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Transanal Stapling Techniques
for Anorectal Prolapse
Transanal Stapling Techniques
for Anorectal Prolapse
Edited by
David Jayne
Department of Colorectal Surgery, Leeds General Hospital, Great George Street, Leeds,
LS1 3EX, UK
Angelo Stuto
2nd Surgical Unit, “Ospedale S: maria degli Angeli”, Pordenone, Italy
Editors
David Jayne Angelo Stuto
Department of Colorectal Surgery 2
nd
Surgical Unit
Leeds General Hospital “Ospedale S: Maria degli Angeli”
Great George Street Pordenone
Leeds, LS1 3EX Italy
UK
ISBN: 978-1-84800-904-2 e-ISBN: 978-1-84800-905-9
DOI: 10.1007/978-1-84800-905-9
British Library Cataloguing in Publication Data
Library of Congress Control Number: 2008941018
© Springer-Verlag London Limited 2009
Apart from any fair dealing for the purposes of research or private study, or criticism or review, as permitted under the Copyright,
Designs and Patents Act 1988, this publication may only be reproduced, stored or transmitted, in any form or by any means, with the
prior permission in writing of the publishers, or in the case of reprographic reproduction in accordance with the terms of licences
issued by the Copyright Licensing Agency. Enquiries concerning reproduction outside those terms should be sent to the publishers.
The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specifi c statement, that such
names are exempt from the relevant laws and regulations and therefore free for general use.
Product liability: The publisher can give no guarantee for information about drug dosage and application thereof contained in this
book. In every individual case the respective user must check its accuracy by consulting other pharmaceutical literature.
Printed on acid-free paper
Springer Science+Business Media
springer.com
Foreword
It has never been easy to introduce new concepts and therapeutic in-terventions into surgical
practice. When attempting to do so, one is faced with the interagency of traditional dogma,
which still in this era of evidence-based medicine tends to dominate the surgical thought process. This is particularly so in the area of coloproctology, where prejudice and personal opinion
often influence objective analysis whenever tradition is challenged. A large body of literature
on anorectal prolapse has accumulated over the years; although much is based on personal
viewpoint rather than scientific evidence, it has nevertheless been passed down through the
generations as ac-cepted wisdom and practice. As a consequence, it is a challenge to change
the mindset of a generation of surgeons and to introduce new concepts and novel techniques
which at first might appear to be a radical departure from conventional teaching.
It is obviously not possible to present the basis for the develop-ment of transanal stapling
techniques for anorectal prolapse in this Foreword; this is dealt with in detail elsewhere in
this book. The in-terested reader will have the opportunity to share in the new and emerging
concepts surrounding anorectal prolapse and to deepen their understanding of the pathophysiology and basis for surgical correction. Although hemorrhoidal disease and external
rectal prolapse have been known about for centuries, the understanding of internal rectal
prolapse (intussusception) and rectocele has only really advanced with the emergence of
radiological imaging tech-niques, such as defecography. With a heightened awareness
of the condition, it has become apparent that the prevalence of sympto-matic anorectal
prolapse is far more common than originally por-trayed, and that its impact on quality of
life has been underestimated and undervalued. Perhaps for the first time, modern surgical
tech-niques can now offer symptomatic improvement and enhanced qual-ity of life for those
unfortunate enough to suffer with this chronic condition.
Historically, hemorrhoidal prolapse, internal and external rectal prolapse, and rectocele
have been considered as separate clinical en-tities, with distinct etiologies. Modern thinking and clinical observa-tion, however, would suggest that the different manifestations of
anorectal prolapse in fact share a common pathophysiological basis. There is thus emerging
a unified theory for anorectal prolapse.
Transanal Stapling for Anorectal Prolapse provides the reader with a clear overview of
the pathophysiological basis of the disease and the evolution of transanal stapling techniques. Chapters have been contributed by an international panel of expert colorectal surgeons to give a broad and comprehensive coverage of the subject. As well as covering the
history and pathophysiology of anorectal prolapse, this book provides a structured approach
to anorectal sta-pling techniques along with “tips and tricks” for success. This book will be
an essential reference for all specialists with an interest in coloproctology.
