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Background: Obstructed defecation syndrome (ODS) is one of the commonest constipation related disorders confronted by surgeons in Bangladesh. Stapled transanal rectal resection (STARR) is a novel surgical technique specific for ODS. This study was designed to evaluate the effectiveness of STARR on patients with ODS in Bangladesh. Methods: Thirty (30) female patients (age: 46±13.2 years) with ODS, were selected for this observational study, from July 2016 to July 2019, in a private hospital of Dhaka. Patients were interviewed with standardized questionnaire at study enrolment and up to 3 months postoperatively. Surgical outcome was quantified according to the Longo’s Modified ODS score (MODS). Results: At initial consultation, the mean Longo’s MODS score was 17.6+1.9. Mean operative time was 39+6.2 minutes. Commonest complication was ‘staple line bleeding’ in 24(80%) patients intraoperatively & ‘defecatory urgency’ in 18(60 %) patients postoperatively. At postoperative 3-month follow-up, statistically significant (p

Objectives There are no uniform screening recommendations for anal cancer. Medical practice guidelines are now available on the use of Digital Anal Rectal Examinations (DARE) for the detection of anal cancer; however, because screening can result in more harm than benefit, our objective was to assess the evidence for use of DARE as a public health screening tool. Materials and methods We conducted a current critical appraisal of anal cancer literature using World Health Organization criteria for assessing the potential utility of a public health screening program. Results Digital Anal Rectal Examination satisfies most, but not all, World Health Organization criteria for a public health program that seeks to detect early invasive anal cancer in populations at high risk for anal cancer, most notably HIV-positive men who have sex with men; however, DARE is not appropriate when facilities for treatment are nonexistent. In addition, there are insufficient data on DARE sensitivity and specificity. Conclusions The mildly invasive nature of DARE, limited likelihood of adverse procedure-related events, cost-effectiveness and patient acceptability, as well as wide availability of DARE support consideration of its integration into screening for populations at high risk of anal cancer, especially HIV-positive men who have sex with men.

Background: Condylomata acuminata (CA) are a common sexually transmitted disease. The recurrence rate of condyloma acuminatum using traditional treatments is higher than that of applying ph...

Mistrangelo et al raise a number of issues in connection with the International Anal Neoplasia Society guidelines for the practice of High Resolution Anoscopy (HRA) in the era of COVID‐19.The authors suggest that the guidelines advocate “mandatory” HRA for “screening”. On the contrary, the guidelines clearly define risk prioritisation, in terms of both potential COVID‐19 exposure and the dangers associated with delayed diagnosis of anal cancers.Centres without access to high quality HRA services may have to rely on digital anal rectal examination to eventually diagnose large anal cancers. HRA has the ability to accurately identify early anal cancers and worrisome pre‐cancerous lesions, and thus to facilitate early intervention. It therefore has the capacity to substantially improve survival and quality of life of patients. This remains true in the era of COVID‐19, and will be of increasing importance as the epidemic continues and services remain disrupted.

Background Nucleic Acid Amplification Testing (NAT) assay is the new tool that may diagnose gonorrhoea and or chlamydia more sensitive and specific. The test, however, is not widely used in Indonesia, time consuming and expensive. Pooling of samples may significantly reduce the cost while maintaining the effectiveness of the test with high specificity and sensitivity rate for the detection of CT/NG infections. This study aimed to examine the effectiveness of 3-in-1 pooled samples from anal, rectal and throat of GenXpert CT/NG among MSM in Bali, Indonesia Methods A quantitative study was conducted between July 2017 and July 2018 in an MSM clinic in Bali. Xpert CT/NG samples were collected from throat, anal swab and first pass urine which then pooled into one cartridge. The pooled samples results were compared with each site results by CT/NG GeneXpert® assay. Results A total of 502 swabs were collected from 251 participants, comprises 251 pharyngeal and rectal swabs respectively, along with 251 First Pass Urine. Sensitivities and specificities of the GeneXpert® CT/NG assay was calculated using the pooled 3-in-1 sites compare to each site result as standard. 4/251 (1.5%) of rectal swab samples invalid and/or error by CT/NG GeneXpert® assay that most likely due to contamination with stools. The study shown the performance of 3-in-1 pooled samples (from anal, rectal and throat) of GeneXpert® CT/NG was highly effective due to the high rate of sensitivity and specificity, particularly from anal site as shown in table 1. Conclusion This is the first study ever conducted to report data on the performance of pooled samples of GeneXpert® CT/NG among MSM in Indonesia. Consistent with similar study in other countries using other NAT platform, this study found the high rate of sensitivity and specificity for CT/NG detection. To be concluded, pooled samples among MSM can be considered in the resource-constraint setting. Disclosure No significant relationships.

