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Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jan 28, 2015; 21(4): 1053-1060
Published online Jan 28, 2015. doi: 10.3748/wjg.v21.i4.1053
Management of obstructed defecation
Vlasta Podzemny, Lorenzo Carlo Pescatori, Mario Pescatori, Coloproctology Unit, Parioli Clinic, 00100 Rome, Italy
Author contributions: Pescatori LC and Podzemny V reviewed the literature; Pescatori M wrote the paper; Podzemny V revised the English language; Pescatori LC, Pescatori M and Podzemny V approved the paper.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Lorenzo Carlo Pescatori, MD, Coloproctology Unit, Parioli Clinic, Via Felice Giordano 8, 00100 Rome, Italy. lorenzo.carlo.pescatori@gmail.com
Telephone: +39-33-81388577 Fax: +39-6-80777290
Received: June 23, 2014
Peer-review started: June 23, 2014
First decision: July 21, 2014
Revised: August 3, 2014
Accepted: September 29, 2014
Article in press: September 30, 2014
Published online: January 28, 2015

Abstract

The management of obstructed defecation syndrome (ODS) is mainly conservative and mainly consists of fiber diet, bulking laxatives, rectal irrigation or hydrocolontherapy, biofeedback, transanal electrostimulation, yoga and psychotherapy. According to our experience, nearly 20% of the patients need surgical treatment. If we consider ODS an “iceberg syndrome”, with “emerging rocks”, rectocele and rectal internal mucosal prolapse, that may benefit from surgery, at least two out of ten patients also has “underwater rocks” or occult disorders, such as anismus, rectal hyposensation and anxiety/depression, which mostly require conservative treatment. Rectal prolapse excision or obliterative suture, rectocele and/or enterocele repair, retrograde Malone’s enema and partial myotomy of the puborectalis muscle are effective in selected cases. Laparoscopic ventral sacral colporectopexy may be an effective surgical option. Stapled transanal rectal resection may lead to severe complications. The Transtar procedure seems to be safer, when dealing with recto-rectal intussusception. A multidisciplinary approach to ODS provides the best results.

Key Words: Constipation, Obstructed defecation, Pelvic floor rehabilitation, Rectopexy, Rectal prolaxectomy

Core tip: Obstructed defecation mainly effect women and may be due both to functional and organic disorders. Some of them, i.e., rectocele, are more evident and easy to detect. Two out of ten patients present with occult causes, more difficult to diagnose, which may be looked at as “underwater rocks” of an iceberg. Most patients may be treated conservatively, with fiber diet, laxatives, rectal irrigation, pelvic floor rehabilitation and psychotherapy; and a minority requires surgery, including rectocele repair, prolapse excision, rectopexy and, more rarely, transanal rectal resection. Due to its complex etiology and psychological involvement, obstructed defecation needs a multidisciplinary approach.



SYMPTOMS AND DIAGNOSIS

Obstructed defecation syndrome (ODS) is a type of constipation characterized by fragmented stools, need for straining at defecation, sense of incomplete evacuation, tenesmus, urgency, pelvic heaviness and self-digitation[1,2]. Most patients are females. The aim of self-digitation is two-fold: (1) by compressing the rectocele pouch through the vagina, the patient makes the anorectum straight and facilitates the evacuation of the stool; and (2) by pushing on the perineum, the transverse muscles of the perineum are stimulated, and this elicits a reflex rectal contraction aimed at evacuating the feces[3]. Unfortunately, self-digitation may cause anorectal ulcerations followed by bleeding and discomfort and anal fibrosis leading to a stricture. The diagnosis of ODS is based on a careful evaluation of the patient’s clinical history. The severity of symptoms may be objectively evaluated using a validated score[4].

Transanal-vaginal ultrasound (US)[5], defecography[6], anorectal manometry and the balloon expulsion test[7], entero defecography, dynamic perineal US and magnetic resonance imaging defecography[8,9], pudendal nerve motor latency[10] and psychological evaluation[11] may be useful for the assessment of ODS.

ODS AS AN "ICEBERG SYNDROME"

ODS has been also defined an “iceberg syndrome”, as the two most frequent lesions, i.e., rectocele and rectal internal mucosal prolapse, present in more than 90% of patients with ODS, are easily detectable and may be considered “emerging rocks”, whereas the “surgical ship” is likely to “sink” due to the “underwater rocks”, i.e., the occult lesions. At least two occult lesions were present in all patients with ODS in a prospective study conducted by our group[12].

They are more difficult to diagnose and may be either functional or organic. The former are: anxiety/depression, anismus or non-relaxing puborectalis muscle on straining, rectal hyposensation, pudendal neuropathy and spastic colon. The latter are: peritoneo- entero- and sigmoidocele, colpocele, cystocele, recto-rectal intussusception and solitary rectal ulcer. Therefore, rectocele and rectal prolapse, which are usually the target of surgery, are more effects than causes of symptoms[13].

An excessive straining is likely to be the “primum movens”, causing tissue weakness and organ descent, and often is due to long-standing anxiety, muscle tension and consequent non-relaxing puborectalis muscle. The increased straining causes pudendal nerve stretch which may lead to a pudendal neuropathy which affects rectal sensation. The stool becomes small and hard and more difficult to evacuate, as they are less effective in stimulating the rectal wall, and then eliciting the peristaltic reflex aimed at inhibiting the rectal internal sphincter and facilitating the evacuation of the stool. It is clear that surgery has a secondary role in correcting the above-mentioned defects, as they are mainly psychological and/or muscular and/or neurological. Unfortunately, they would require long and complex treatment, i.e., change of dietary regimen, psychological support, pelvic floor rehabilitation. Instead, both patients and surgeons prefer a faster solution of the problem, i.e., a straightforward operation. This explains why most, if not all surgical procedures tend to fail in the long term[14-17].

As reported by the Wexner group, many women with rectocele suffer from ODS, but only in a minority of them are the symptoms due to rectocele[18].

Vermeulen et al[19], when reporting the high failure rate after surgery for rectocele, states that “to restore anatomy does not mean to restore function”.

Therefore, caution is needed prior to recommending surgery in a patient with ODS.

