From the Guidelines
The STARR procedure is used to treat obstructed defecation syndrome (ODS) caused by rectocele, rectal intussusception, or rectal prolapse, but it should not be routinely performed for correction of structural abnormalities in patients with defecatory disorders, as stated in the most recent and highest quality study 1.
Overview of the STARR Procedure
The STARR procedure (Stapled Transanal Rectal Resection) is a minimally invasive surgical technique that involves removing excess rectal tissue and reinforcing the rectum using special stapling devices inserted through the anus.
- The procedure aims to restore normal bowel function by correcting anatomical abnormalities that cause symptoms like incomplete evacuation, straining during bowel movements, and the sensation of a blockage.
- Patients typically require general or spinal anesthesia, and recovery involves 1-2 days in hospital followed by 2-4 weeks of limited activity.
Indications and Effectiveness
- The STARR procedure works by removing redundant tissue that creates a mechanical obstruction to stool passage and by restoring normal rectal anatomy.
- While effective for many patients with ODS, it's usually considered after conservative treatments like dietary changes, pelvic floor exercises, and biofeedback therapy have failed to provide adequate relief, as supported by a prospective, multicenter trial 1.
- However, the correlation between symptoms and rectocele size is weak, and the correlation between improvement in symptoms and anatomy after the STARR procedure is also weak, as noted in a study published in Clinical Gastroenterology and Hepatology 1.
Recommendations and Considerations
- Biofeedback therapy is the treatment of choice for defecatory disorders, and the STARR procedure should not be routinely performed for correction of structural abnormalities in patients with defecatory disorders, as recommended in the best practice advice 1.
- The procedure may be considered in selected cases, but patients should be informed about the potential risks and benefits, including the possibility of adverse events such as infection, pain, incontinence, bleeding, UTI, or depression, as reported in a study published in Clinical Gastroenterology and Hepatology 1.
- Other treatment options, such as sacral nerve stimulation, perianal bulking injection, and sphincteroplasty, may be considered for patients with medically-refractory severe fecal incontinence or defecatory disorders, as suggested in the best practice advice 1.
From the Research
STARR Procedure Overview
The STARR procedure, or stapled transanal rectal resection, is a surgical approach used to treat obstructed defecation syndrome (ODS) associated with rectal intussusception and rectocele.
Indications for the STARR Procedure
- Rectal intussusception
- Ventral rectocele
- Obstructed defecation syndrome (ODS)
- Refractory constipation
- Rectal prolapse
Effectiveness and Safety of the STARR Procedure
- The procedure has been shown to be safe and effective for symptom improvement and resolution in ODS associated with rectal intussusception in the short-term 2, 3, 4.
- However, disappointing functional results, particularly related to fecal incontinence and urgency, severe complications, and high rates of revision surgery have also been documented 2.
- A study with 15 years of experience reported minor complications in 6% of patients and total fecal incontinence in 0.05% of patients 5.
Decision-Making Algorithm for the STARR Procedure
- A decision-making algorithm for the STARR procedure in obstructed defecation syndrome has been developed by a group of experts, including a clear decision-making algorithm specifically focusing on the role of the STARR procedure based on clinical symptoms and dynamic imaging 6.
- Patient selection for the STARR procedure seems to be the key for success, and careful evaluation of long-term function, symptom resolution, and quality of life is necessary 2, 4.