Functional Constipation and Obstructed Defecation.

Constipation encompasses symptoms of decreased colonic motility or difficulty with the defecation process. As a broad definition, this can be inclusive of functional constipation (FC) or colonic inertia, obstructed defecation (OD), and irritable bowel syndrome-constipation type (IBS-CS). After excluding IBS-C, FC and OD diagnosis and management require a multidisciplinary approach often involving nutritionists, pelvic floor therapists, urogynecologists, and colon and rectal surgeons. Differentiating the presence or absence of each can direct therapy and prognosticate chances for improvement in this often complex combination of disorders.

The role of GSTM1 gene polymorphism in pathophysiology, evaluation, and management of constipation of anorectal outlet obstruction.

Constipation of anorectal outlet obstruction may be caused by mechanical or functional causes. This complication is a debilitating disease that needs proper and timely treatment. Many studies have shown that there is a direct link between constipation and intestinal cancer. One of the most effective ways to prevent or diagnose intestinal cancer is through genetic studies. Evaluation of people's polymorphism shows how much they are at risk for cancer. Therefore, in this study, the GSTM1 gene polymorphism was evaluated in patients with constipation of anorectal outlet obstruction to assess better and manage this disease and investigate the possibility of anorectal cancer in these people. In this regard, 40 people with constipation of anorectal outlet obstruction were compared with 40 healthy people. In the case group (patients), in addition to demographic and clinical evaluations, the anorectal manometric test was used to diagnose the pathology of the disease. Results showed that out of 40 patients with constipation of anorectal outlet obstruction, 5 cases (12.5%) had megarectum, 7 cases (17.5%) had anismus, 10 cases (25%) had Hirschsprung's disease, 5 cases (12.5%) had descending perineum syndrome, 6 cases (15%) had rectal prolapse, 4 cases (10%) had enterocele, and 3 cases (7.5%) were with rectocele. Also, the results of GSTM1 gene deletion polymorphism showed that patients with constipation of anorectal outlet obstruction were almost two times more exposed to the null genotype than the control group (P <0.04). Therefore, in people with both constipation of anorectal outlet obstruction and null genotype (i.e., deletion in the GSTM1 gene), because they do not have glutathione-S transferase, they appear to be at higher risk for anorectal cancer than healthy people with the same genotype.

The edible Lactobacillus paracasei X11 with Konjac glucomannan promotes intestinal motility in zebrafish.

BACKGROUND: Constipation is a gastrointestinal symptom with high incidence rate and large number of patients. It is becoming one of the urgent medical problems. Poor intestinal motility is one of the important causes of constipation. Current drug treatments for constipation are associated with many side effects; thus, it is necessary to study more effective treatment methods and potential mechanism. METHODS: A zebrafish model of intestinal motility obstruction was established by loperamide hydrochloride to evaluate the effect of probiotic, food ingredients, and combination on intestinal peristalsis according to intestinal peristalsis frequency counts. The gastrointestinal survival ability of the best probiotics was evaluated by surface hydrophobicity, self-aggregation, acid and bile salt tolerance, and gastrointestinal transit tolerance. Interactions between probiotics and food ingredients were studied in vivo and in vitro. The expression of 5-HT was detected by ELISA and fluorescence immunoassay, and 5-HT related genes were detected by RT-PCR. KEY RESULTS: We obtained the probiotics, food ingredients, and combination that effectively promoted intestinal peristalsis, X11 and YRL577, P. persica and KGM, KGM + X11, respectively. Both KGM and P. persica promoted colonization of probiotics in vivo. KGM + X11 could effectively promote the increase in 5-HT synthesis in zebrafish via up-regulating gene expression of TPH-1, TPH-2, and 5-HTR and down-regulating gene expression of SERT. The specific in-depth mechanism needs further study. CONCLUSIONS AND INFERENCES: The combinations of KGM with X11 effectively promoted intestinal peristalsis. We provide a theoretical basis for new modalities that can promote intestinal peristalsis and alleviate constipation.

Systematic Characterization of Defecographic Abnormalities in a Consecutive Series of 827 Patients With Chronic Constipation.