Background: Laparoscopic ventral mesh rectopexy (LVMR) and stapled trans-anal rectal resection (STARR) are effective and well-recognized treatments for symptoms of obstructed defecation syndrome (ODS) in the context of rectal prolapse and rectocele. However, recurrence and postoperative complications including symptomatic grade III/IV hemorrhoids develop in patients undergo LVMR. It was hypothesized that adding STARR to LVMR is effective in improving the clinical symptoms and functional outcomes and reducing the postoperative complications after repair of ODS. Methods/Design: In this prospective, single-blind, randomised trial, consecutive patients aged 18 years or older at a single center in China with ODS are randomly assigned (1:1) to either LVMR or LVMR plus STARR. Functional assessment is done preoperatively and 12 months postoperatively. The primary outcome is the rate of complications started in the hospital and is followed up in the outpatient setting until 12 months after surgery. Patients and those assessing the outcomes were masked to the procedure. The primary analysis is done in the per-protocol population. Outcomes are assessed in the entire cohort. Discussion: This study will add to the scant literature regarding surgical management of ODS.

Purpose: Traditional intersphincteric resection is a technically demanding procedure that required a perineal approach dissection and a handsewn coloanal anastomosis. Our study was to inve...

Contains fulltext : 215651.pdf (Publisher’s version ) (Open Access) OBJECTIVE: The aim of the study was to develop recommended techniques and quality assurance metrics for the practice of Digital Anal Rectal Examination (DARE). MATERIALS AND METHODS: The International Anal Neoplasia Society undertook a literature review and, using the AGREE II technique, developed guidelines for performing DARE. RESULTS: A consensus was formed regarding the optimum conditions and characteristics of DARE. Several Quality Assurance metrics were developed. CONCLUSIONS: Digital Anal Rectal Examination is a cheap and potentially universally available technique, which has the potential to facilitate the early diagnosis of anal cancers, when they are most amenable to treatment. These guidelines provide a basis for teaching the technique and may be used as for evaluation research.

Background: Stapled transanal rectal resection (STARR) has been shown to improve patients’ functional and quality of life outcomes in several studies. Although it is a safe and effective treatment for obstructive defecation syndrome, still data on long-term follow-up are missing. Methods: From January 2010 to July 2014, 46 consecutive patients undergoing STARR using the CONTOUR&reg TRANSTAR&#8482 device, shortly named TRANSTAR (transanal stapler assisted resection), were prospectively followed. Recurrence rate, quality of life (Patient Assessment of Constipation-Quality of Life (PAC-Qol)) and complication were documented at baseline, 12 and 24 months after operation. Two subgroups of patients were compared to assess the impact of resection length on outcome. Results: We included 46 patients (89% female) in the study. The mean age was 65 ± 16 years and the duration of the operation was 48 ± 4 min. Total PAC-QoL score improved from 2.0 (SD 0.3) to 0.9 (1.4) after 12 months, but deteriorated to 1.2 (0.3) after 24 months (p < 0.001 for both comparisons). Complications were noted in 7% of the patients: Urinary retention (2 patients), postoperative bleeding (1 patient). No major complications or mortality were seen. After one year, we had one prolapse recurrence and after 24 month we had another. There was no significant relation between the length of the specimen and the improvement of life quality. Conclusions: The STARR procedure seems to be a safe and fast therapeutic option for patients with ODS and/or rectal prolapse. It is a tailored transanal full-thickness rectal resection improving the patients’ quality of life still two years after the operation.

Increased defecation frequency and soiling are common complications of surgery for right-sided Hirschsprung's disease (HD). Though the laparoscopic Duhamel procedure is a favorable option in right-sided HD, the conventional laparoscopic technique is time consuming and has complications that are associated with the reservoir. In this study, we described a modified laparoscopic Duhamel technique with ex-anal rectal transection combined with the Deloyer's procedure for right-sided HD.Between March 2010 and January 2015, 18 right-sided HD underwent this modified laparoscopic Duhamel procedure (MLDP). The main modifications were to mobilize the colon and to dissect the retrorectal space under laparoscopy, pull out, and transect ex-anally by using a linear stapling device through a transverse incision on posterior wall of the rectum. Seven age-matched patients who underwent a conventional laparoscopic Duhamel procedure (CLDP) between March 2008 and December 2010 were included as the control group. Demographics, surgical procedures, operative data, postoperative complications, and clinical outcomes were compared between these two groups.Operative time was significantly shorter in the MLDP group (150 minutes versus 195 minutes; P = .03). There was no significant difference in mean timespan to obtain a normal defecation frequency (3.8 months versus 3.6 months), incidence of soiling (11.1% versus 14.3%; P = .34), and constipation (5.6% versus 14.3%; P = .69). Pouchitis were not found in the MLDP group, whereas 2 patients in the CLDP group (28.6%) presented with pouchitis and intractable diarrhea, requiring spur division. The incidence of postoperative enterocolitis was not significantly different in the two groups (11.1% in MLDP versus 14.3% in CLDP; P = .68). All 22 patients had a normal defecation over 4 years of age.Laparoscopic Duhamel with ex-anal rectal transection is a simple, easy-to-learn, and effective procedure for right-sided HD. It has low postoperative pouchitis because of a short pouch.

