LAUSR

A stapled technique for treatment of rectal mucosal prolapse was initially proposed by Pescatori, who published the first cases in 1997 [1]. Following that, Longo developed the first specific stapler (PPH 33 mm) for hemorrhoidopexy and popularized the technique worldwide. Additionally, using the same stapler, he developed another technique, stapled transanal rectal resection (STARR), to treat obstructed defecation syndrome (ODS) associated with rectocele or intussusception. With the PPH stapler, only a limited amount of tissue can be removed, the cartridge cannot be detached and the shaft inside the cartridge is covered by a tube. This makes it difficult for the surgeon to assess what is incorporated in the stapler, remove a large sleeve of rectum and remove a symmetric amount of tissue. With the development of new and more dedicated staplers like HEM EEA-33 (Covidien), TST STARR PLUS (Touchstone) and Transtar (Ethicon), it is currently possible for the surgeon to achieve all these technical goals. In this issue of Techniques in Coloproctology, Naldini et al. [2] describe in great detail the technique and results of circumferential removal of the rectal wall using the TST STARR PLUS stapler in patients with rectocele and internal prolapse associated with ODS. Besides the choice of the stapler and the surgical technique to be used, the most important factor determining satisfactory functional results is careful patient selection. This is achieved by evaluating all the patients with standardized questionnaires, physical examination and imaging. The dysfunctions of the posterior pelvic compartment are like an iceberg [3]: Rectocele is the first anatomical defect to appear but there are always others not readily seen, such as rectal intussusception or enterocele, or others such as anismus that can be found only after specific tests are performed. Based on this concept, it is mandatory to carry out a careful proctology examination and to confirm and quantify the physical findings with imaging tests such as cinedefecography, echodefecography (dynamic three-dimensional rectal ultrasound) and dynamic magnetic resonance imaging. It is also important to perform anal manometry to exclude anismus and evaluate sphincter function, and finally perform an urogynecologic evaluation before choosing the most appropriate surgical technique. Surgical treatment with a transanal stapled technique is indicated only if, after this comprehensive evaluation, the presence of rectocele, full mucosal prolapse and/or rectal intussusception is confirmed and anismus, enterocele, anterior or middle compartment prolapse, urge fecal incontinence or weak sphincters are excluded and only after the patient fails conservative treatment with fiber, laxatives and pelvic floor rehabilitation. Which stapler and which technique? In patients with rectocele, the resection must be close to the dentate line (approximately 1.0 cm proximally) because the herniation starts at the anterior upper anal canal, as suggested by echodefecography [4], and consequently the herniation will persist if the stapled suture is positioned far above that level. Therefore, in female patients with rectocele associated with rectal intussusception, we have proposed the transanal repair of rectocele and rectal mucosectomy with one circular stapler (TRREMS) which may be performed with either the EEA-33 or TST STARR PLUS stapler [5]. These staplers make it possible to quantify the amount of tissue that must be removed and are associated with a low incidence of bleeding after firing which requires hemostatic suture (approximately 7%). In contrast, the PPH stapler has a limited capacity and haemostatic suturing is required in about 20% of patients [6]. In the TREMMS technique, the rectocele is first removed manually using a continuous suture about 2.0 cm from the dentate line. Following that, a purse-string suture is placed to include both the intussusception and the rectocele sutures in order to remove a symmetric wedge of tissue (Fig. 1). This technique has been shown to be safe and effective in * F. S. P. Regadas Filho [email protected]