BACKGROUND: Barium defecography can assess structural and functional abnormalities in patients with chronic constipation. OBJECTIVE: The purpose of this study was to determine the prevalence of individual and overlapping defecographic findings in this setting. DESIGN: This was a cross-sectional study. SETTINGS: The study was conducted at a university hospital tertiary GI physiology department. PATIENTS: Consecutive examinations of 827 consecutive patients presenting over a 30-month period with well-defined symptom severity (≥12 points on the Cleveland Clinic Constipation score) were included. Systematic evaluation of images with results stratified by sex is described. MAIN OUTCOME MEASURES: Six individual functional or anatomic (intussusception, rectocele, enterocele, megarectum, excessive dynamic perineal descent) defecographic observations were defined a priori, thus permitting 26 possible combinations of findings (ie, 63 abnormal types + 1 normal). RESULTS: Patients with constipation (mean symptom score = 19) were predominantly female (88%), with median age of 49 years (range, 17-98 y) . All 6 individual radiologic findings were identified with a total of 43 combinations found in the cohort; the 14 most prevalent of these accounted for >85% of patients. Only 136 patients (16.4%) had a normal defecography (34.3% males vs 13.9% females; p < 0.0001). Overall, 612 patients (74.0%) had structural (n = 508 (61.4%)) or functional (n=104 (12.6%)) abnormalities in isolation, with 79 (9.6%) others exhibiting combinations of both. Functional abnormalities in isolation were more common in males compared with females (22.5% vs11.2%; p = 0.025) as opposed to structural abnormalities (57.8% vs 85.7%; p < 0.0001). Expulsion time was longer in females compared with males (110 s (60-120 s) vs 90 s (60-120 s); p = 0.049). LIMITATIONS: The study was limited by its lack of multiorgan opacification. CONCLUSIONS: These results provide a contemporary atlas of defecographic findings in constipation. Several individual structural and functional features have been systematically classified, with overlap greater than previously acknowledged and profound differences among sexes that carry implications for tailoring management. See Video Abstract at http://links.lww.com/DCR/B552. CARACTERIZACIN SISTEMTICA DE ANOMALAS DEFECOGRFICAS EN UNA SERIE CONSECUTIVA DE PACIENTES CON ESTREIMIENTO CRNICO: ANTECEDENTES:La defecografía con bario puede evaluar anomalías estructurales y funcionales en pacientes con estreñimiento crónico.OBJETIVO:Determinar la prevalencia de hallazgos defecográficos individuales y superpuestos en este entorno.DISEÑO:Transversal.ENTORNO CLINICO:Hospital Universitario de tercer nivel, departamento de fisiología gastrointestinal.PACIENTES:Exploraciones consecutivas de 827 pacientes consecutivos que se presentaron durante un período de 30 meses con una gravedad de los síntomas bien definida (≥12 puntos en la escala de estreñimiento de la Cleveland Clinic): evaluación sistemática de imágenes con resultados estratificados por sexo.PRINCIPALES MEDIDAS DE VALORACION:Se definieron a priori seis observaciones defecográficas individuales, funcionales o anatómicas (intususcepción, rectocele, enterocele, megarecto, descenso perineal dinámico excesivo), lo que permitió 26 combinaciones posibles de hallazgos (es decir, 63 tipos anormales + 1 normal).RESULTADOS:Los pacientes con estreñimiento (puntuación media de síntomas, 19) eran predominantemente mujeres (88%) con una edad mediana de 49 (17-98) años. Se identificaron 6 hallazgos radiológicos individuales con un total de 43 combinaciones encontradas en la cohorte; los 14 más predominantes de éstos representaron >85% de los pacientes.Solo 136 (16,4%) pacientes tuvieron una defecografía normal (34,3% hombres vs. 13,9% mujeres; P < 0,0001). En general, 612 (74,0%) pacientes tenían anomalías estructurales (n = 508 [61,4%]) o funcionales (n = 104 [12,6%]) de forma aislada, y otros 79 (9,6%) presentaban combinaciones de ambas. Las anomalías funcionales aisladas fueron más comunes en los hombres en comparación con las mujeres (22,5% vs. 11,2%, P = 0,025) en comparación con las anomalías estructurales (57,8 vs. 85,7%, P < 0,0001). El tiempo de expulsión fue mayor en las mujeres en comparación con los hombres (110 [60-120] vs. 90 [60-120] segundos; P = 0,049).LIMITACIONES:Falta de opacificación multiorgánica.CONCLUSIONES:Estos resultados proporcionan un atlas contemporáneo de hallazgos defecográficos en estreñimiento. Varias características individuales, estructurales y funcionales; se han clasificado sistemáticamente, con una superposición mayor que la reconocida anteriormente y con grandes diferencias entre los sexos que tienen implicaciones para adaptar su tratamiento. Consulte Video Resumen en http://links.lww.com/DCR/B552.

Obstructed defaecation syndrome: European consensus guidelines on the surgical management.

Clinical decision-making in the treatment of patients with obstructed defaecation remains controversial and no international guidelines have been provided so far. This study reports a consensus among European opinion leaders on the management of obstructed defaecation in different possible clinical scenarios.

