Franc H. Hetzer

Decision-making algorithm for the STARR procedure in obstructed defecation syndrome: position statement of the group of STARR Pioneers.

Internal rectal prolapse (rectal intussusception) and rectocele are frequent clinical findings in patients suffering from refractory constipation that may be best characterized as obstructive defecation syndrome. However, there is still no clear evidence whether the stapled transanal rectal resection (STARR) procedure provides a safe and effective surgical option for symptom resolution in patients with obstructive defecation syndrome, as evidence-based guidelines and functional long-term results are still missing. On the basis of the need for objective evaluation, a European group of experts was founded (Stapled Transanal Rectal Resection Pioneers). Derived from 2 meetings (October 26-28, 2006, Gouvieux, France and November 28-29, 2007, St Gallen, Switzerland) a concept for treatment options in patients suffering from obstructive defecation syndrome was developed, including a clear decision-making algorithm specifically focusing on the role of the stapled transanal rectal resection procedure based on clinical symptoms and dynamic imaging and inclusion and exclusion criteria for the stapled transanal rectal resection procedure.

First experiences with pudendal nerve stimulation in fecal incontinence: a technical report

Sacral nerve stimulation (SNS) is an established treatment for refractory lower urinary tract and bowel dysfunction. In some urological patients, SNS does not have satisfactory results. Pudendal nerve stimulation (PNS) has recently been proposed for these patients and successfully tested. Given the sometimes unsatisfactory results after SNS in fecal incontinence (FI), we tested PNS on patients suffering from FI. We used the device and implantation technique described by Spinelli et al. By making a slight change in the device, we developed a quick and easy-to-use method for successful PNS implantation, based on electrophysiological response. We present the results of a feasibility study, in which we tested the effectiveness of PNS with our modified implantation technique on 2 patients, with very satisfactory early results in a 4-month follow-up.

Clinical and Morphologic Correlation after Stapled Transanal Rectal Resection for Obstructed Defecation Syndrome

PurposeThe clinical and morphologic outcome of patients with obstructed defecation syndrome after stapled transanal rectal resection was prospectively evaluated.MethodsTwenty-four consecutive patients (22 women; median age, 61 (range, 36–74) years) who suffered from obstructed defecation syndrome and with rectal redundancy on magnetic resonance defecography were enrolled in the study. Constipation was assessed by using the Cleveland Constipation Score. Morphologic changes were determined by using closed-configuration magnetic resonance defecography before and after stapled transanal rectal resection.ResultsAfter a median follow-up of 18 (range, 6–36) months, Cleveland Constipation Score significantly decreased from 11 (range, 1–23) preoperatively to 5 (range, 1–15) postoperatively (Pu2009=u20090.02). In 15 of 20 patients, preexisting intussusception was no longer visible in the magnetic resonance defecography. Anterior rectoceles were significantly reduced in depth, from 30xa0mm to 23xa0mm (Pu2009=u20090.01), whereas the number of detectable rectoceles did not significantly change. Complications occurred in 6 of the 24 patients; however, only two were severe (1 bleeding and 1 persisting pain requiring reintervention).ConclusionsClinical improvement of obstructed defecation syndrome after stapled transanal rectal resection correlates well with morphologic correction of the rectal redundancy, whereas correction of intussusception seems to be of particular importance in patients with obstructed defecation syndrome.

Functional outcome and quality of life after stapled transanal rectal resection for obstructed defecation syndrome.

PURPOSE: Clinical studies have demonstrated that stapled transanal rectal resection with Contour Transtar (Transtar procedure) is a safe and effective treatment for patients with obstructive defecation syndrome. The aim of this study was to determine functional outcome and quality of life after the procedure. METHODS: Female patients with obstructive defecation syndrome were enrolled prospectively for the Transtar procedure. Intussusception and anterior rectocele were confirmed by clinical investigation and by magnetic resonance defecography. Functional outcome was measured by obstructed defecation syndrome score, severity of symptoms score, and Wexner score preoperatively and postoperatively. Quality of life was assessed by the Cleveland Clinic constipation score, the fecal incontinence quality of life scale, and the SF-36v2 health survey. RESULTS: Between January 2007 and November 2008, 52 consecutive patients (median age: 64 years) were included in the study. Before the surgery, 12 patients experienced fecal incontinence. Functional scores improved significantly: 6 weeks after surgery, the obstructed defecation syndrome score decreased from a median of 16 (range, 9–22) to 5 (range, 2–10) and the severity of symptoms score, from 16 (range, 9–21) to 4 (range, 0–9) (each P < .0001). After 6 weeks, 10 patients had fecal incontinence and 12 patients experienced fecal urgency. At 3 months, 6 patients were still incontinent, 3 of whom were treated successfully with sacral neuromodulation. Fecal urgency resolved in all cases after 6 months. Quality of life improved, particularly in the mental components. CONCLUSION: Despite the described postoperative symptoms, most of which can be treated conservatively, the Transtar procedure is an effective treatment for patients with obstructive defecation syndrome and improves quality of life significantly.

