The efficacy of the STARR procedure in the treatment of ODS has been proven by numerous prospective randomized studies. In terms of improvement of constipation after one year and long-term (up to 68 months), functional results demonstrate a response of up to 90% with a recurrence rate of 5-18%. In summary, the STARR operation represents a well evaluated surgical procedure in the treatment of ODS refractory to conservative measures 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, the UK and Germany) with enrolled 2838 patients, 2224 of which with 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 functional outcome data set after 12 months.
It was demonstrated that STARR surgery was associated with a significant reduction in constipation and improvement in overall and symptom-specific quality of life. At the same time, morbidity of severe complications was justifiably low, and mortality was 0%. It is worth noting that the general complication rate is still quite high at 36 percent. In first place with the rather high rate of 20 percent are patients with urge incontinence, while persistent pain accounted for seven percent. Similar outcomes are also reported for the evaluation of the German STARR register <3. More favorable results can be achieved under suitable selection criteria and in specialized centers [4, 14]. At present, only a limited amount of long-term data is available. Over a long-term follow-of 24 to 68 months, there is a largely stable effect on constipation with a recurrence rate of 5-18.7% [1,15,16,17,18,19]. In 2007 continued development of the procedure resulted in the introduction of the Contour-TRANSTAR. The benefit of this new stapler is that it is now possible to perform a more extensive rectal wall resection, although there is currently no proof that a larger resection area correlates with better outcome. A comparative study of the two techniques with a follow-up of 12 months reveals a treatment success of 89 percent in the STARR group and 81 percent in the Contour-TRANSTAR group [4]. Also, it must be noted that the follow-up rate after 12 months was only 58 percent, which means that the findings can only be regarded with reservations. Further comparison studies, which were also unable to identify functional differences to the STARR operation, came to the same conclusion [5,12]. No clear edge for the newer technique has been proven to date.
The outcome of abdominal rectopexy in outlet constipation is different. Evidently the best results will be achieved by resection rectopexy with suture fixation [6,7,8,9]. However, the indication must be assessed extremely critically, especially as these procedures are associated with a considerable morbidity rate against the background of a functional disorder, and deterioration of the clinical situation is often described in the literature.
In any case, conservative treatment options should always be exhausted prior to possible surgical interventions [10]. It should be borne in mind that biofeedback therapy, for example, has no basic impact on rectal intussusception or rectocele. In prospective randomized comparison it is also inferior to the STARR operation [11].
The presence of enterocele or manifest fecal incontinence does not constitute a contraindication for the procedure. In patients with enterocele studies have demonstrated a very good response to STARR surgery in terms of improving constipation [12]. In patients with ODS and concurrent manifest fecal incontinence, the STARR procedure alone improves continence performance in up to 50% of cases [13].
The presence of intussusception and/or rectocele is a predictor of improvement in postoperative constipation. On the other hand, preoperative evidence of a pronounced pelvic floor resting prolapse, a low squeeze pressure and small rectum diameter is unfavorable regarding new-onset fecal incontinence. These findings are of decisive importance for meaningful patient selection [20].