Outlet obstructive constipation (OSD) is a common clinical condition, and the most common causes are anterior rectal protrusion and prolapsed rectal mucosa. Since 2004, transanal anastomotic proctocolectomy has been used for the treatment of OSD in combination with resection of rectal protrusion and prolapsed rectal wall with satisfactory results. Since January 2007, we have applied STARR to treat 56 cases of ODS, and the results are summarized as follows. I. Inclusion criteria of the study subjects: (1) meet the Rome III chronic constipation diagnostic criteria of mouth 3; (2) at least 3 of the following symptoms exist: incomplete defecation, obstructive defecation, prolonged defecation but difficult defecation, requiring perineal pressure and/or special posture for defecation, requiring transanal or transvaginal finger-assisted defecation, and defecation only by enema; (3) at least 2 of the following manifestations on fecal imaging (3) at least 2 of the following on fecal imaging: intra-rectal mucosal overturning ≥ 1 cm, anterior rectal protrusion ≥ 3 cm during forceful evacuation, and barium residue in the anterior rectum after defecation; (4) unsatisfactory medical treatment; (5) exclusion of slow colonic transmission or constipation-type irritable bowel syndrome. II. General data From January 2007 to August 2008, 56 cases of ODS were treated by STARR in the Second Artillery General Hospital and Beijing Chaoyang Hospital in Beijing, of which 55 cases were female and 1 case was male. The age was 29-70 (mean 46.8) years. The duration of disease ranged from l to 40 years, with an average of 11.5 years. All patients were examined by fecal imaging, colonic transmission test and colonoscopy before surgery. The intestinal preparation was performed with oral magnesium sulfate or polyethylene glycol electrolyte dispersion in the afternoon of 1 d before surgery. Subarachnoid anesthesia or epidural anesthesia was used for the procedure, and the patient was placed in the folding knife position. The patient is placed in the folding position. A Johnson PPH 01 tubular hemorrhoid anastomosis is inserted through the anus with a transparent dilator and fixed, and the anterior rectal wall (usually the most relaxed mucosal area) is sutured with 3 full rectal semicircular sutures with a 7-gauge silk thread 2-5 cm above the dentate line, each 1 cm apart. The anastomotic staple is inserted into the rectum. The first anastomosis is inserted, and the end of the purse string is pulled out of the lateral aperture of the anastomosis with a wire hook to tighten the purse string so that the anterior rectal wall is drawn into the staple compartment. After the anastomosis, the anastomosis was withdrawn, the mucosal bridge was cut, and the anastomosis was carefully inspected. If there was pulsatile bleeding, the bleeding was stopped with 3-0 absorbable sutures; then two full-layer semi-peripheral sutures were made in the posterior wall of the rectum, and the cerebral pressure plate was placed in the rectum in front of the anal dilator, and the second anastomosis was replaced in the same way as the first anastomosis. After the operation, the anal canal was left in place for 1-2 d, fasting for 1-2 d, liquid food for 2 d, and intravenous rehydration and antibiotics for 3 d. Observation indexes and efficacy assessment criteria (1) surgery-related indexes: including operation time, histological examination of postoperative specimens, and surgical complications; (2) postoperative pain score: the visual analogue scale (VAS) was used to score pain within 3 d after surgery (2) Postoperative pain score: the pain score was rated by visual analogue scale (VAS) for 3 d after surgery, with 0-10, 0 indicating no pain and 10 indicating severe pain and intolerable, and the application of pain medication was recorded; (3) Pre- and postoperative symptoms were compared using questionnaires and telephone follow-up, including difficult defecation, obstructive defecation, incomplete defecation, the need for perineal or vaginal assisted defecation, the need for laxative defecation, and the need for cathartic or enema defecation, and the incidence of each symptom was compared before and after surgery. The incidence of each symptom before and after surgery was compared, and the scores of each symptom were quantified and compared. (4) Overall satisfaction survey: Patients rated the treatment process, postoperative recovery, surgical efficacy and treatment cost overall, with O-lO points, 0 being very dissatisfied and 10 being very satisfied. V. Statistical methods SPSS 10.0 software was used to statistically analyze the data. x2 test was used to compare the preoperative and postoperative remission rates of each symptom, and Wilcoxon rank sum test was used to compare the preoperative and postoperative scores of each symptom, and the difference was considered statistically significant at P<0.05. I. Preoperative fecal imaging results All 56 patients had different degrees of rectal prolapse, among which 42 cases had combined rectal mucosal prolapse, and some patients also had intestinal hernia and perineal descent. The average operation time was 28 min (20-50 min), and the width of the resected specimen was 3.8 era (2.5-4.8 em) in the anterior wall and 2.8 cm (2.0-4.0 cm) in the posterior wall, and all specimens reached the deep muscle layer on histological examination. The mean VAS pain score was 3.2 (0-8) within 3 d postoperatively. 