Association of feces sign with prognosis of non-emergency adhesive small bowel obstruction.

BACKGROUND: /Objective: The feces sign has been reported as a possible predictive factor for non-operative treatment of small bowel obstruction. However, its relationship with prognosis of non-emergency adhesive small bowel obstruction remains unclear. This study aimed to clarify the relationship between the feces sign and prognosis of non-emergency adhesive small bowel obstruction. METHODS: Ninety-two patients with non-emergency adhesive small bowel obstruction with the transitional zone visible on computed tomography were included. Patients were categorized into two groups: feces sign positive (n = 40) and negative (n = 52). Clinical features and prognosis were compared between the two groups. Cox proportional hazards regression models incorporating the feces sign were used to analyze odds of diet resumption and discharge. RESULTS: Patients with feces sign were younger (p = 0.015), had a higher body mass index (p = 0.027), and a lower white blood cell count (p = 0.019) on admission. More patients with feces sign were successfully treated with fasting and/or nasogastric tube placement (p < 0.001), and no patient with feces sign suffered from recurrent obstruction after diet resumption. Kaplan-Meier analysis showed that patients with feces sign took less time for diet resumption (p = 0.007) and discharge (p = 0.004) than those without it. Using Cox proportional hazards regression model, the feces sign was reported as an independent predictor of diet resumption (odds ratio 1.685, p = 0.018) and discharge (odds ratio 1.861, p = 0.007). CONCLUSIONS: The feces sign is associated with improved odds for diet resumption and discharge.

Adequacy of lymph node harvest following colectomy for obstructed and nonobstructed colon cancer.

BACKGROUND: Technical and clinical differences in resection of obstructed and non-obstructed colon cancers may result in differences in lymph node retrieval. The objective of this study is to compare the lymph node harvest following resection of obstructed and nonobstructed colon cancer patients. METHODS: A retrospective analysis utilizing the 2014-2018 NSQIP colectomy targeted data set was conducted. One-to-one coarsened exact matching (CEM) was utilized between patients undergoing resection for obstructed and non-obstructed colon cancer. The primary outcome was the adequacy of lymph node retrieval (LNR, ≥12 nodes). RESULTS: CEM resulted in 9412 patients. Patients with obstructed tumors were more likely to have inadequate LNR (13.3% vs 8.2%, p < .001) compared to those with nonobstructed tumors. Multivariate analysis demonstrated that patients with obstructing tumors had worse LNR compared to non-obstructed tumors (odds ratio [OR]: 0.74, 95% confidence interval [CI]: 0.62-0.87; p < .005). Increased age (OR: 0.99, 95% CI: 0.098-0.99), presence of preoperative sepsis (OR: 0.70, 95% CI: 0.055-0.90), left-sided and sigmoid tumors compared to right-sided (OR: 0.64, 95% CI: 0.51-0.81; OR: 0.69, 95% CI: 0.58-0.82, respectively), and open surgical resection compared to an minimally invasive surgical approach were associated with inadequate LNR (p < .05). CONCLUSION: This study demonstrated that resection for obstructing colon cancer compared to non-obstructed colon cancer is associated with increased odds of inadequate lymph node harvest.

The management of adult patients with severe chronic small intestinal dysmotility.

Adult patients with severe chronic small intestinal dysmotility are not uncommon and can be difficult to manage. This guideline gives an outline of how to make the diagnosis. It discusses factors which contribute to or cause a picture of severe chronic intestinal dysmotility (eg, obstruction, functional gastrointestinal disorders, drugs, psychosocial issues and malnutrition). It gives management guidelines for patients with an enteric myopathy or neuropathy including the use of enteral and parenteral nutrition.

The Pathophysiology of Small Intestinal Foreign Body Obstruction and Intraoperative Assessment of Tissue Viability in Dogs: A Review.

Small intestinal foreign body obstructions occur commonly in dogs, accounting for 80% of all canine intestinal obstructions. Such obstructions induce local aberrations in secretion, absorption, and intestinal motility that can precipitate devastating systemic consequences, including a systemic inflammatory response, sepsis, and multiorgan dysfunction. Radiographic diagnosis is poorly sensitive relative to ultrasonography for diagnosing the presence of obstructive foreign material. Emergent surgical intervention is indicated for dogs with obstructive foreign material due to an inability to assess the degree of compromise of the intestinal wall that may precipitate intestinal perforation and to mitigate progression of life-threatening electrolyte and acid-base imbalances secondary to sequestration and emesis. Intraoperatively, an enterotomy or resection and anastomosis may be required to remove the obstructive material. A number of subjective and objective techniques for assessing the viability of intestinal tissue have been described due to the poor accuracy associated with surgeon assessment of color, peristalsis, pulsation, bleeding, and mural thickness alone. Such techniques have the potential to alter the surgeon's decision-making regarding performance of an enterotomy or resection and anastomosis, potentially reducing morbidity associated with intestinal surgery.

