Surgery for obstructed defecation in over 65 year old patients

Background

The treatment of obstructed defecation is one of the currently most debated topics in the field of surgery of the pelvic floor. For elderly people conservative methods are often suggested. The aim of this study is to report clinical results of three different surgical approaches for the correction of rectocele and anorectal prolapse.

Materials and methods

32 over 65-years old patients underwent surgery for obstructed defecation syndrome and then observed prospectively by the Coloproctological Unit of Surgical Clinic III, S. Antonio Hospital, Padova, from 2001 to 2007. All patients were evaluated with a dedicated questionnaire: Knowles-Eccerseley-Scott score (KESS) for all patients and Obstructed Defecation score (ODS) for two groups, proctological and gynecological examination, colpocystodefecography before surgery and 6 months afterwards.

The three surgical techniques adopted were: posterior colporrhaphy and rectal mucosectomy with mechanical circular stapler PPH01^® (Ethicon Endo Surgery, Cincinnati, OH, USA) (CPR-PPH Group), stapled transanal rectal resection with two stapler PPH01^® (STARR Group) and stapler rectal resection with CCS30 Contour Transtar^® (Transtar Group).

In two cases we associated laparoscopic assistance to transanal technique in general anaesthesia for suspected enterocele not confirmed by peritoneal exploration. All other operations were performed in spinal anaesthesia.

Results

There was an improvement of post-operative symptoms in all approaches without significant differences between the techniques. There was one major complication (suspected microperforation of the rectum resolved with conservative therapy) in the Transtar Group. Medium KESS score significantly decreased in all groups (from 16.2 to 4.8 in the first group, from 18.8 to 5.7 in the second group, from 21.8 to 5.8 in the third group, p < 0.0001 Wilcoxon's test). Also Medium ODS significantly decreased in the two groups analyzed (from 17.7 to 3.3 in STARR Group, from 21.2 to 4 in Transtar Group, p < 0.0001 Wilcoxon's test). The STARR technique showed a benefit in reducing the operating time, the maintenance of urinary catheter and hospital stay.

Conclusion

The surgical approaches proposed showed effectiveness and safety in improving symptoms of obstructed defecation. This surgery fits also elderly patients because of the lower surgical risk and the decreased hospital stay than traditional abdominal approaches.

In particular STARR procedure offers advantage in elderly patients because of reduced operative time and hospital stay and reduced maintenance of urinary catheter.