CONSERVATIVE TREATMENT

Fiber diet, plenty of water and bulking laxatives are the most used frequently conservative treatments of ODS[20]. Chocolate and other foods which increase stool viscosity thus making more difficult stool expulsion “in one shot” should be avoided[21]. Hydrocolontherapy or lavage, consisting of retrograde large bowel irrigation with warm water through a tube gently inserted into the anorectum, also has a positive role in the treatment of ODS and there is no risk of side effects[22,23]. Several authors are in favour of rectal irrigation, which is reported to be effective in nearly half of the patients with intestinal dysfunction[24,25]. Nevertheless it is well known that the abuse of self- administered enemas may cause anorectal fibrosis and stricture, due to repeated microtrauma. Biofeedback is indicated in case of anismus[26,27] and rectal hyposensation[28].

Anismus may be also cured with yoga exercises[29] and botulinum toxin A, (50 units injected into the puborectalis muscle), with a short-term cure rate of about 50% and minor or rare side effects, such as transient anal incontinence and hypotension[30]. Transanal electrostimulation, which may be carried out as a home procedure using small probe inserted into the anus and connected with a portable electrostimulator, may be effective in both pudendal neuropathy and rectal hyposensation[31].

Rectocele and recto-rectal intussusceptions, despite being organic lesions, may be successfully treated with pelvic floor rehabilitation, provided that they are not long-standing. When these lesions become larger and more significant, they become causes of the ODS symptoms and require surgery[32,33].

Psychological counselling is helpful in patients with either depression or anxiety or both, whose psychosomatic condition may be also diagnosed with reactive graphic tests such as the “draw-the-family” test[34,35]. It should be noted that one-third of the females complaining of ODS and proctalgia report episodes of sexual trauma during childhood or adolescence[36].

For the patients who are not willing to undergo formal psychotherapy, simple pelvic floor and abdominal muscle relaxation exercises taught by a psychologist may be useful to improve evacuation.

Recently a new procedure has been proposed by our group for patient with anismus and altered psychological pattern, combining guided imagery and relaxation techniques with ultrasound-guided biofeedback, namely psycho-echo-biofeedback, with is successful in half of the cases at two year[37].

Unfortunately, in many papers on the surgical treatment of ODS, at least half of the above- mentioned therapies are not listed among the conservative measures carried out before surgery is proposed[38,39], which shows that there is a tendency towards surgical overtreatment, i.e., more than half of patients with ODS undergo stapled transanal rectal resection (STARR), compared with the lower operative rate of 14% according to other series[40,41].

SURGICAL TREATMENT: MANUAL TECHNIQUES

Basically, the options at disposal of the surgeon who deals with ODS are as follows: (1) to perform a kind of “surgical” irrigation; (2) to perform either a resection or a plication or a pexy in case of internal mucosal prolapse; (3) to reinforce the rectovaginal septum and/or, again, resect the redundant mucosa, in case of significant rectocele; and (4) to perform miotomy in case ODS is due to a muscular disorder.

Malone and others have reported surgical procedures which are modifications of the appendicostomy performed to treat children with chronic constipation[42,43].

Either the appendix or a segment of terminal ileum are sutured to the underskin of the umbilicus or the right iliac fossa with a flap valve mechanism, aimed at preventing the external leakage of fecal matter.

Cosmesis is good because the surgical wound is small. The patient has to irrigate his/her intestine with water through a syringe, thus carrying out an anterograde enema and facilitating defecation. The limitation of the procedure is the relatively frequent occurrence of a sliding of the bowel which affects the valve mechanism and requires a reoperation.

Rectal prolapsectomy may be carried out via a transanal route in case of significant, i.e., 2nd or 3rd degree rectal internal mucosal prolapse or recto-anal intussusceptions[44].

In case of high rectocele and large mucosal prolapse, the whole anterior aspect of the rectal mucosa is excised transanally, followed by a “concertina”- like plication of the denuded rectal muscle[45].

An alternative minimally invasive procedure, which is indicated when dealing with smaller prolapse and rectocele, consists of an over-running suture on the anterior midline starting from the dentate line up to the apex of the rectocele and then reversal, going back to the dentate line. The consequent plication of the rectal layers forms a kind of barrier and reinforces the weakened recto-vaginal septum obliterating both the prolapse and the rectocele[46].

In case of mucosal prolapse, another minimally invasive procedure has been proposed by El Sibai and Shafik[47]. It consists of cauterization and plication of the prolapse. This and other transanal, transperineal and abdominal operations have been reported by Pescatori and Zbar[48].

Resection rectopexy, the internal Delorme procedure or circumferential rectal mucosectomy with rectal muscle plication, sacral rectopexy and ventral laparoscopic rectopexy[49-53] have been used with satisfactory short-term outcomes when dealing with ODS due to recto-rectal intussusception, but the long-term outcomes are less encouraging, as nearly half of the patients have a recurrence of ODS symptoms at 4 years[14].

Ventral mesh rectopexy can also be carried out robotically[54].

Instead, nearly 90% of the patients are cured at 4 years after a combined transanal-transperineal and abdominal approach, i.e., positioning of mesh at the pelvic outlet, for rectocele-internal rectal prolapse and enterocele. The reason for the high success rate is that the other occult concomitant functional diseases, such as anismus, are cured with psycho-echo-biofeedback. This novel procedure, which involves a psychologist, consists of breathing exercises accompanied by hypnotic words, while the patient strains and is encouraged to carefully watch the contraction-relaxation of the puborectalis muscle on the screen of the transanal or, better yet, the transvaginal US machine[37].

Recently, a surgical operation has been reported as effective in patients whose ODS is due to animus.

It consists of a transperineal bilateral partial myotomy of the puborectalis muscle, aimed at favouring its relaxation on straining. According to its inventor, the operation is more effective than biofeedback conditioning and botulinum toxin A injection[55,56].

We developed a modified Farid procedure using a semiclosed transperineal approach, with neither sepsis nor incontinence postoperatively and an 80% cure rate at one year in a small series (unpublished data).

Rectocele repair may be carried out using other procedures than the above mentioned transanal approaches, such as transperineal or transvaginal interposition of a biological mesh of porcine collagen[57] anterior levatorplasty, which may cause dyspareunia in sexually active females[58] or the novel transvaginal Schwandner repair[59]. It may be also repaired using a laparoscopic approach, as reported by Vermeulen et al[19]. Sacral neuromodulation with an implanted pace-maker, which was first proposed by Pescatori et al[60-62] in constipated patients is helpful in case of slow transit constipation, but may be also effective for ODS according to Falletto et al[63], provided that patients are carefully selected.

