817 Diseases of the Colon & ReCtum Volume 58: 8 (2015) obstructed defecation is a common syndrome, frequently affecting middle-aged women. it is associated with the abnormal function of muscles involved in defecation as a result of anatomical alterations. uncoordinated contraction and relaxation of pelvic floor muscles may occur often with intussusception of the rectal wall and/or rectocele. the introduction of stapled transanal rectal resection (staRR) contributed to the increased interest in the underlying anatomical lesions associated with obstructed defecation syndrome. several surgical techniques have been described to address those lesions with variable outcome and reported complications. stapled transanal rectal resection is recognized as an effective treatment of obstructed defecation syndrome associated with intussusception of the rectal wall and/or rectocele. the staRR, as previously described by longo, is based on the application of the PPh-01 or Contour 30 stapler. the use of 2 PPh-01 circular staplers has been shown as a safe and effective midterm treatment strategy for obstructed defecation syndrome. however, circular staplers have recently been associated with infrequent but serious complications, such as rectal diverticulum, rectovaginal fistula, total rectal obliteration, rectal wall hematoma, and perforation. such early complications of staRR seem to be reduced by using a parachute suture, rather than a pursestring suture, to thoroughly control the selected prolapsing tissue. Despite these technical adjustments, the optimal and standardized use of PPh-01 still remains a much debated topic. one reported drawback of PPh-01 is that it is a “single fire stapler,” closed and fired blindly, so that surgeons may experience difficulties in checking the correct rectal wall position in the case. the surgeon’s experience and learning curve are mandatory to overcome such issues, but the risks of complications related to PPh-01 kit design might explain the slow spread of staRR worldwide. such drawbacks could be avoided by using a curved stapler device that warrants multifire applications under better visibility and a complete removal of rectal prolapse without leaving any lateral flap remnants. although the volume of tissue resected by using the Contour transtar is almost double that obtained by PPh-01-staRR, the semicircular stapler was initially reported to be as safe and effective as PPh-01-staRR in a recent multicenter european study. in this european trial, technical difficulties in attaining a sufficient longitudinal opening of the prolapse were also described with a risk of causing a spiral of the suture line by applying variable traction on the parachute stitches during Contour transtar firing. moreover, the semicircular stapler was reported to increase the surgeon's view of the operative field and to warrant safer and larger resection of tissue in comparison with double PPh-01. other authors argued that the functional results were comparable between the 2 techniques, but whether a greater resection obtained by Contour may result in improved functions remains a matter of debate. in summary, the Contour transtar device appears to better facilitate a more tailored surgery, including a real Technical Aspect of Stapled Transanal Rectal Resection. From PPH-01 to Contour to Both: An Optional Combined Approach to Treat Obstructed Defecation?
L. Brusciano, P. Limongelli, S. Tolone
Diseases of the Colon & Rectum