Impact of barometric pressure on adhesive small bowel obstruction: a retrospective study.

BACKGROUND: Adhesive small bowel obstruction (ASBO) is one of the most common causes of postoperative morbidity. According to Boyle's law, decreased barometric pressure expands the volume of intestinal gas. We aimed to elucidate the relationship between barometric pressure and ASBO. METHODS: We divided 215 admissions of 120 patients with ASBO into three groups: the fasting group, which responded to fasting (n = 51); the decompression group, which was successfully treated with gastrointestinal decompression (n = 104); and the surgery group which required emergency or elective surgery to treat ASBO (n = 60). We compared and examined clinical backgrounds, findings on admission, and barometric pressure during the peri-onset period (29 days: from 14 days before to 14 days after the onset of ASBO). RESULTS: There were significant differences among the three groups regarding gender, history of ASBO, hospital length of stay, and barometric pressure on the onset day of ASBO. Barometric pressure on the onset day was significantly higher in the fasting group than in the decompression group (p = 0.005). During pre-onset day 5 to post-onset day 2, fluctuations in the barometric pressure in the fasting and decompression groups showed reciprocal changes with a symmetrical axis overlapping the median barometric pressure in Matsumoto City; the fluctuations tapered over time after onset. In the fasting group, the barometric pressure on the onset day was significantly higher than that on pre-onset days 14, 11, 7, 4, 3, and 2; post-onset days 3 and 10; and the median pressure in Matsumoto City. Conversely, in the decompression group, the barometric pressure on the onset day was lower than that on pre-onset days 14, 5-2; post-onset days 1, 2, 7, 8, 11, 13, and 14; and the median pressure in Matsumoto City. In the surgery group, the barometric pressure on the onset day was equivalent to those on the other days. CONCLUSIONS: ASBO with response to conservative treatment is vulnerable to barometric pressure. Additionally, ASBO that is successfully treated with fasting and decompression is associated with a different barometric pressure on the onset day and reciprocal fluctuations in the barometric pressure during the peri-onset period.

Small bowel knots.

INTRODUCTION: Intertwining of bowel loops to form a knot is very rare cause of intestinal obstruction. Among intestinal knots, ileoileal knotting is the most rare, with only a handful of cases reported in literature. We present a rare case of ileoileal knotting and review of small bowel knots. The aim of this review was to summarise the existing evidence on small bowel knots and to postulate the possible mechanisms for knotting. METHODS: A systematic search was conducted for literature published up to December 2019 using MEDLINE, PubMed and Google Scholar databases, together with the references of the full-text articles retrieved. Papers with case reports of small bowel knots were considered to be eligible for inclusion in the review. FINDINGS: A total of 14 case reports were evaluated. There was no clear predilection for age or sex. Mostly cases were from Asia and Africa with no cases from the West. The presenting complaints were abdominal pain (93%), vomiting (64%), abdominal distention (57 %) and obstipation (43%). The bowel was gangrenous in 78% of cases. All underwent exploration, with the majority requiring resection and anastomosis of the involved segment. CONCLUSION: Ileoileal knotting is a very rare cause of intestinal obstruction. Possible mechanisms include loaded bowel with longer mesentery, vigorous peristalsis, single bulky meal, pregnancy and intussusception. The condition is extremely difficult to diagnose preoperatively and it is usually diagnosed intraoperatively. The standard of treatment is resection of gangrenous part and anastomosis.

Malignant Brenner tumour of the ovary manifesting as distal intestinal obstruction and perforation.

A rare case of malignant Brenner tumour of ovary manifesting with intestinal perforation due to colonic infiltration is elaborated in the present report. Brenner's tumour accounts for 1%-2% of all ovarian neoplasms and malignant Brenner tumour is even rarer and only about 5% of Brenner tumours are malignant. A 62-year-old woman came to surgical emergency with 1-month history of abdominal pain, vomiting and constipation with a palpable mass in right iliac fossa. Abdominal radiograph was suggestive of colonic obstruction. Contrast-enhanced CT of the abdomen revealed cystic right ovarian mass of 10.2×8.8 cm2 with pneumoperitoneum. Exploratory laparotomy was done, which revealed mass arising from right ovary involving terminal ileum, cecum and ascending colon. Possibility of ovarian malignancy was kept. Patient underwent debulking surgery along with ileostomy and descending colon mucous fistula was created. Histology was compatible with malignant Brenner tumour of the ovary.

