The STARR procedure has been proven effective for the treatment of ODS through numerous studies, some of which are prospective-randomized. The functional results in terms of improvement in constipation after one year and in the long-term course (up to 68 months) show a response rate of up to 90% with a recurrence rate of 5–18%. In summary, the STARR procedure represents a well-evaluated surgical method for the treatment of conservatively refractory ODS with a high primary response rate, acceptable morbidity, and an apparently stable long-term effect.
Jayne (2) presented the results of the European STARR Registry (online-based, non-randomized, prospective, multicenter database in Italy, Great Britain, and Germany) with 2838 recorded patients, of whom 2224 had a minimum follow-up of 12 months. Unfortunately, the value of the study is limited by the fact that only 41 percent of the patients had a complete dataset of functional results after 12 months.
It could be demonstrated that the STARR procedure was associated with a significant reduction in constipation and improvement in general and symptom-specific quality of life. At the same time, the morbidity of severe complications was acceptably low and the lethality 0%. Noteworthy is a still quite high general complication rate of 36 percent. In first place is the relatively high proportion of 20 percent of patients with urge incontinence and seven percent with persistent pain. Similar results are also reported in the evaluation of the German STARR Registry <3. Under suitable selection criteria and in specialized centers, more favorable results can be achieved [4, 14]. Long-term data are currently available only to a limited extent. With a long-term course of 24 to 68 months, a largely stable effect results in terms of constipation with a recurrence rate of 5–18.7% [1,15,16,17,18,19].
In 2007, resection with the Contour-TRANSTAR was introduced as a further development. The advantage of this new stapling device lies in the possibility of performing a larger area rectal wall resection, although proof that a larger resection area is associated with better results is currently lacking. A comparative study of the two procedures sees a treatment success of 89 percent in the STARR group and 81 percent in the Contour-TRANSTAR group at a follow-up of 12 months (4). Also, a follow-up rate of only 58 percent of patients after 12 months is to be noted, so that the statements are to be classified only with restrictions. Other comparative studies come to the same result, which functionally also could not work out any difference to the STARR procedure [5,12]. A clear advantage for the newer procedure has not been proven to date.
The results of abdominal rectopexy for outlet obstruction are varied. The best successes are apparently achieved through resection rectopexy with suture fixation [6,7,8,9]. However, the indication must be made extremely critically, especially since these procedures are associated with a significant morbidity rate in the context of a functional disorder and deteriorations of the clinical picture are also frequently described in the literature.
In any case, before possible surgical interventions, conservative therapy options should generally be exhausted (10). It should be considered that biofeedback therapy, for example, in principle can neither causally influence a rectal intussusception nor a rectocele. In addition, it is inferior to the STARR procedure in prospective-randomized comparison (11).
No contraindication for the procedure is the detection of an enterocele or manifest fecal incontinence. Studies demonstrate a very good response to the STARR procedure in patients with enterocele in terms of improvement in constipation (12). In patients with ODS and coincidental manifest fecal incontinence, continence performance improves solely through the STARR procedure in up to 50% of cases (13).
Predictive for improved postoperative constipation is the detection of an intussusception and/or rectocele. Unfavorable in terms of newly occurring fecal incontinence is, however, the preoperative detection of pronounced pelvic floor descent at rest, low squeeze pressure, and small rectal diameter. These findings are of decisive importance for meaningful patient selection(20).