The advantage is that the procedure is minimally invasive as it may be performed under local anesthesia. The disadvantage is the high cost of the pace-maker, around 15000 euros.

SURGICAL TREATMENT: STAPLING TECHNIQUES

The first stapled procedure for rectal mucosal prolapse causing ODS was reported by Pescatori et al[64], using a circular stapler in a small series with good short-term results and no relevant complications. It has been replicated by Zacharakis et al[65] with encouraging results.

The first study on STARR, was published by Boccasanta et al[66], who reported good results in around 90% patients in the short term, but painful defecation at one year in 20%. Post-STARR chronic proctalgia, which may be severe and affect patients’ quality of life, is likely to be due to the fibrosis around retained staples, which triggers the nerve spindles on the levator ani and puborectalis muscles[67].

Removal of retained staples reduces pain only in a minor proportion of patients[68].

According to the invited comment of Robin Phillips to the above-mentioned paper by Boccasanta et al[66], “to resect the rectum for constipation is like resecting a lung for asthma”.

Other complications have been reported following STARR, such as severe rectal bleeding, fecal urgency and anal incontinence, recto-vaginal fistulae, retrorectal hematoma, pelvic sepsis requiring a diverting stoma, and deaths[69-73]. A comprehensive review of post-STARR complications has been reported by Pescatori and Gagliardi[74].

Unfortunately, the potential risks of the STARR procedure are underestimated, also in part due to a strong media campaign, as shown by the definition of STARR as a “sutureless operation” given by newspapers[75].

Ira Kodner, the past-president of the American Society of Colon and Rectal Surgeons stated that those who report misleading messages should be excluded from the surgical community[76].

As far as clinical outcome is concerned, 55% of the patients still had at least 3 symptoms of ODS at 18 mo after STARR in a retrospective multicentric study of the Italian Society of Colo-Rectal surgery and 19% of the cases required a reintervention, either because of postoperative complications or recurrence of symptoms[77]. Reinterventions after STARR are likely to fail in patients with an altered mental pattern[78].

Some studies report lower complication rates and better clinical results[79,80].

A high recurrence rate in the long term has been reported by Hussein[15].

Fecal urgency and anal incontinence after STARR are most likely to be due to the reduced size of the rectal reservoir[81,82]. The more recent Transtar procedure, carried out with the Contour device (Ethicon Endosurgery, Cincinnati, Ohio, United States), seems to achieve better results, e.g., in terms of chronic postoperative proctalgia[83]. Nevertheless, life-threatening retro-rectal hematoma has also been reported following Transtar[84]. A recent European multicentre study reported a relief of symptoms in most patient on the short term without a significant improving of St. Mark’s score quality of life, neither major complication nor post operative mortality was reported[85].

Both clinical and functional results seem satisfactory in a large multicentre series reported by Jayne et al[86] but the follow-up is short and incomplete. However, this relatively novel procedure carried both satisfactory and unsuccessful outcomes as reported by several authors, and merits further evaluations prior to be considered a fully safe and effective operation[86-97]. It has to be performed by colorectal surgeons specifically trained with novel instruments, such as the Contour devices[98-100].

CONCLUSION

The outcome of surgery alone for ODS may be good in the short term, but it worsens over time, probably due to the fact that both the diagnosis and the management of the “occult” lesion(s) causing symptoms are neglected. The psychosomatic component of ODS should be recognized and managed as it affects two-thirds of the patients. Several conservative treatments are available and should be attempted prior to surgical management of ODS. The holistic approach is important, i.e., psyche and soma should be considered a unique entity. The key to successful treatment of ODS appears to be a multidisciplinary approach.

Footnotes

P- Reviewer: Brisinda G, Gillessen A S- Editor: Ma YJ L- Editor: A E- Editor: Zhang DN

