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Obstructed defecation: STARR or rectopexy?

Innovation in the surgical treatment of obstructed defaecation (OD) was initiated by Antonio Longo with his introduction of stapled transanal rectal resection (STARR) in 1998 [1]. This was then followed by the development of diagnostic tools such as OD specific symptom scoring systems [2] and the introduction of laparoscopic ventral rectopexy (VR) by D’Hoore and Penninckx in 2004 [3]. The latter contributed to a more profound understanding of OD and led to a new range of treatments for patients. Transanal techniques (STARR and Contour transtar) and VR, the most widespread transabdominal procedure used in Europe, represent the two approaches for correction of the anatomical abnormality in OD. Both techniques are characterized by low morbidity and a promising reduction of OD after surgery [3–7], but due to lack of comparative data there is no current evidencebased guideline available to guide the treatment of OD. During discussion of OD at the Tripartite Meeting held in Birmingham in 2014 we were invited to present the current trends in Europe of the surgical management of OD. Besides taking the opportunity to pay tribute to Professor Freddy Penninckx for his major contribution to this field [8], we conducted a survey among colorectal specialists from European centres of their past and present operative treatment strategy for patients with OD. The results clearly showed a change in practice. Of 32 responding centres from 13 European countries, all but one would consider surgical treatment of OD. Three quarters of the centres had been using STARR or Contour transtar, whereas all but one had implemented VR. Furthermore one-third of units who had introduced STARR, ceased to employ this technique, but all centres continued to perform VR. Although the surgeons surveyed were not asked for the reason for ceasing to perform STARR, impairment of faecal continence might have contributed to its decline. Despite the fact that half the patients with preoperative incontinence experience improvement after STARR, 10% report new onset faecal incontinence, and 25–33% with pre-existing faecal incontinence suffer from faecal urgency after STARR [5,6,9]. Patients with a preoperatively reduced rectal diameter and high grade pelvic floor descent seem to be at risk of postoperative incontinence and faecal urgency [10]. VR results in improvement of constipation in 70% of patients with this symptom preoperatively, and de novo incontinence occurs rarely in 1–2.3%, even where recurrence of symptoms is observed in 9.4% [8,11]. Despite a incidence of low morbidity, 8% of patients undergo reoperation after VR [3,10–12]. Revisional surgery can be demanding especially when mesh-induced complications have arisen, and considerable experience is necessary for a favourable outcome of removal of the mesh [10,11,13]. For these reasons the indication for VR has to be considered carefully and patients must be informed about the potential risks and benefits. To enable evidence-based recommendations for the surgical treatment of OD, a prospective randomized trial is highly desirable, but the complex functional and anatomical disturbances of OD and the difficulty to standardise the patient’s profile will make it hard to accomplish. At present it seems that expert opinion has already decided between the two approaches despite the lack of comparative evidence, as is often observed in surgery, and the trend in practice seems unambiguously favour laparoscopic rectopexy.