Prospective analysis of cosmesis, morbidity, and patient satisfaction following Limberg flap for the treatment of sacrococcygeal pilonidal sinus.

PURPOSE: Recent studies have reported excellent healing and low recurrence rates for rhomboid flaps for pilonidal sinus disease. The cosmetic outcome has been less investigated and is the focus of this study following Limberg flap reconstruction of recurrent and complex pilonidal disease. METHODS: From August 2006 to December 2007 patients with a recurrent or complex pilonidal sinus were enrolled consecutively. All underwent excision and closure with a Limberg flap. At 3 weeks, morbidity was assessed in the outpatient clinic. Recurrence rate, self-esteem, cosmetic outcome, body image, and patient satisfaction were analyzed prospectively at 1 year. RESULTS: Seventy patients (57 males) with a median age of 24.8 years (range, 14.7–46.5) were operated on. Median follow-up was 1.4 years (range, 1.0–2.8). The mean cosmetic score was reduced to 16.4 (±4.3) of 24, the mean body image score was good with 17.9 (±2.6) of 20, and the mean overall satisfaction was high at 7.6 (±2.3) of 10. Self-esteem remained unchanged after surgery; it was 7.8 (±2.3) preoperatively and 7.8 (±2.1) postoperatively (P = .818). After 3 weeks 84.3% of the wounds were completely healed. Complications occurred in 18 patients (25.7%), including superficial infection and partial suture dehiscence. Six (8.6%) needed reoperation, and all belonged to the group with acute infection before flap closure (P < .001). There was no incidence of flap necrosis. The recurrence rate was 1.6% at 1-year follow-up. CONCLUSION: Initial wound closure and low recurrence rates after treatment with Limberg flap in pilonidal sinus disease lead to high patient satisfaction. The cosmetic outcome is acceptable, but an issue for some patients. These results support the use of the Limberg flap in complex pilonidal sinus disease after carefully informing patients about the cosmetic consequences.

Midterm results after perineal stapled prolapse resection for external rectal prolapse.

BACKGROUND: Previous studies showed that perineal stapled prolapse resection for external rectal prolapse improves continence and has short operation times and low complication rates. OBJECTIVE: The aim of this study was to assess the midterm recurrence rates, functional results, and patient satisfaction after perineal stapled prolapse resection. DESIGN: This was a retrospective study. SETTINGS: The study was performed at a tertiary hospital in Switzerland. PATIENTS: From November 2007 to October 2011, a total of 56 consecutive patients were included in the study. MAIN OUTCOME MEASURES: Recurrence rates, functional results according to the Wexner incontinence scale, and patient satisfaction using a visual analog scale were determined RESULTS: The median age was 78.5 years (range, 24–94 years), and 2 patients were men. Midterm results were available for 46 (82%) of 56 patients after a median follow-up of 25.5 months (range, 2–47 months). In 10 cases (18%) data collection was not possible. The recurrence rate at 3 years was 19.7% (95% CI 4.2%–32.7%). The Wexner incontinence score improved from a median of 14.5 presurgery to 4.0 points (p < 0.0001) after surgery. Twenty-five patients (54%) stated that their bowel movements were regular postoperatively. On a visual analog scale that measured satisfaction, the median patient score was 9 (range, 0–10), indicating high patient satisfaction. LIMITATIONS: Limitations included the retrospective study design and the lack of clinical examinations to determine recurrence rates. CONCLUSIONS: Perineal stapled prolapse resection is an alternative technique for treating rectal prolapse with a recurrence rate similar to the Altemeier-Mikulicz or Delorme procedures. This technique is a quick and reliable procedure for use in patients with advanced age.

Long-term outcome after transanal rectal resection in patients with obstructed defecation syndrome.

BACKGROUND: Stapled transanal rectal resection with a new, curved, multifire stapler (Transtar procedure) has shown promising short- and midterm results for treating obstructed defecation syndrome. However, few results have been published on long-term outcome. OBJECTIVE: This study aimed to investigate long-term functional results and quality of life after the Transtar procedure. DESIGN: This is a retrospective study. SETTING: This study was conducted at a tertiary hospital in Switzerland. PATIENTS: Seventy consecutive patients (68 female) with obstructed defecation syndrome had a median age of 65 years (range, 20–90). INTERVENTION: The Transtar procedure was performed between January 2007 and March 2010. MAIN OUTCOME MEASURES: Postoperative functional results were evaluated with the Symptom Severity Score, Obstructed Defecation Score, and Cleveland Incontinence Score. Quality of life was evaluated with the Fecal Incontinence Quality of Life Score and the SF-36 Health Survey. Data were divided into 4 groups of 1-, 2-, 3-, and 4-year follow-ups. RESULTS: The functional scores showed significant postoperative improvement throughout the studied period (p = 0.01). The quality-of-life scores showed a tendency for improvement only in the mental components on the SF-36 Health Survey (p = 0.01). Sixteen patients reported postoperative fecal urgency, but this subsided within a few months. Nine patients reported new postoperative episodes of incontinence and required further treatment. LIMITATIONS: This study was limited by its retrospective nature, the selection bias, and a bias by the small number of questionnaires available for some scores. CONCLUSION: The Transtar procedure was successful for long-term treatment of obstructed defecation syndrome. Fecal urgency and incontinence were observed, but typically resolved within months. Therefore, the Transtar procedure appears to be a reasonable approach to treating obstructed defecation syndrome in the long term.

