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

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Obstructed Defecation Syndrome Diagnosis
Surgical Treatment

• By
• Dr Ashwin Porwal
• Consultant Procto-Surgeon
• Apollo Jehangir Hospital
• Poona Hospital
• Inamdar Hospital

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Obstructed Defecation Syndrome (ODS)
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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

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NICE guidelines for STARR Surgery for ODS
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.
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Rectocele in females A Rectovaginal Defect
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Rectocele Prevalence

• 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

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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

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Diagnostic Approach for ODS
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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

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History Taking for Constipation
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Dr Longos ODS Score
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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

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Case Internal Rectal Prolapse Rectocele
(Conventional Defecography)
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Intussusception Rectocele (1)
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Intussusception Rectocele (2)
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Intussusception Rectocele (3)
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Intussusception Rectocele (4)
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MR Defecography
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MRI Defecography Videos
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ODS Cause Substantiated by Defecography Findings
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Patient Inclusion Criteria for STARR Surgery
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Patient Exclusion Criteria for Surgery
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Surgical Treatment for ODS Stapled Transanal
Rectal Resection(STARR)
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Treatment for ODS
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STARR Videos
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Complications
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Conclusion
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Treating ODS - A Patient Case Study!

• 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 Longos ODS Score ? 24
• MR Defecography findings ? Moderate anterior
  Rectocele with severe descent of the Rectum
• Advise ? STARR Surgery

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Patient Case Study continued...

• 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.

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Patient Case Study continued...

• 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

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My experience of 1st 100 STARRs
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ODS Score for 1st 100 STARR Cases
Symptoms Mean Pre-op Score Mean 12 Months Post-op Score
Defecation frequency 1 0
Straining Intensity 1 0
Extension of time in defecation 2 1
Sensation of incomplete evacuation 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 Longos ODS Score 26 8
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Thank You!