References
1.  Ellis CN, Essani R. Treatment of obstructed defecation. Clin Colon Rectal Surg. 2012;25:24-33.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 38]  [Cited by in F6Publishing: 31]  [Article Influence: 2.8]  [Reference Citation Analysis (0)]
2.  Khaikin M, Wexner SD. Treatment strategies in obstructed defecation and fecal incontinence. World J Gastroenterol. 2006;12:3168-3173.  [PubMed]  [DOI]  [Cited in This Article: ]
3.  Shafik A, Shafik AA, Ahmed I. Role of positive anorectal feedback in rectal evacuation: the concept of a second defecation reflex: the anorectal reflex. J Spinal Cord Med. 2003;26:380-383.  [PubMed]  [DOI]  [Cited in This Article: ]
4.  Altomare DF, Spazzafumo L, Rinaldi M, Dodi G, Ghiselli R, Piloni V. Set-up and statistical validation of a new scoring system for obstructed defaecation syndrome. Colorectal Dis. 2008;10:84-88.  [PubMed]  [DOI]  [Cited in This Article: ]
5.  Brusciano L, Limongelli P, Pescatori M, Napolitano V, Gagliardi G, Maffettone V, Rossetti G, del Genio G, Russo G, Pizza F. Ultrasonographic patterns in patients with obstructed defaecation. Int J Colorectal Dis. 2007;22:969-977.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 55]  [Cited by in F6Publishing: 49]  [Article Influence: 2.9]  [Reference Citation Analysis (0)]
6.  Taylor SA. Defecographic study of rectal evacuation in constipated patients. Benign anorectal diseases: diagnosis with endoanal and endorectal ultrasound and new treatment options. Milan, Italy: Springer 2006; 231-241.  [PubMed]  [DOI]  [Cited in This Article: ]
7.  Pucciani F. Anorectal manometry. Pelvic Floor Disorders: Imaging and Multidisciplinary Approach to Management. Milan, Italy: Springer 2010; 447-449.  [PubMed]  [DOI]  [Cited in This Article: ]
8.  Piloni V, Tosi P, Vernelli M. MR-defecography in obstructed defecation syndrome (ODS): technique, diagnostic criteria and grading. Tech Coloproctol. 2013;17:501-510.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 37]  [Cited by in F6Publishing: 22]  [Article Influence: 2.0]  [Reference Citation Analysis (1)]
9.  Beer-Gabel M, Assoulin Y, Amitai M, Bardan E. A comparison of dynamic transperineal ultrasound (DTP-US) with dynamic evacuation proctography (DEP) in the diagnosis of cul de sac hernia (enterocele) in patients with evacuatory dysfunction. Int J Colorectal Dis. 2008;23:513-519.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 55]  [Cited by in F6Publishing: 55]  [Article Influence: 3.4]  [Reference Citation Analysis (0)]
10.  Hill J, Hosker G, Kiff ES. Pudendal nerve terminal motor latency measurements: what they do and do not tell us. Br J Surg. 2002;89:1268-1269.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 45]  [Cited by in F6Publishing: 45]  [Article Influence: 2.0]  [Reference Citation Analysis (0)]
11.  Russo A, Pescatori M. Psychological assessment of patients with proctological disorders. Complex Anorectal Disorders. Investigation and Management. London, England: Springer 2005; 741-760.  [PubMed]  [DOI]  [Cited in This Article: ]
12.  Pescatori M, Spyrou M, Pulvirenti d’Urso A. A prospective evaluation of occult disorders in obstructed defecation using the ‘iceberg diagram’. Colorectal Dis. 2007;9:452-456.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 55]  [Cited by in F6Publishing: 57]  [Article Influence: 3.4]  [Reference Citation Analysis (0)]
13.  Hicks CW, Weinstein M, Wakamatsu M, Pulliam S, Savitt L, Bordeianou L. Are rectoceles the cause or the result of obstructed defaecation syndrome? A prospective anorectal physiology study. Colorectal Dis. 2013;15:993-999.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 27]  [Cited by in F6Publishing: 23]  [Article Influence: 2.1]  [Reference Citation Analysis (0)]
14.  Roman H, Michot F. Long-term outcomes of transanal rectocele repair. Dis Colon Rectum. 2005;48:510-517.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 56]  [Cited by in F6Publishing: 54]  [Article Influence: 2.8]  [Reference Citation Analysis (0)]
15.  Madbouly KM, Abbas KS, Hussein AM. Disappointing long-term outcomes after stapled transanal rectal resection for obstructed defecation. World J Surg. 2010;34:2191-2196.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 52]  [Cited by in F6Publishing: 44]  [Article Influence: 3.1]  [Reference Citation Analysis (0)]
16.  Brown AJ, Anderson JH, McKee RF, Finlay IG. Surgery for occult rectal prolapse. Colorectal Dis. 2004;6:176-179.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 38]  [Cited by in F6Publishing: 41]  [Article Influence: 2.1]  [Reference Citation Analysis (0)]
17.  Pescatori M, Boffi F, Russo A, Zbar AP. Complications and recurrence after excision of rectal internal mucosal prolapse for obstructed defaecation. Int J Colorectal Dis. 2006;21:160-165.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 51]  [Cited by in F6Publishing: 49]  [Article Influence: 2.7]  [Reference Citation Analysis (0)]
18.  Piccirillo MF, Teoh TA, Yoon KS, Patiňo Paul RA, Lucas J, Wexner SD. Rectoceles: the incidence and clinical significante. Tech Coloproctol. 1996;2:75-79.  [PubMed]  [DOI]  [Cited in This Article: ]
19.  Vermeulen J, Lange JF, Sikkenk AC, van der Harst E. Anterolateral rectopexy for correction of rectoceles leads to good anatomical but poor functional results. Tech Coloproctol. 2005;9:35-41; discussion 41.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 30]  [Cited by in F6Publishing: 25]  [Article Influence: 1.7]  [Reference Citation Analysis (1)]
20.  Bove A, Pucciani F, Bellini M, Battaglia E, Bocchini R, Altomare DF, Dodi G, Sciaudone G, Falletto E, Piloni V. Consensus statement AIGO/SICCR: diagnosis and treatment of chronic constipation and obstructed defecation (part I: diagnosis). World J Gastroenterol. 2012;18:1555-1564.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in CrossRef: 82]  [Cited by in F6Publishing: 70]  [Article Influence: 5.8]  [Reference Citation Analysis (0)]
21.  Dietz HP. Rectocele or stool quality: what matters more for symptoms of obstructed defecation? Tech Coloproctol. 2009;13:265-268.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 23]  [Cited by in F6Publishing: 17]  [Article Influence: 1.2]  [Reference Citation Analysis (0)]
22.  Pizzetti D, Annibali R, Bufo A, Pescatori M. Colonic hydrotherapy for obstructed defecation. Colorectal Dis. 2005;7:107-108.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 12]  [Cited by in F6Publishing: 14]  [Article Influence: 0.7]  [Reference Citation Analysis (0)]