New kid on the block: perineal stapled prolapse resection (PSP) is it worthwhile in the long-term?

PurposePerineal stapled prolapse resection (PSP) has been described as a new surgical treatment for external rectal prolapse in 2008. Short-term and midterm results acknowledged PSP as a safe, fast and simple procedure for high-risk patients. This study aims to assess long-term results after PSP.MethodsAll patients who underwent PSP from 2007 to 2015 were analyzed retrospectively. Data was gathered from medical records and operative reports and by interviews with the general practitioner or the patient.ResultsIndication for PSP was provided in 64 cases. One procedure had to be changed to an Altemeier’s and another to a laparoscopic rectopexy. The median age was 79.9xa0years (range 25.9–97.5). Spinal anaesthesia was used in 19 patients. The median operation time was 32.5xa0min (range 25–51.2). There was no mortality. One patient had to be reoperated. All other complications were minor. The median hospital stay was 6.0xa0days (range 2–23). Median follow-up of patients alive was 6.0xa0years (range 0.2–8.4). The 5-year recurrence-free survival rate for primary prolapse was 70.1xa0% compared to 34.3xa0% for recurrent prolapses (pu2009=u20090.048). Further positive prognostic factors were specimen length over 8xa0cm and lack of preoperative obstructed defecation syndrome. Faecal incontinence was remedied in 18, and new onset was recorded in 6 patients (significant incontinence rate reduction (pu2009=u20090.025)).ConclusionDue to low morbidity and the possibility of spinal anaesthesia, PSP is suitable for frail patients. The recurrence rate for primary prolapse is similar to alternative perineal procedures like Delorme’s and Altemeier’s, but inferior to the laparoscopic techniques.

A new stomaplasty ring (Koring™) to prevent parastomal hernia: an observational multicenter Swiss study.

AbstractBackgroundnParastomal hernias (PSH) are one of the most frequent complications of enterostomies with a non-negligible complication rate and a significant socioeconomic effect. Therefore, preventing PSH by placing a mesh at the time of primary surgery has been advocated. The aim of our study was to evaluate the safety and feasibility of the new stomaplasty ring [Koring™, (Koring GmbH, Basel, Switzerland)] and investigate the reason why surgeons are reluctant to take preventive measures.MethodsA multicenter observational study was conducted on 30 patients between December 2013 and January 2015. In permanent end colostomies and end ileostomies, the Koring™ was implanted. The primary outcome was the 30-day morbidity (infection and other stoma-related complications). Secondary endpoints were the technical feasibility and the time needed to fix the ring. In addition, an online survey of 107 surgeons was performed.ResultsTwenty-seven patients received permanent end colostomies, and three received end ileostomies. No stoma-related complication was detected within the first 30xa0days post-operatively. The Koring™ ring was evaluated by the surgeons as easy and very easy to implant in more than half of the patients. Average additional operating time for ring implantation was 19xa0min.ConclusionsKoring™ implantation at the time of creating the stoma is safe, easy and only adds minimally operating time. A long-term follow-up as well as a randomized controlled study is needed to evaluate the impact of the Koring™ on PSH prevention. The ease and rapidity with which Koring™ can be implanted may help surgeons to overcome their apprehension of using a preventative device.

Percutaneous tibial nerve stimulation (pTNS): success rate and the role of rectal capacity

PurposePercutaneous tibial nerve stimulation (pTNS) was originally developed to treat urinary incontinence. Recently, some case series have also documented its success in the treatment of fecal incontinence. Nevertheless, the mechanism underlying this effect remains unknown but may be related to changes in rectal capacity. The aim of this study was to investigate the success of pTNS for the treatment of fecal urge incontinence and assess the influence of rectal capacity on treatment efficacy.MethodsAll patients undergoing pTNS for fecal incontinence between July 2009 and March 2014 were enrolled in a prospective, observational study consisting of a therapeutic regimen that lasted 9xa0months. Therapy success was defined as a reduction in the CCI (Cleveland Clinic incontinence) score of ≥50% and patient-reported success. Furthermore, quality of life (Rockwood’s scale) and changes in anorectal physiology were recorded.ResultsFifty-seven patients with fecal urge incontinence were eligible, nine of whom were excluded. The success rate was 72.5%. Incontinence events and urge symptoms were significantly reduced after 3xa0months and at the end of therapy. The median CCI score decreased from 12 to 4 (Pxa0<xa00.0001), and the quality of life was significantly improved. However, rectal capacity was not significantly related to treatment success before or after therapy. No adverse events were observed.ConclusionsThese results demonstrate that pTNS can improve the symptoms and quality of life of patients with fecal urge incontinence. However, the study fails to demonstrate a correlation between treatment success and changes in rectal capacity.