Die STARR-Operation zur Therapie des obstruktiven Defäkationssyndroms

Zusammenfassung

Die transanale Staplerresektion des Rektums (STARR) ist ein gut evaluiertes Operationsverfahren zur Behandlung einer morphologischen Outletobstruktion im Rahmen eines konservativ refraktären obstruktiven Defäkationssyndroms (ODS). Entsprechend muss zunächst die Diagnose eines ODS gestellt und objektiviert werden, welches sich idealerweise durch Erhebung von speziellen Bewertungsbögen (Scores) realisieren lässt. Neben der allgemeinen koloproktologischen Abklärung ist die Defäkografie wichtigstes bildgebendes Verfahren der präoperativen Diagnostik. Differenzialdiagnostisch gilt es insbesondere die Beckenboden-Dyssynergie und die Slow-Transit-Konstipation auszuschließen. Die operative Therapie erfolgt von transanal als Vollwandresektion entweder konventionell durch 2 einzelne Resektate der vorderen und hinteren Zirkumferenz des Rektums (PPH01) oder als tubuläre Monoblockresektion mit dem Contour Transtar®. Die Morbidität des Verfahrens ist durch Analyse von n = 2838 konsekutiven Patienten des europäischen STARR-Registers mit einer Gesamtrate von 36 % ausgewiesen, wobei der unwillkürliche Stuhldrang mit 20 % und die Nachblutung mit 5 % den größten Anteil davon ausmachen. In spezialisierten Zentren sind bei strenger Selektion der Patienten wesentlich bessere Ergebnisse erzielt worden. Die funktionellen Resultate in Bezug auf eine Verbesserung der Konstipation nach 1 Jahr und im Langzeitverlauf von aktuell bis zu 68 Monaten zeigen ein Ansprechen von bis zu 90 % bei einer Rezidivrate von 5–18 %. Zusammenfassend stellt die STARR-Operation ein gut evaluiertes operatives Verfahren zur Behandlung einer konservativ refraktären Outletobstruktion dar mit einer hohen primären Ansprechrate, einer akzeptablen Morbidität und ersten Analysen nach offenbar mit einer guten Langzeiteffektivität.

Abstract

Stapled transanal rectal resection (STARR) has become a well-evaluated surgical procedure for the treatment of outlet obstruction in the context of conservative refractory obstructed defaecation syndrome (ODS). The diagnosis of ODS needs to be objectified which can be best ensured by clinical scoring systems. Besides a general coloproctological examination, dynamic defecography represents the most important diagnostic procedure. Pelvic floor dyssynergia and slow transit constipation should always be taken into account for the differential diagnosis and for which the STARR procedure is generally contraindicated. Surgery is performed via a transanal approach using a full thickness rectal resection of either the ventral or dorsal proportion of the rectal wall in the PPH01 conventional procedure or circumferentially by monoblock resection in the contour transtar® procedure. Morbidity is best characterised by data of the European STARR registry which contains a total number of n = 2,838 consecutive patients. The overall morbidity rate was 36 % whereby urgency (20 %) and bleeding (5 %) were the most frequent complications. More favourable data have been published in single centre studies. Functional results are available with a follow-up of 1 year up to 68 months postoperatively. Response rates of up to 90 % were reported whereas recurrence rates were given with a maximum of 18 % at 68 months follow-up. In summary, the STARR procedure provides good functional results in conservative refractory outlet obstruction with minor morbidity and the outcome seems to remain stable in the long-term follow-up.

Schlüsselwörter

STARR - Contour Transtar® - Konstipation - ODS - obstruktives Defäkationssyndrom

Key words

STARR - contour transtar® - constipation - ODS - obstructed defaecation syndrome

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