Wien, Austria
Antonio Longo
v
Contents
Foreword ...................................................................................................................... v
Contributors ................................................................................................................ ix
Introduction ................................................................................................................. 1
David Jayne and Angelo Stuto
1 Historical Background: Treatments for Hemorrhoids
and ODS Prior to Transanal Stapling Techniques ............................................ 3
Longo L. Lenisa and V. Landolfi
2 Anatomy and Physiology of Anorectal Prolapse ............................................... 19
S.R. Brown and A.J. Shorthouse
3 Diagnosis of Hemorrhoids and ODS ................................................................... 31
D. Jayne and K.P. Nugent
4 Evaluation of Patients with Symptomatic Hemorrhoids
and Obstructed Defecation .................................................................................. 43
F. Pigot, F. Hetzer, and J.-J. Tuech
5 Patient Selection for Stapled Hemorrhoidopexy and STARR .......................... 59
Oliver Schwandner and Roland Scherer
6 Stapled Hemorrhoidopexy: The Technique ....................................................... 71
E. Espin and F. Corbisier
7 Stapled Transanal Rectal Resection Procedure ................................................. 85
D.G. Jayne and A. Stuto
8 The Evidence for Stapled Hemorrhoidopexy and STARR ............................... 95
F.H. Hetzer and A. Senagore
9 Areas of Controversy and Future Research ....................................................... 117
D.G. Jayne and A. Stuto
Index ............................................................................................................................. 133
vii
Contributors
Steven Brown
Northern General Hospital, Sheffield, UK
Fabrice Corbisier
CH Notre-Dame et Reine, Fabiola, Belgium
Eloy Espin
Hospital Univeritari Vall, Barcelona, Spain
Franc Hetzer
Kantonsspital St. Gallen, St. Gallen, Switzerland
David Jayne
Academic Surgical Unit, St. James's University Hospital, Leeds, UK
V. Landolfi
General Surgery, “Landolfi”; Hospital, Solofra (AV), Italy
Leonardo Lenisa
Casa di Cura San Pio X, Milan, Italy
Antonio Longo
St. Elizabeth Hospital, Wien, Austria
Karen Nugent
Southampton General Hospital, Southampton, UK
Francois Pigot
Bagatelle-Maison de Sante, Talence Cedex, France
Roland Scherer
Krankenhaus Waldfriede, Berlin, Germany
Oliver Schwandner
Caritas Krankenhaus Str. Josef, Regensburg, Germany
Anthony Senagore
Department of Surgery, Medical University of Ohio, Toledo, OH, USA
ix
x Contributors
Andrew Shorthouse
Northern General Hospital, Sheffield, UK
Angelo Stuto
2nd Surgical Unit, Ospedale S. Maria degli Angeli, Pordenone, Italy
Jean-Jacques Tuech
CHU Hopitaux de Rouen, Rouen, France
Introduction
David Jayne and Angelo Stuto
The first transanal stapling technique for the treatment of anorectal prolapse was presented at the
2nd World Congress of Coloproctology in Rome
in 1998 by Dr. Antonio Longo [1] . This described
a novel technique for the surgical correction of
prolapsing hemorrhoids, originally referred to as
procedure for prolapse and hemorrhoids (PPH) and
more recently as stapled hemorrhoidopexy. Since
that time, the technique has developed and gone
on to enjoy tremendous success, due mainly to its
benefits in reducing postoperative pain, shortening hospital stay, and achieving an earlier return
to normal activities. Although a source of controversy in the early years, it has subsequently been
subjected to critical appraisal and has provoked
many randomized clinical trials, meta-analyses,
and more recently in 2007 a favorable review
from the National Institute for Health and Clinical
Excellence (NICE) [2] .
A natural evolution of stapled hemorrhoidopexy
was its application to patients with obstructed
defecation syndrome (ODS). This condition is
common among multiparous women, and results
from a dysfunctional pelvic floor giving rise to
symptoms of constipation and an inability to satisfactorily evacuate the rectum. It is associated
with characteristic anatomical abnormalities of the
lower rectum, which impede the normal expulsion
of feces. These abnormalities include rectocele formation, rectal intussusception (internal prolapse),
and mucosal prolapse. The stapled transanal rectal
resection (STARR) procedure is an extension of
stapled hemorrhoidopexy, but instead of producing
a mucosal resection of the hemorrhoidal prolapse it
achieves a full-thickness resection of the lower rectum, incorporating any rectocele, intussusception,
or prolapse. In this way, the anatomical obstruction
to evacuation is removed, and normal defecatory
function is restored. Although still a relatively new
technique, the STARR procedure is attracting great
interest among coloproctologists. This enthusiasm
is fueled, at least in part, by encouraging early
results which suggest a short-term efficacy of
around 80% with acceptable rates of morbidity.
The time is now right for a book on transanal stapling techniques for anorectal prolapse. Both stapled hemorrhoidopexy and STARR have recently
enjoyed widespread exposure and their application
is spreading rapidly, particularly in Europe, but
also across the rest of the world. However, many
areas of controversy remain and warrant comprehensive discussion. Our current thinking on
anorectal prolapse and its treatment has evolved
significantly in recent years and this needs to be
updated and documented.
The aims of this book are to fill a knowledge
gap and to provide a comprehensive review of
current thinking and practice in the management
of anorectal prolapse, with emphasis on stapled
hemorrhoidopexy for prolapsing hemorrhoids and
the STARR procedure for ODS. This will be set
against a historical background recording the
development of the two procedures to put them
in context and to provide further interest for the
reader. In addition, it is hoped that the book will
provide practical guidance in the application of
D. Jayne and A. Stuto (eds.), Transanal Stapling Techniques for Anorectal Prolapse, 1
DOI: 10.1007/978-1-84800-905-9_1, © Springer-Verlag London Limited 2009
2 D. Jayne and A. Stuto
the techniques with criteria for patient selection,
tips, and tricks for obtaining the best outcomes,
and how to avoid and deal with potential complications. Wherever possible, the views of the
authors will be supported by evidence drawn
from personal experience and the literature. The
final section of the book will concentrate on unresolved controversies and suggest areas for further
research and development.
It is hoped that this book will be of benefit to
higher surgical trainees who are learning for the
first time the complexities of proctological practice
as well as established general surgeons and coloproctologists who encounter the conditions on a
frequent basis. It is increasingly being recognized
that anorectal prolapse is often one component of a
more complex pelvic floor disorder, which necessitates multidisciplinary collaboration between coloproctologists, gynecologists, and urologists. This
book may therefore also appeal to practitioners in
these associated specialties.
The editors have been privileged to receive contributions from a dedicated and enthusiastic international panel of experts. It is hoped that the reader
will benefit from their collective experience and
insights into the rapidly evolving arena of transanal
stapling for anorectal prolapse.
References
1. Longo A. Treatment of haemorrhoidal disease by
reduction of mucosal and haemorrhoidal prolapse
with a circular stapling device: a new procedure.
Proceedings of the 6th World Congress of Endoscopic
Surgery. Rome, Italy, 1998, June 3–6, pp 777–84
2. National Institute for Health and Clinical Excellence
(2007) Stapled haemorrhoidopexy for the treatment of
haemorrhoids: NICE technology appraisal guidance
128. Available at http://www.nice.org.uk/TA128