Prospective multicentre clinical trial of stapled transanal rectal resection for obstructive defaecation syndrome.

Prospective multicentre clinical trial of stapled transanal rectal resection for obstructive defaecation syndrome (p.1521-1527) A. Arroyo, F. X. Gonzalez-Argente;, M. Garcia-Domingo, E. Espin-Basany, F. De-la-Portilla, F. Perez-Vicente, R. Calpena Published Online: Oct 21 2008 10:57AM DOI: 10.1002/bjs.6328 Sir, we would like to raise some points on the article by Arroyo et al. on stapled transanal rectal resection (STARR) for obstructive defaecation syndrome (ODS) (1). No psychiatric evaluation was performed, in spite of data showing that 66% of patients with ODS suffer from anxiety or depression (2). The authors operated on 59.1% of patients. This matches with operation rates on constipated patients by others, who also perform STARR, such as 58.1% (3), but contrasts with all the others, who consistently report lower operation rates for constipation, such as 7.3% (4) or 14% (2). Are surgeons who perform STARR, by any chance, over-treating their patients? While the authors state that they referred 75 patients for biofeedback, they did not take into any account, prior to operate on the remaining 104, conservative measures such as colonic irrigation, which has proven successful in a substantial number of constipated patients (5). Indeed, STARR can be effective, but, it is a worryingly invasive and irreversible procedure, bearing a number of complications (6). Sadly, STARR was recently passed off to the general Italian public as a panacea to magically solve a complex condition, such as constipation, ‘with no stitches’ (although, in reality, 56 titanium staples are fired), and ‘without opening’ (7). The authors are to be commended for reporting that in 30-72% of patients with ODS anatomical correction is fruitless (1). For those who consider patients with ODS to suffer more from bowel function than from its anatomy, STARR equals to ‘removing part of a lung to treat asthma or chopping off an arm to treat high blood pressure’ (8). Luigi Basso, Giuseppe Gagliardi*, Mario Pescatori*. University of Rome ‘Sapienza’ 1st Medical School, and * Coloproctology Unit, ‘Ars Medica’ Hospital, Rome, Italy. References 1. Arroyo A, González-Argenté FX, García-Domingo M, Espin-Basany E, De-la-Portilla F, Pérez- Vicente F, Calpena R. Prospective multicentre clinical trial of stapled transanal rectal resection for obstructive defaecation syndrome. Br J Surg 2008; 95: 1521-7. 2. Pescatori M, Spyrou M, Pulvirenti d'Urso A. A prospective evaluation of occult disorders in obstructed defecation using the ¿iceberg diagram¿. Colorectal Dis 2006; 8: 785-9. 3. Boccasanta P, Venturi M, Roviaro G. Stapled transanal rectal resection versus stapled anopexy in the cure of hemorrhoids associated with rectal prolapse. A randomized controlled trial. Int J Colorectal Dis 2007; 22: 245-51. 4. Nyam DC, Pemberton JH, Ilstrup DM, Rath DM. Long-term results of surgery for chronic constipation. Dis Colon Rectum 1997; 40: 273-9. 5. Prospective study of colonic irrigation for the treatment of defaecation disorders. Koch SM, Melenhorst J, van Gemert WG, Baeten CG. Br J Surg 2008; 95: 1273-9. 6. Pescatori M, Gagliardi G. Postoperative complications after procedure for prolapsed hemorrhoids (PPH) and stapled transanal rectal resection (STARR) procedures. Tech Coloproctol 2008; 12: 7-19. 7. Pappagallo M. La giungla dei rimborsi. ‘E io opero in Austria’ [The jungle of reimbursements. ‘Hence, I operate in Austria’]. Corriere della Sera (Milan, Italy). 2008 Sep 8: 11. Italian. 8. Phillips RKS. Invited Commentary. Dis Colon Rectum 2004; 47: 1296.