23.  Taffinder NJ, Tan E, Webb IG, McDonald PJ. Retrograde commercial colonic hydrotherapy. Colorectal Dis. 2004;6:258-260.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 17]  [Cited by in F6Publishing: 17]  [Article Influence: 0.9]  [Reference Citation Analysis (0)]
24.  Koch SM, Melenhorst J, van Gemert WG, Baeten CG. Prospective study of colonic irrigation for the treatment of defaecation disorders. Br J Surg. 2008;95:1273-1279.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 36]  [Cited by in F6Publishing: 37]  [Article Influence: 2.3]  [Reference Citation Analysis (0)]
25.  Christensen P, Krogh K, Buntzen S, Payandeh F, Laurberg S. Long-term outcome and safety of transanal irrigation for constipation and fecal incontinence. Dis Colon Rectum. 2009;52:286-292.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 129]  [Cited by in F6Publishing: 107]  [Article Influence: 7.1]  [Reference Citation Analysis (0)]
26.  Pucciani F, Reggioli M, Ringressi MN. Obstructed defaecation: what is the role of rehabilitation? Colorectal Dis. 2012;14:474-479.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 22]  [Cited by in F6Publishing: 22]  [Article Influence: 1.8]  [Reference Citation Analysis (0)]
27.  Bove A, Bellini M, Battaglia E, Bocchini R, Gambaccini D, Bove V, Pucciani F, Altomare DF, Dodi G, Sciaudone G. Consensus statement AIGO/SICCR diagnosis and treatment of chronic constipation and obstructed defecation (part II: treatment). World J Gastroenterol. 2012;18:4994-5013.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in CrossRef: 104]  [Cited by in F6Publishing: 86]  [Article Influence: 7.2]  [Reference Citation Analysis (0)]
28.  Peticca L, Pescatori M. Outlet obstruction due to anismus and rectal hyposensation: effect of biofeedback training. Colorectal Dis. 2002;4:67.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 19]  [Cited by in F6Publishing: 20]  [Article Influence: 0.9]  [Reference Citation Analysis (0)]
29.  Dolk A, Holmström B, Johansson C, Frostell C, Nilsson BY. The effect of yoga on puborectalis paradox. Int J Colorectal Dis. 1991;6:139-142.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 20]  [Cited by in F6Publishing: 19]  [Article Influence: 0.6]  [Reference Citation Analysis (0)]
30.  Maria G, Sganga G, Civello IM, Brisinda G. Botulinum neurotoxin and other treatments for fissure-in-ano and pelvic floor disorders. Br J Surg. 2002;89:950-961.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 39]  [Cited by in F6Publishing: 31]  [Article Influence: 1.4]  [Reference Citation Analysis (0)]
31.  Matzel KE. Invited comment. Benign Anorectal Disease: diagnosis with Endoanal and Endorectal Ultrasound and New Treatment Options. Milan, Italy: Springer 2006; 367-368.  [PubMed]  [DOI]  [Cited in This Article: ]
32.  Hwang YH, Person B, Choi JS, Nam YS, Singh JJ, Weiss EG, Nogueras JJ, Wexner SD. Biofeedback therapy for rectal intussusception. Tech Coloproctol. 2006;10:11-15; discussion 15-16.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 37]  [Cited by in F6Publishing: 22]  [Article Influence: 1.2]  [Reference Citation Analysis (0)]
33.  Pucciani F, Iozzi L, Masi A, Cianchi F, Cortesini C. Multimodal rehabilitation for faecal incontinence: experience of an Italian centre devoted to faecal disorder rehabilitation. Tech Coloproctol. 2003;7:139-47; discussion 147.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 39]  [Cited by in F6Publishing: 28]  [Article Influence: 1.4]  [Reference Citation Analysis (0)]
34.  Devroede G. Psychophysiological considerations in subjects with chronic idiopathic constipation. Constipation: etiology, evaluation and management. London, England: Butterworth Heinemann 1995; 103-134.  [PubMed]  [DOI]  [Cited in This Article: ]
35.  Miliacca C, Gagliardi G, Pescatori M. The ‘Draw-the-Family Test’ in the preoperative assessment of patients with anorectal diseases and psychological distress: a prospective controlled study. Colorectal Dis. 2010;12:792-798.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 16]  [Cited by in F6Publishing: 18]  [Article Influence: 1.3]  [Reference Citation Analysis (0)]
36.  Devroede G. Early life abuses in the past history of patients with gastrointestinal tract and pelvic floor dysfunctions. Prog Brain Res. 2000;122:131-155.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 12]  [Cited by in F6Publishing: 14]  [Article Influence: 0.6]  [Reference Citation Analysis (0)]
37.  Del Popolo F, Cioli VM, Plevi T, Pescatori M. Psycho-echo-biofeedback: a novel treatment for anismus--results of a prospective controlled study. Tech Coloproctol. 2014;18:895-900.  [PubMed]  [DOI]  [Cited in This Article: ]
38.  Boccasanta P, Venturi M, Salamina G, Cesana BM, Bernasconi F, Roviaro G. New trends in the surgical treatment of outlet obstruction: clinical and functional results of two novel transanal stapled techniques from a randomised controlled trial. Int J Colorectal Dis. 2004;19:359-369.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 143]  [Cited by in F6Publishing: 146]  [Article Influence: 7.3]  [Reference Citation Analysis (0)]
39.  Boccasanta P, Venturi M, Roviaro G. Stapled transanal rectal resection versus stapled anopexy in the cure of hemorrhoids associated with rectal prolapse. A randomized controlled trial. Int J Colorectal Dis. 2007;22:245-251.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 60]  [Cited by in F6Publishing: 63]  [Article Influence: 3.7]  [Reference Citation Analysis (0)]
40.  Arroyo A, González-Argenté FX, García-Domingo M, Espin-Basany E, De-la-Portilla F, Pérez-Vicente F, Calpena R. Prospective multicentre clinical trial of stapled transanal rectal resection for obstructive defaecation syndrome. Br J Surg. 2008;95:1521-1527.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 44]  [Cited by in F6Publishing: 49]  [Article Influence: 3.1]  [Reference Citation Analysis (0)]
41.  Goede AC, Glancy D, Carter H, Mills A, Mabey K, Dixon AR. Medium-term results of stapled transanal rectal resection (STARR) for obstructed defecation and symptomatic rectal-anal intussusception. Colorectal Dis. 2011;13:1052-1057.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 38]  [Cited by in F6Publishing: 41]  [Article Influence: 3.2]  [Reference Citation Analysis (0)]
