1. 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

2. 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

3. 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

4. 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

5. Brij B Agarwal (2012) ACRSICON, Dubai

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

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

14. Brij B Agarwal (2012) ACRSICON, Dubai

15. Brij B Agarwal (2012) ACRSICON, Dubai

16. Brij B Agarwal (2012) ACRSICON, Dubai

17. Brij B Agarwal (2012) ACRSICON, Dubai

18. 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

19. Thank You
Brij B Agarwal (2012) ACRSICON, Dubai