligaments
โข mid level rectoceles ๏ most common and
are associated with loss of pelvic floor
support
โข low-level rectoceles ๏ can be caused by
obstetric trauma
7. Rectocele: Prevalence
Prevalence in young nulliparous women : 12%
โข 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%
โข Source: American Journal of Obst & Gynec
๏ฑ 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
8. Rectocele & ODS
Symptoms of Rectocele include:
โ Pain or pressure in the vagina
โ Pain during sexual intercourse
โ Pain or pressure in the rectum
โ Feeling of tissue bulging out of vagina
โ Constipation: ODS (Obstructed Defecation Syndrome)
โข Difficult passage of stool
โข Needing to apply pressure on vagina to pass stool
โข Feelings of incomplete stool passage
9. Diagnostic Approach for ODS
Before
patient sees
surgeon
โข Colonoscopy to rule out tumors + IBD
โข Conservative treatment with laxatives /enemas / diet failed
Patient sees
the surgeon
โ Patient
Interview
โข
โข
โข
โข
Clinical
Examination
โข Perinea Examination
โข Proctoscopy resting / straining
โข Urogenital Examination
Clinical
Evaluation
Patient history
Dr Longoโs Score (ODS Score) assessment
Incontinence / Urogenital assessment to rule out other complications
Quality of life / Patient motivation assessment
โข Conventional Defecography / MRI Defecography
โข Anal- manometry and Endo-anal ultrasound โ only if incontinence or suspicion of
sphincter damage โ otherwise not mandatory
โข Colon transit โ suspicion of slow bowel movement
10. Patients of ODS: Symptoms and Signs
โข
โข
โข
โข
โข
โข
โข
โข
โข
โข
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
11. History Taking for Constipation
Obstructive
โข Excessive Straining
โข Poor response to Laxatives over
a period of time
โข Either 2-3 visits/day or 2-3 visits
in a week to toilet
โข Inadequate Defecation
โข Feeling of stools obstructed in
Rectum
โข Rectal and or Vaginal Digitations
for Evacuation
Functional / IBS
โข Straining + โข No feeling of stools obstructed
in rectum
โข Usually responds to laxatives
โข Inadequate Defecation +
โข Multiple visits to toilet +
โข Usually no history of digitation
13. Defecography
โข Salient phases of Conventional / MRI
Defecography ๏ Image captured
โ During rest with filled anal bulb
โ During maximum contraction of anal sphincter
and pelvic floor muscles
โ During straining without evacuation
โ During evacuation
โ During rest when evacuation is completed
24. ODS Cause Substantiated by
Defecography Findings
Rectal Intussusception ๏ Internal Rectal
Prolapse
โข closure of the anus by prolapse of the
rectum into the anal canal
Rectocele
โข accumulation of stool in ventral protrusion
of the rectal anterior wall
25. Patient Inclusion Criteria for STARR
Surgery
Symptomatic ๏ Dr Longoโs Score more than 15
โข Evacuation by prolonged or repeated straining
โข Frequent calls to defecate prior to or following evacuation
โข Use of digital means to effect evacuation
โข Laxative and or Enema use required to defecate
โข Sense of incomplete evacuation
โข Excessive time spent on the toilet
โข Pelvic Pressure, Rectal discomfort, and Perinea pain
Radiological & Clinical Findings
โข Recto rectal Intussusceptions
โข Reconcile
Failure with medical management for 3-6 Months: By Means of Diet & Pelvic floor
physiotherapy
26. Patient Exclusion Criteria for Surgery
General Exclusion Criteria
โข
โข
โข
โข
โข
Active anorectal infection
Concurrent severe anorectal pathology
Proctitis (Inflammatory Bowel Disease (IBD), Radiation)
Enterocele at rest (low, stable)
Chronic Diarrhea
Relative Exclusion Criteria
โข Previous transanal surgery (Rectal anastomosis)
โข Presence of foreign material adjacent to the rectum (mesh)
โข Concurrent psychiatric disorder
28. Treatment for ODS
STARR (Stapled Transanal Rectal Resection)
โข Transanal resection of the lower rectum
โข Full thickness resection of the anterior rectum wall by stapler after
longitudinal stitches at 10, 12 and 2 oโclock positions. Similar approach
at the posterior wall with stitches at 4, 6 and 8 oโclock positions.
โข Suturing of the overlaping dog ears at 3 and 9 oโclock positions.
32. 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
33. Treating ODS - A Patient Case Study!
History Taking
Diagnosis
STARR Surgery
After Care & Follow up
๏ฑ Complain: Chronic Constipation since 3 years
๏ฑ Patient Profile: 26 year old nulliparous female
๏ฑ Patient History:
๏ง Chronic constipation for over 3 years
๏ง 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
๏ง No relief with diet and pelvic floor physic for 6 months
๏ฑ Diagnosis:
๏ง P/R examination ๏ Anterior Rectocele
๏ง Dr Longoโs ODS Score ๏ 24
๏ง MR Defecography findings ๏ Moderate anterior Rectocele with severe
descent of the Rectum
๏ง Advise ๏ STARR Surgery
34. Patient Case Study continued...
History Taking
History Taking
Diagnosis
STARR Surgery
STARR Surgery
After Care & Follow up
Follow up
๏ฑ Surgery ๏ Stapled Transanal Rectal Resection (STARR)
๏ง 3hrs after surgery ๏ the patient complained of mild pain in the anal region,
Was advised to discontinue NBM and take regular Maharashtrian dinner.
๏ง 12hrs after surgery ๏ bearable pain, passed motion with slight discomfort
and observed a few drops of blood during defecation.
๏ง Discharged 24 hrs after hospitalization and subsequently the patient
resumed work after 4 days.
๏ฑ Follow up
๏ 2 Weeks:
๏ง 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:
๏ง Motion was fine, evacuation was complete with lesser dose of
laxatives.
35. Patient Case Study continued...
History Taking
Diagnosis
STARR Surgery
After Care & Follow up
๏ฑ Follow up
๏ 3 Months:
๏ง Patient was not on laxative but motion was sooth and without straining
๏ Findings of MR Defecography repeated after 3 months
๏ง 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
36. My experience of 1st 100 STARRsโฆ
Patient inclusion criteria
โข Symptomatic with Dr Longoโs ODS score above 15
โข Rectocele > 3cm & Recto rectal Intussusceptions
Patient distribution
โข Male 43 , Female 57
โข Age 37 < 40 yrs, 63 > 40 yrs
โข Nulliparous Female 33%
โข Rectocele ๏ Males: 67 % Females: 90%
โข Recto rectal Intussusceptions ๏ Males: 87% Females: 53%
Follow up Schedule
โข 2 weeks, 1 Month, 3 Months, 6 Months & 1 Year
Findings
โข Average Dr Longoโs ODS score pre operatively = 26
โข Average Dr Longoโs ODS score 12 months post operatively =8
37. 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 Longoโs ODS Score
26
8
Symptoms