42.  Poirier M, Abcarian H, Nelson R. Malone antegrade continent enema: an alternative to resection in severe defecation disorders. Dis Colon Rectum. 2007;50:22-28.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 40]  [Cited by in F6Publishing: 44]  [Article Influence: 2.6]  [Reference Citation Analysis (0)]
43.  Altomare DF, Rinaldi M, Rubini D, Rubini G, Portincasa P, Vacca M, Artor NA, Romano G, Memeo V. Long-term functional assessment of antegrade colonic enema for combined incontinence and constipation using a modified Marsh and Kiff technique. Dis Colon Rectum. 2007;50:1023-1031.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 30]  [Cited by in F6Publishing: 33]  [Article Influence: 1.9]  [Reference Citation Analysis (0)]
44.  Pescatori M, Quondamcarlo C. A new grading of rectal internal mucosal prolapse and its correlation with diagnosis and treatment. Int J Colorectal Dis. 1999;14:245-249.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 56]  [Cited by in F6Publishing: 55]  [Article Influence: 2.2]  [Reference Citation Analysis (0)]
45.  Sarles JC, Arnaud A, Selezneff I, Olivier S. Endo-rectal repair of rectocele. Int J Colorectal Dis. 1989;4:167-171.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 96]  [Cited by in F6Publishing: 91]  [Article Influence: 2.6]  [Reference Citation Analysis (0)]
46.  Block IR. Transrectal repair of rectocele using obliterative suture. Dis Colon Rectum. 1986;29:707-711.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 72]  [Cited by in F6Publishing: 71]  [Article Influence: 1.9]  [Reference Citation Analysis (0)]
47.  El-Sibai O, Shafik AA. Cauterization-plication operation in the treatment of complete rectal prolapse. Tech Coloproctol. 2002;6:51-4; discussion 54.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 14]  [Cited by in F6Publishing: 15]  [Article Influence: 0.7]  [Reference Citation Analysis (0)]
48.  Pescatori M, Zbar AP. Tailored surgery for internal and external rectal prolapse: functional results of 268 patients operated upon by a single surgeon over a 21-year period*. Colorectal Dis. 2009;11:410-419.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 31]  [Cited by in F6Publishing: 32]  [Article Influence: 2.1]  [Reference Citation Analysis (0)]
49.  Nicholls RJ, Simson JN. Anteroposterior rectopexy in the treatment of solitary rectal ulcer syndrome without overt rectal prolapse. Br J Surg. 1986;73:222-224.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 63]  [Cited by in F6Publishing: 58]  [Article Influence: 1.5]  [Reference Citation Analysis (0)]
50.  Mercer-Jones MA, D’Hoore A, Dixon AR, Lehur P, Lindsey I, Mellgren A, Stevenson AR. Consensus on ventral rectopexy: report of a panel of experts. Colorectal Dis. 2014;16:82-88.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 94]  [Cited by in F6Publishing: 92]  [Article Influence: 9.2]  [Reference Citation Analysis (0)]
51.  Trompetto M, Clerico G, Realis Luc A, Marino F, Giani I, Ganio E. Transanal Delorme procedure for treatment of rectocele associated with rectal intussusception. Tech Coloproctol. 2006;10:389.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 15]  [Cited by in F6Publishing: 6]  [Article Influence: 0.4]  [Reference Citation Analysis (0)]
52.  Lauretta A, Bellomo RE, Galanti F, Tonizzo CA, Infantino A. Laparoscopic low ventral rectocolpopexy (LLVR) for rectal and rectogenital prolapse: surgical technique and functional results. Tech Coloproctol. 2012;16:477-483.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 25]  [Cited by in F6Publishing: 19]  [Article Influence: 1.6]  [Reference Citation Analysis (0)]
53.  Panis Y. Laparoscopic ventral rectopexy: resection or no resection? That is the question…. Tech Coloproctol. 2014;18:611-612.  [PubMed]  [DOI]  [Cited in This Article: ]
54.  Mantoo S, Podevin J, Regenet N, Rigaud J, Lehur PA, Meurette G. Is robotic-assisted ventral mesh rectopexy superior to laparoscopic ventral mesh rectopexy in the management of obstructed defaecation? Colorectal Dis. 2013;15:e469-e475.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 61]  [Cited by in F6Publishing: 62]  [Article Influence: 5.6]  [Reference Citation Analysis (0)]
55.  Farid M, Youssef T, Mahdy T, Omar W, Moneim HA, El Nakeeb A, Youssef M. Comparative study between botulinum toxin injection and partial division of puborectalis for treating anismus. Int J Colorectal Dis. 2009;24:327-334.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 30]  [Cited by in F6Publishing: 30]  [Article Influence: 2.0]  [Reference Citation Analysis (0)]
56.  Faried M, El Nakeeb A, Youssef M, Omar W, El Monem HA. Comparative study between surgical and non-surgical treatment of anismus in patients with symptoms of obstructed defecation: a prospective randomized study. J Gastrointest Surg. 2010;14:1235-1243.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 37]  [Cited by in F6Publishing: 38]  [Article Influence: 2.7]  [Reference Citation Analysis (0)]
57.  Smart NJ, Mercer-Jones MA. Functional outcome after transperineal rectocele repair with porcine dermal collagen implant. Dis Colon Rectum. 2007;50:1422-1427.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 35]  [Cited by in F6Publishing: 34]  [Article Influence: 2.0]  [Reference Citation Analysis (0)]
58.  Ayabaca SM, Zbar AP, Pescatori M. Anal continence after rectocele repair. Dis Colon Rectum. 2002;45:63-69.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 76]  [Cited by in F6Publishing: 80]  [Article Influence: 3.6]  [Reference Citation Analysis (0)]
59.  Fischer F, Farke S, Schwandner O, Bruch HP, Schiedeck T. [Functional results after transvaginal, transperineal and transrectal correction of a symptomatic rectocele]. Zentralbl Chir. 2005;130:400-404.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 7]  [Cited by in F6Publishing: 6]  [Article Influence: 0.3]  [Reference Citation Analysis (0)]
60.  Pescatori M, Meglio M, Cioni B, Colagrande C. Spinal cord stimulation in two constipated neurological patients. Gastrointestinal motility disorders. New York, US: Raven Press 1982; 541-547.  [PubMed]  [DOI]  [Cited in This Article: ]
61.  Pescatori M. Spinal cord stimulation for constipated patients. Dis Colon Rectum. 2009;52:1196.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 5]  [Cited by in F6Publishing: 6]  [Article Influence: 0.4]  [Reference Citation Analysis (0)]