Obstructed defecation syndrome (ODS) is one of the most widespread clinical problems which frequently affect middle - aged females. There is a new surgical technique called stapled trans-anal rectal resection, (STARR) which makes it possible to remove the anorectal mucosa circumferential and reinforce the anterior anorectal junction wall with the use of a circular stapler. This surgical technique developed by Antonio Longo, was proposed as an effective alternative for the treatment of ODS. In this study we present our preliminary results with the STARR operation for the treatment of ODS. For this purpose, 40 consecutive female patients with ODS due to rectal intussusception (RI) and/or rectocele (RE),were recruited in this prospective clinical study, from May 2008 to October 2010. No major operative or postoperative complications were recorded, and after 12-months follow-up, significant improvement in the ODS score system was observed. The symptoms of constipation improved in 90% of patients, 20% of patients judged their final clinical outcome as excellent, 55% as good, 15% as moderate, with only 10% having poor results. After analyzing our results we can conclude that STARR is an effective and safe procedure for the treatment of obstructed defecation syndrome due to rectal intussusception and/or rectocele, and can be performed safely without major morbidity.

Purpose: To assess both short and long-term functional outcomes and quality of life of patients treated with stapled trans-anal rectal resection (STARR) for obstructed defecation syndrome (ODS). Methods: 46 patients with ODS, due to rectocele and/or rectal intussusceptions were treated with STARR. Data collected included demographics, OR time, pain score using visual analog scale (VAS), and complications. The study included defecographic assessment and anal manometry [Urge to defecate volume (UTDV) and maximum tolerable volume (MTV)], both were done preoperative and 1 year postoperative. Modified obstructed-defecation questionnaire (MODS), patient assessed constipation-quality of life (PAC-QOL) score and Cleveland clinic foundation (CCF) continence score were all recorded preoperative and every 6 months during follow-up. Results: Mean age was 48.4 years. 45 patients had mild postoperative pain (VAS: 1-2). Only one male patient had severe pain (VAS: 7). Three patients developed stenosis at the staple line 6 months postoperative and were dilated manually. Follow-up period range was (18 – 48) and median follow-up period was 42 month. Recurrence rate was 6.5% after 18 months, 10.8% after 36 months and 13 % after 42 months. Significant reduction in maximal tolerable volume (MTP) and urge to defecate volume (UTDV) was recorded. Modified obstructed-defecation questionnaire (MODS) and PAC-QOL showed significant improvement after 6 months and this improvement was maintained for 18 months then rapid decline till the end of follow up period. Conclusions: STARR is a safe surgical procedure that effectively restores anatomy and function of the anorectum in patients with ODS. This correction improves functional and QOL scores, however high rate of symptomatic recurrence and QOL score decline are expected after18 months.

Longo's procedure of double stapled trans anal rectal resection (STARR) has been evocated as surgical treatment of the obstructed defecation syndrome (ODS) in patients with rectal mucosal prolapse. The aim of this study was to investigate the post-interventional findings of this technique, to help radiologist in knowledge of the changed morphology of the rectal lumen, also in attempt to recognize some potential related complications.

L’intervention de STARR permet de traiter les troubles de l’evacuation rectale en pratiquant une resection rectale par voie transanale. La correction d’une rectocele et/ou de la procidence interne du rectum permet ainsi de faciliter la vidange du rectum. Cette methode mini-invasive necessite de respecter, de facon rigoureuse, le protocole operatoire et de bien selectionner les patient(e)s pour pretendre a des resultats satisfaisants et durables.

Objectives To modify our technique of perianal anesthesia and use it in patients with painful conditions of the rectum and/or anus. Methods A total of 31 consecutive patients with anal-rectal problems underwent prostate needle biopsy. Of these, 17 were referred to our hospital after vain attempts to insert a transrectal ultrasound probe. Patients received a perianal-pericapsular injection of 1% lidocaine. Pain perception was separately assessed for probe insertion and biopsies using a visual pain analog score. Results Only in 1 patient were we unable to insert the transrectal ultrasound probe. The mean patient age was 65.28 ± 5.35 years. We performed a mean of 12.25 biopsies per case. At probe insertion, the mean pain score was 2.2 ± 0.83. During the biopsy punctures, the mean pain level was 2.53 ± 1.054. We did not find any increase in the complication rate related to the anesthesia method. Conclusions Modified perianal anesthesia can be used for transrectal ultrasound-guided biopsy of the prostate in patients with anal-rectal problems, because it provides significant pain relief.

