Comment on Ribaric et al: STARR with CONTOUR® TRANSTAR™ device for obstructed defecation syndrome: one-year real-world outcomes of the European TRANSTAR registry.

Abstract

Dear Editor: The article by Ribaric et al. (Ribaric et al. In J Colorectal Dis 2014;29:611-622) on the use of the CONTOUR TRAN STARTM device for obstructed defecation syndrome (ODS) raises many questions that the authors have not addressed adequately in their manuscript. In pelvic floor disorders, the correlation between anatomic correction and functional outcome is frequently inconsistent. Therefore, it is crucial to achieve a correct diagnosis and have well-defined criteria for surgery. The authors reported that “patients were selected for surgery on the basis of recognized clinical symptoms of ODS associated with evidence of rectal pathology such as rectocele and/or internal rectal prolapse confirmed by clinical examination with proctoscopy and/or diagnostic imaging (defecography or MRI)”. However, in this multicentre study, imaging was not standardized, to the point that it was not performed in three patients and the other 97 were studied either by defecography (68 %) or MRI (29 %). Moreover, it should be noted that MRI is usually performed with the patient in the supine position, which may limit the validity of any findings because it underestimates the extent of the pelvic organ prolapse (Maglinte et al. Radiology 2011;258:23–39). Imaging demonstrated a rectocele in 80 % of patients and an internal rectal prolapse in 73% of cases but, unfortunately, details of the disorders (e.g. grade of rectocele/ intussusception) causing the ODS was not provided. This is crucial as anterior rectoceles in females and rectal intussusception without an effect on evacuatory function has been diagnosed proctographically in healthy volunteers (Palit et al. Colorectal Dis 2014 doi: 10.1111/codi.12595). Furthermore, the authors have not demonstrated that they distinguished between patients with rectal abnormalities causing ODS and those with anatomical abnormalities secondary to dyssynergic defecation. Moreover, it would be interesting to know the patient outcomes depending on the rectal abnormality that was treated (rectocele, rectal intussusception or both). Finally, dyssynergic defecation is frequently associated with structural disorders; thus, it would be also interesting to know the number of patients that had both functional and structural disorders, as well as the outcomes of biofeedback presumably performed before surgery. Pelvic floor disorders are complicated to both understand and treat, especially when constipation and faecal incontinence coexist. It can be argued that the authors generalize when they state that “faecal incontinence usually improves after transanal stapling procedures for ODS”. While an intussusception reaching the anal canal may cause an insufficiency of the anal sphincter, a patient with an isolated rectocele would not have faecal incontinence unless there are associated sphincter or nerve injuries. It is surprising that “adequate anal sphincter function was assessed at least with a digital rectal examination”. It is standard practice worldwide to perform anorectal physiology not only to assess preoperative sphincter function, but also to exclude dyssynergic defecation which is treated conservatively. Ribaric et al. referenced several studies. In the study of Jayne et al. (Jayne DG et al . Dis Colon Rectum 2009;52:1205–1214), there was a significant improvement in the Cleveland Clinic incontinence score, but 20 % of the patients reported defecatory urgency postoperatively. The Y. Ribas (*) Department of Surgery, Ctra.de Torrebonica s/n. Consorci Sanitari de Terrassa, 08227 Terrassa, Barcelona, Spain e-mail: yribas@cst.cat