62.  Pescatori M. Systematic review of sacral nerve stimulation for faecal incontinence and constipation (Br J Surg 2004; 91: 1559-1569). Br J Surg. 2005;92:379.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 7]  [Cited by in F6Publishing: 9]  [Article Influence: 0.5]  [Reference Citation Analysis (0)]
63.  Falletto E, Ganio E, Naldini G, Ratto C, Altomare DF. Sacral neuromodulation for bowel dysfunction: a consensus statement from the Italian group. Tech Coloproctol. 2014;18:53-64.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 20]  [Cited by in F6Publishing: 15]  [Article Influence: 1.4]  [Reference Citation Analysis (0)]
64.  Pescatori M, Favetta U, Dedola S, Orsini S. Transanal stapled excision of rectal mucosa prolapse. Tech Coloproctol. 1997;12:7-19.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 221]  [Cited by in F6Publishing: 163]  [Article Influence: 10.2]  [Reference Citation Analysis (0)]
65.  Zacharakis E, Pramateftakis MG, Kanellos D, Kanellos I, Betsis D. Long-term results after transanal stapled excision of rectal internal mucosal prolapse. Tech Coloproctol. 2007;11:67-68.  [PubMed]  [DOI]  [Cited in This Article: ]
66.  Boccasanta P, Venturi M, Stuto A, Bottini C, Caviglia A, Carriero A, Mascagni D, Mauri R, Sofo L, Landolfi V. Stapled transanal rectal resection for outlet obstruction: a prospective, multicenter trial. Dis Colon Rectum. 2004;47:1285-196; discussion 1285-196;.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 220]  [Cited by in F6Publishing: 222]  [Article Influence: 11.1]  [Reference Citation Analysis (0)]
67.  De Nardi P, Bottini C, Faticanti Scucchi L, Palazzi A, Pescatori M. Proctalgia in a patient with staples retained in the puborectalis muscle after STARR operation. Tech Coloproctol. 2007;11:353-356.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 26]  [Cited by in F6Publishing: 22]  [Article Influence: 1.3]  [Reference Citation Analysis (0)]
68.  Petersen S, Jongen J, Schwenk W. Agraffectomy after low rectal stapling procedures for hemorrhoids and rectocele. Tech Coloproctol. 2011;15:259-264.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 16]  [Cited by in F6Publishing: 8]  [Article Influence: 0.6]  [Reference Citation Analysis (0)]
69.  Dodi G, Pietroletti R, Milito G, Binda G, Pescatori M. Bleeding, incontinence, pain and constipation after STARR transanal double stapling rectotomy for obstructed defecation. Tech Coloproctol. 2003;7:148-153.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 135]  [Cited by in F6Publishing: 105]  [Article Influence: 5.3]  [Reference Citation Analysis (0)]
70.  Pescatori M, Dodi G, Salafia C, Zbar AP. Rectovaginal fistula after double-stapled transanal rectotomy (STARR) for obstructed defaecation. Int J Colorectal Dis. 2005;20:83-85.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 69]  [Cited by in F6Publishing: 72]  [Article Influence: 3.8]  [Reference Citation Analysis (0)]
71.  Bassi R, Rademacher J, Savoia A. Rectovaginal fistula after STARR procedure complicated by haematoma of the posterior vaginal wall: report of a case. Tech Coloproctol. 2006;10:361-363.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 44]  [Cited by in F6Publishing: 46]  [Article Influence: 2.6]  [Reference Citation Analysis (0)]
72.  Naldini G. Serious unconventional complications of surgery with stapler for haemorrhoidal prolapse and obstructed defaecation because of rectocoele and rectal intussusception. Colorectal Dis. 2011;13:323-327.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 76]  [Cited by in F6Publishing: 75]  [Article Influence: 5.8]  [Reference Citation Analysis (0)]
73.  Pescatori M. Trouble shooting the STARR Procedure. Recostructive Surgery of the Rectum, Anus and Perineum. London, England: Springer-Verlag 2013; 305-314.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 2]  [Cited by in F6Publishing: 1]  [Article Influence: 0.1]  [Reference Citation Analysis (0)]
74.  Pescatori M, Gagliardi G. Postoperative complications after procedure for prolapsed hemorrhoids (PPH) and stapled transanal rectal resection (STARR) procedures. Tech Coloproctol. 2008;12:7-19.  [PubMed]  [DOI]  [Cited in This Article: ]
75.  Boffi F. Sutureless PPH and STARR. Tech Coloproctol. 2008;12:352.  [PubMed]  [DOI]  [Cited in This Article: ]
76.  Kodner IJ. Innovations in colorectal surgery. Tech Coloproctol. 2009;13:167-168; discussion 167-168.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 8]  [Cited by in F6Publishing: 9]  [Article Influence: 0.6]  [Reference Citation Analysis (0)]
77.  Gagliardi G, Pescatori M, Altomare DF, Binda GA, Bottini C, Dodi G, Filingeri V, Milito G, Rinaldi M, Romano G. Results, outcome predictors, and complications after stapled transanal rectal resection for obstructed defecation. Dis Colon Rectum. 2008;51:186-195; discussion 195.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 139]  [Cited by in F6Publishing: 142]  [Article Influence: 8.9]  [Reference Citation Analysis (0)]
78.  Pescatori M, Zbar AP. Reinterventions after complicated or failed STARR procedure. Int J Colorectal Dis. 2009;24:87-95.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 61]  [Cited by in F6Publishing: 66]  [Article Influence: 4.4]  [Reference Citation Analysis (0)]
79.  Isbert C, Reibetanz J, Jayne DG, Kim M, Germer CT, Boenicke L. Comparative study of Contour Transtar and STARR procedure for the treatment of obstructed defecation syndrome (ODS)--feasibility, morbidity and early functional results. Colorectal Dis. 2010;12:901-908.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 46]  [Cited by in F6Publishing: 46]  [Article Influence: 3.3]  [Reference Citation Analysis (0)]
80.  Masoni L, Mari FS, Favi F, Gasparrini M, Cosenza UM, Pindozzi F, Pancaldi A, Brescia A. Stapled transanal rectal resection with contour transtar for obstructed defecation syndrome: lessons learned after more than 3 years of single-center activity. Dis Colon Rectum. 2013;56:113-119.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 15]  [Cited by in F6Publishing: 8]  [Article Influence: 0.7]  [Reference Citation Analysis (0)]
81.  Wadhawan H, Shorthouse AJ, Brown SR. Surgery for obstructed defaecation: does the use of the Contour device (Trans-STARR) improve results? Colorectal Dis. 2010;12:885-890.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 24]  [Cited by in F6Publishing: 24]  [Article Influence: 1.7]  [Reference Citation Analysis (0)]