Background: Laparoscopic Ventral Mesh Rectopexy (LVR) corrects both, internal and external rectal prolapse, improving obstructed defaecation symptoms (ODS) and faecal incontinence. Similarly, Stapled Trans-Anal Rectal Resection (STARR) allows resolution of ODS. However data from retrospective series or prospective trials comparing the two procedures for internal rectal prolapse (IRP, defined as recto-rectal or recto-anal intussusception) are absent. In this matched cohorts study we compared outcomes in terms of surgical complications and functional results of LVR and STARR in order to better understand the ideal surgical approach for IRP. Patients and Methods: All patients underwent preoperative evaluation with defaecating proctography or pelvic dynamic MRI. Only patients with recto-rectal or recto-anal intussusception, rectocoele with or without enterocoele or sigmoidocoele were considered from our prospectively kept database. Patients with concomitant middle and anterior pelvic compartment prolapses, were excluded. Two groups of patients were considered according to the surgical technique (LVR or STARR) and matched for demographics, symptoms and characteristics of the prolapse. Only patients with a minimum of 1 year follow-up were considerd. End-points were surgical complications and functional results expressed as Wexner Constipation Score (WCS) and Faecal Incontinence Severity Index (FISI). Results: Twenty-seven patients who underwent LVR were compared to 27 patients who underwent STARR. After LVR, overall complications rate was 15% similar to STARR (11%), all minor. After LVR, WCS significantly improved to 5+/-3 from preoperative 15+/5 (p 0.03). Constipation improved in 89% and was cured in 81%. Similarly, after STARR, WCS score significantly improved to 6+/-5 from preoperative 16+/-11(p 0.03). Recurrence rate was 22%. Constipation improved in 85% and was cured in 78%. No significative differences were observed between the two groups. Considering incontinence, after LVR the FISI score significantly improved to 2+/-2 from preoperative 7+/-3 (p 0.03). Incontinence improved in 90% and was completely cured in 90%. After STARR, the FISI score improved to 4+/-2 from preoperative 8+/-5(p 0.06). Incontinence improved in 54% and was completely cured in 45%. These percentages were significantly lower compared to those observed after LVR. Conclusions: LVR and STARR seems to be equally valid to treat constipation associated to IRP, but LVR has greater chances to cure incontinence.

T UMORS of the anus and rectum can be paIpated. The common mahgnant and benign neopIasms (adenocarcinema, polyps) of the anorectum are rarely confusing. However, there is a group of unusua1 tumors in this area which is often confused with carcinomas; the tumors are misdiagnosed because of their deviant pattern or are mistakenIy accepted as benign growths. This unusua1 group invoIves important diagnostic and therapeutic probIems. The foIIowing tumors were seen at our Institution from 1930 to 1947: maIignant meIanoma of the anorectum, hemangioma of the rectum, malignant Ieiomyoma of the rectum, Iymphosarcoma of the anorectum, synchronous carcinomas of anus and rectum, retrorecta1 or sacrococcygea1 teratoma and chordoma, sacra1 region.

INTRODUCTION Rectovaginal fistula (RVF) is a rare but debilitating complication of a variety of pelvic surgical procedures. PRESENTATION OF CASE We report the case of a 45-year-old female who underwent the STARR (Stapled Trans Anal Rectal Resection) procedure, that was complicated by a 30mm rectovaginal fistula (RVF). We successfully repaired the fistula by trans-perineal approach and pubo-coccygeus muscle interposition. Seven months later we can confirm the complete fistula healing and good patient's quality of life. We carefully describe our technique showing the advantages over alternative suturing, flap reconstruction or resection procedures. DISCUSSION This technique is fairly easy to perform and conservative. The pubo-coccygeus muscle is quickly recognizable during the dissection of the recto-vaginal space and the tension-free approximation of this muscle by single sutures represents an easy way of replacement of the recto-vaginal septum. CONCLUSION In our experience the use of pubo-coccygeus muscle interposition is an effective technique for rectovaginal space reconstruction and it should be considered as a viable solution for RVF repair.

It is just ten years ago since a separate department devoted exclusively to the treatment of anal, rectal and colonic diseases was instituted in the San Francisco Polyclinic. As this was the first clinic of its kind established west of the Mississippi River, its growth was at the beginning quite slow, since it took some time before the internists, surgeons and allied specialists recognized its value as an aid in diagnosis and treatment. In recent years, however, through the cooperation of my colleagues in the different clinics, the rectal department has gradually grown until now, in point of attendance, at least, it compares most favorably with like clinics in older established institutions in Eastern cities. To the genito-urinary surgeons in particular does it seem to have been satisfactorily demonstrated that the proctoscope may be at times of valuable assistance in diagnosing some of their more puzzling cases. Through their courtesy