5 patients received one oral analgesic tablet on the same day postoperatively, and 2 patients received 100 rag intramuscular injection of brucine hydrochloride for analgesia on the same day postoperatively. All patients were followed up for 3-18 months, with an average of 8 months. 2 patients had mild anal incontinence at 6 months after surgery, manifesting as fecal soiling in the underwear. 2 patients had mild inflammation of the anastomosis at 2 and 4 months, respectively, resulting in mild pain in the anal region during defecation, and were treated with compound keratanide suppositories in the anus. No other complications were found. Table 2 Preoperative fecal imaging results of patients with outlet obstruction constipation: -------------------------------------------------------- Fecal imaging performance Number of cases (%) --------------------------------------------------------- Rectal protrusion (forceful evacuation) 2-3 cm 10(18) ≥3-4 cm 35(62) ≥4 cm 11(20) Rectal mucosal sleeve prolapse (≥l cm) 40(71) Intestinal hernia 7(12) Perineal descent 8(t4) --------------------------------------------------------- Discussion Rectal protrusion and rectal mucosal sleeve prolapse are common in female population and are the common causes of ODS in women. The pathophysiological alteration of anterior rectal protrusion is an internal hernia formed by the weakness of the rectovaginal septum and the protrusion of the anterior rectal wall into the vagina in the form of a pouch. Excessive forceful defecation dilates the anterior rectal wall and changes the direction of fecal discharge, making it difficult to discharge feces; and prolapsed rectal mucosa further hinders the discharge of feces. The principle of STARR is to use the transanal double anastomosis technique. The first anastomosis is performed on the anterior rectal wall to remove the anterior part of the prolapsed rectum and the protruding part of the anterior rectum, and the anastomosis is completed at the same time to correct the anatomical abnormality of the anterior rectal wall. The second anastomosis is performed on the posterior wall of the rectum to remove the posterior half of the prolapsed rectal sleeve and complete the anastomosis at the same time. This procedure corrects both anatomic abnormalities of the anterior rectum and rectal sleeve prolapse, and theoretically should have better efficacy than conventional surgery. Various traditional surgeries such as transanal, perineal, transvaginal or transabdominal can only correct one anatomical abnormality of prolapsed rectum or rectal sleeve, but many patients with ODS have both problems, which directly affects the efficacy of traditional surgeries. In our group, the results of fecal imaging showed that 40 patients (71%) had both anatomical abnormalities. In recent years, several studies have been conducted abroad to evaluate the efficacy of STARR. Boccasanta et al.1 followed up 90 patients after STARR for 1 year, and the relief rate of incomplete defecation was 81.1%, and the relief rate of manipulation-assisted defecation was 83.4%, and the anterior and posterior rectal diameters were reduced, rectal compliance was restored, and the rectal sensory threshold was lowered. improved. The results of our study showed that the incidence of all exit obstruction symptoms decreased significantly after surgery, especially the incidence of dyspareunia and obstructive bowel sensation decreased by more than 50%. After comparing the quantitative scores, the postoperative score of dyspareunia decreased by 65% compared with the preoperative score, and the remaining symptom scores decreased by 72% or more, and the total score decreased by 77%. It was suggested that some patients still had some symptoms of obstruction after surgery, but the degree of symptoms was significantly reduced compared with that before surgery. The procedure required the use of two anastomoses and was costly, but the overall patient satisfaction score, including the cost of treatment, was 7.8, showing good patient compliance. In this group of patients, the operation time was short and postoperative pain was low, mostly due to intraoperative anal dilation and postoperative retention of anal canal, and most of them did not need analgesic treatment. 2 patients with postoperative analgesia by intramuscular injection of brucine hydrochloride had anal fissures caused by anal dilation and severe pain, which later healed on their own. The postoperative complications of STARR reported in the literature include intraoperative or postoperative hemorrhage, postoperative anal incontinence, anastomotic stricture, rectovaginal fistula, pelvic infection, rectal diverticulum and other M canals. In our group, no other complications were found except for 2 patients with mild inflammation of the anastomosis after surgery and 2 patients with mild postoperative incontinence manifestations. We believe that STARR is simple, less traumatic, less complications, and has satisfactory recent efficacy, but the indications need to be strictly mastered. This procedure should be considered only in patients with clear rectal protrusion and rectal mucosal overt prolapse as the main cause of constipation.