82.  Boccasanta P, Venturi M, Roviaro G. What is the benefit of a new stapler device in the surgical treatment of obstructed defecation? Three-year outcomes from a randomized controlled trial. Dis Colon Rectum. 2011;54:77-84.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 48]  [Cited by in F6Publishing: 47]  [Article Influence: 3.6]  [Reference Citation Analysis (0)]
83.  Lenisa L, Schwandner O, Stuto A, Jayne D, Pigot F, Tuech JJ, Scherer R, Nugent K, Corbisier F, Espin-Basany E. STARR with Contour Transtar: prospective multicentre European study. Colorectal Dis. 2009;11:821-827.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 73]  [Cited by in F6Publishing: 71]  [Article Influence: 4.7]  [Reference Citation Analysis (0)]
84.  Gelos M, Frommhold K, Mann B. Severe mesorectal bleeding after stapled transanal rectal resection (STARR-operation) using the ‘Contour Transtar curved cutter stapler’. Colorectal Dis. 2010;12:265-266.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 12]  [Cited by in F6Publishing: 14]  [Article Influence: 1.0]  [Reference Citation Analysis (0)]
85.  Ribaric G, D’Hoore A, Schiffhorst G, Hempel E. STARR with CONTOUR® TRANSTAR™ device for obstructed defecation syndrome: one-year real-world outcomes of the European TRANSTAR registry. Int J Colorectal Dis. 2014;29:611-622.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 42]  [Cited by in F6Publishing: 42]  [Article Influence: 4.2]  [Reference Citation Analysis (0)]
86.  Jayne DG, Schwandner O, Stuto A. Stapled transanal rectal resection for obstructed defecation syndrome: one-year results of the European STARR Registry. Dis Colon Rectum. 2009;52:1205-1212; discussion 1205-1212.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 113]  [Cited by in F6Publishing: 113]  [Article Influence: 7.5]  [Reference Citation Analysis (0)]
87.  Jayne DG, Finan PJ. Stapled transanal rectal resection for obstructed defaecation and evidence-based practice. Br J Surg. 2005;92:793-794.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 62]  [Cited by in F6Publishing: 66]  [Article Influence: 3.5]  [Reference Citation Analysis (0)]
88.  Pescatori M, Seow-Choen F. Use and abuse of new technologies in colorectal surgery. Tech Coloproctol. 2003;7:1-2.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 13]  [Cited by in F6Publishing: 11]  [Article Influence: 0.5]  [Reference Citation Analysis (0)]
89.  Scarcliff SD, Parker MA, Birmingham AL. Efficacy of stapled transanal rectal resection for the treatment of obstructive defecation syndrome. Dis Colon Rectum. 2010;53:591.  [PubMed]  [DOI]  [Cited in This Article: ]
90.  Stolfi VM, Micossi C, Sileri P, Venza M, Gaspari A. Retroperitoneal sepsis with mediastinal and subcutaneous emphysema complicating stapled transanal rectal resection (STARR). Tech Coloproctol. 2009;13:69-71.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 13]  [Cited by in F6Publishing: 15]  [Article Influence: 1.0]  [Reference Citation Analysis (0)]
91.  Basso L, Pescatori M, La Torre F, Destefano I, Pulvirenti D’Urso A, Infantino A, Amato A. Emerging technologies in coloproctology: results of the Italian Society of Colorectal Surgery Logbook of Adverse Events. Tech Coloproctol. 2013;17:207-211.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 8]  [Cited by in F6Publishing: 8]  [Article Influence: 0.7]  [Reference Citation Analysis (0)]
92.  Stuto A, Renzi A, Carriero A, Gabrielli F, Gianfreda V, Villani RD, Pietrantoni C, Seria G, Capomagi A, Talento P. Stapled trans-anal rectal resection (STARR) in the surgical treatment of the obstructed defecation syndrome: results of STARR Italian Registry. Surg Innov. 2011;18:248-253.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 27]  [Cited by in F6Publishing: 27]  [Article Influence: 2.1]  [Reference Citation Analysis (0)]
93.  Lehur PA, Stuto A, Fantoli M, Villani RD, Queralto M, Lazorthes F, Hershman M, Carriero A, Pigot F, Meurette G. Outcomes of stapled transanal rectal resection vs. biofeedback for the treatment of outlet obstruction associated with rectal intussusception and rectocele: a multicenter, randomized, controlled trial. Dis Colon Rectum. 2008;51:1611-1618.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 97]  [Cited by in F6Publishing: 99]  [Article Influence: 6.2]  [Reference Citation Analysis (0)]
94.  Ellis CN. Stapled transanal rectal resection (STARR) for rectocele. J Gastrointest Surg. 2007;11:153-154.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 26]  [Cited by in F6Publishing: 25]  [Article Influence: 1.5]  [Reference Citation Analysis (0)]
95.  Nicolas R, Meurette G, Frampas E, Mirallie E, Coat K, Leborgne J, Lehur PA. Stapled transanal rectal resection is efficient to correct obstructed defecation but could compromise anal continence. Colorectal Dis. 2004;6:35.  [PubMed]  [DOI]  [Cited in This Article: ]
96.  Schwandner O. Conversion in transanal stapling techniques for haemorrhoids and anorectal prolapse. Colorectal Dis. 2011;13:87-93.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 8]  [Cited by in F6Publishing: 8]  [Article Influence: 0.6]  [Reference Citation Analysis (0)]
97.  Pucciani F, Ringressi MN, Giani I. Persistent dyschezia after double stapled transanal rectal resection for outled obstruction: four case reports. Pelviperineology. 2007;26:132-135.  [PubMed]  [DOI]  [Cited in This Article: ]
98.  Jongen JH, Eberstein A, Peleikis H, Kahlke V. Complaints and patient’s satisfaction after STARR/transSTARR operation for obstructed defecation. Dis Colon Rectum. 2010;53:591-592.  [PubMed]  [DOI]  [Cited in This Article: ]
99.  Renzi A, Talento P, Giardiello C, Angelone G, Izzo D, Di Sarno G. Stapled trans-anal rectal resection (STARR) by a new dedicated device for the surgical treatment of obstructed defaecation syndrome caused by rectal intussusception and rectocele: early results of a multicenter prospective study. Int J Colorectal Dis. 2008;23:999-1005.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 60]  [Cited by in F6Publishing: 58]  [Article Influence: 3.6]  [Reference Citation Analysis (0)]
100.  Renzi A, Brillantino A, Di Sarno G, Izzo D, D’Aniello F, Falato A. Improved clinical outcomes with a new contour-curved stapler in the surgical treatment of obstructed defecation syndrome: a mid-term randomized controlled trial. Dis Colon Rectum. 2011;54:736-742.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 33]  [Cited by in F6Publishing: 30]  [Article Influence: 2.3]  [Reference Citation Analysis (0)]