ODS & STARR Procedure Brij B. Agarwal MBBS, MS (Gold Medalist) FIMSA Dip Yoga (Gold Medalist) FCLS Senior Consultant, Endosurgeon Sir Ganga Ram Hospital, New Delhi, India

Constipation One of the most common gastrointestinal disorder Considered endemic in the elderly population In USA >$1 billion OTC laxative sold Recognized as a major public health problem in USA Brij B Agarwal (2012) ACRSICON, Dubai

Definition Multifactorial Difficult to define Usually <3 bowel movements / week Associated with Straining at stools Hard stools Sense of incomplete evacuation Need for laxatives Brij B Agarwal (2012) ACRSICON, Dubai

Epidemiology No true population based incidence available Prevalence upto 27% Constipation increases with age progressively Progression more marked after age 65 Females > Males ; Non whites >Whites Brij B Agarwal (2012) ACRSICON, Dubai

Brij B Agarwal (2012) ACRSICON, Dubai

Important to rule out medical causes & medicines Amiodarone Antacids (e.g., aluminum) Anticholinergics Anticonvulsants Antidepressants Antihypertensives Calcium channel blockers Diuretics Ganglionic blockers Antiparkinsonians Bismuth Bromocriptine Bulk laxatives with inadequate hydration Carboplatin Cholestyramine Erythropoietin Filgrastim [granulocyte colony-stimulating factor (G-CSF)] Iron Lovastatin Mesalamine Narcotics/opiates Pravachol Sandostatin Valproic acid Vincristine Brij B Agarwal (2012) ACRSICON, Dubai

Important to rule out IBS  Irritable bowel syndrome (IBS) is a common chronic intestinal disorder characterized by abdominal discomfort and altered bowel habits. These symptoms occur in the absence of “structural or biochemical abnormalities  The major subclasses of IBS are the constipation-predominant, diarrhea-predominant, and alternating diarrhea and constipation forms of the condition. Brij B Agarwal (2012) ACRSICON, Dubai

Rome II Criteria for IBS Abdominal discomfort or pain for 12 weeks or more (consecutive or nonconsecutive) with at least two of these features: Relieved with defecation Onset associated with a change of stool frequency Onset associated with a change in stool form * In the absence of structural or metabolic abnormalities to explain the symptoms Brij B Agarwal (2012) ACRSICON, Dubai

Rome II Criteria for Surgical Constipation At least 12 weeks (consecutive or nonconsecutive) in the preceding 12 months of two or more of the following: Straining for more than 25% of defecations Lumpy or hard stools for more than 25% of defecations Sensation of incomplete evacuations in more than 25% of defecations Sensation of anorectal blockage or blockage in more than 25% of defecations Brij B Agarwal (2012) ACRSICON, Dubai

Rome II Criteria for Surgical Constipation Manual maneuvers to facilitate more than 25% of defections (including digital evacuation, support of the pelvic floor, etc). Fewer than three defections per week * In the absolute definition of functional constipation, no loose stools are present and the patient has insufficient criteria for IBS. Brij B Agarwal (2012) ACRSICON, Dubai

Dr. Agarwal’s Surgical Constipation Score Symptoms Frequency   Never Rarely Sometimes Usually Always Excessive straining 1 2 3 4 Incomplete evacuation Use of laxatives Digital pressure Constipation Never = 0; Rarely <1/month; Sometimes <1/week>1/month, Usually <1/day>= 1/week, Always >=1/day A collective score of >5 is suspicious, >10 indicative >15 diagnostic of ODS Brij B Agarwal (2012) ACRSICON, Dubai

Evaluation for Surgical Constipation – SGRH Protocol >6 months medical refractory Complete GI workup including lower GI endoscopy DRE for anal sphincters Defecography Brij B Agarwal (2012) ACRSICON, Dubai

Defecography started in India at SGRH Brij B Agarwal (2012) ACRSICON, Dubai

Brij B Agarwal (2012) ACRSICON, Dubai

Brij B Agarwal (2012) ACRSICON, Dubai

Brij B Agarwal (2012) ACRSICON, Dubai

Brij B Agarwal (2012) ACRSICON, Dubai

STARR – Stapled Trans Anal Rectal Resection Safe, day care procedure Done 1st at SGRH Largest Asian Experience published and presented internationally in Europe / Japan / USA 100% patient relief after 1 year follow up Brij B Agarwal (2012) ACRSICON, Dubai

Thank You www.endosurgeon.org Brij B Agarwal (2012) ACRSICON, Dubai