Intestinal Failure: A Description of the Problem and Recent Therapeutic Advances.

Pediatric intestinal failure occurs when gut function is insufficient to meet the nutrient and hydration needs of the growing child. The commonest cause is short bowel syndrome with maldigestion and malabsorption following massive bowel loss. The remnant bowel adapts during the process of intestinal rehabilitation. Management promotes the achievement of enteral autonomy while mitigating the risk of comorbid disease. The future of care is likely to see expansion of pharmacologic methods for augmenting bowel adaptation, tissue engineering techniques enabling immune suppression-free autologous bowel transplant, and the development of electronic health record tools for efficient, collaborative study and care improvement.

Epithelial changes of congenital intestinal obstruction in a rat model.

INTRODUCTION: Intestinal atresia is a rare congenital affliction that is often associated with severe bacterial infections despite adequate neonatal surgery. Previous studies have focused on enteric nervous system variations. We hypothesized that epithelial systems (ES) may also be involved in the pathophysiology of postnatal disorders. MATERIALS AND METHODS: Global gene expression was measured by transcriptomic analysis in a rat model of induced intestinal atresia. The analyses then focused on genes involved in ES (enterocytes and goblet cells). Rat fetus small intestines at various stages of development (ED15, ED17, ED19, and ED21, n = 22), were used as non-operated controls and compared to the upper and lower segments of rat fetus small intestines with an induced atresia (n = 14; ligature at ED18). The pattern of gene expression was then confirmed by histochemistry, electron microscopy, and RT-qPCR. RESULTS: From ED15 to ED21, the expression of several genes exhibited a physiological increase of ES markers, with a significant increase at the end of gestation. The operated embryos exhibited significantly higher variations of gene expression in the proximal segment than in the distal segment in terms of absorption and the epithelial barrier. An increase in goblet cells and markers was observed in the proximal segment compared to the controls. CONCLUSION: Fetal intestinal obstruction accelerates maturation in the proximal segment and disrupts the intestinal wall in the distal segment, with a decrease in the number of mucosal cells. Moreover, the epithelial cells underwent significant changes, supporting the notion that intestinal disorders involve more than the ENS.

Intestinal Obstruction of Congenital Origin: A Case Report.

Congenital bands are rare causes of intestinal obstruction and often leads to diagnostic challenges. Diagnostic delays in cases of mechanical obstruction might lead to irreversible bowel ischemia and perforation. Presently described is a case of an 18 month young child with severe vomiting developed for one day. The child was initially thought to have acute viral enteritis and treated accordingly. Due to the severity, an X-Ray and computed tomography scan were sent which pointed towards the possibility of having congenital bands. He was treated operatively. The child was kept under observation for eleven days and was discharged. Although rare, intestinal obstruction due to congenital bands must be considered when treating a child with severe vomiting. Keywords: case reports, congenital abnormalities, intestinal obstruction, vomiting.

Experimental Models of Partial Intestinal Obstruction in Young Mice: Establishment, and Evaluation.

BACKGROUND: Partial small bowel obstruction (SBO) is a common, potentially hazardous, surgical entity caused by numerous factors in humans. A number of techniques have been reported as efficient to simulate partial SBO in murine models. However, there is little data concerning their long-term survival. Our study presents a novel technique and evaluates its long-term efficiency compared with other commonly used techniques. MATERIALS AND METHODS: Sixty C57BL/6 mice aged 6 to 8 wk were randomly divided into five intervention groups: ligation, intestinal ring, partial ligation, microclips, and the novel triple suture technique. The ring groups were subdivided into narrow, medium, and wide ring and partial ligation groups were subdivided at 1/3, 1/2, and 2/3 of the lumen. Survival cutoff time was set at 4 wk. Animals were then euthanized and small bowel muscle layer thickness was histopathologically evaluated. RESULTS: None of the animals of the ligation and the ring groups reached the cutoff survival time. The mortality rate of the partial ligation and the microclips groups at the 4-week period were 33.3% and 0%, respectively. However, elimination of the performed intervention was revealed at the time of euthanasia and no alterations of the muscle layer were revealed at histopathology. The "triple suture" group had a survival rate of 90% until euthanasia and the sutures were apparent in all cases. Macroscopic evaluation showed small to mild proximal lumen dilatation in 6 of 10 animals. Histopathological evaluation of the specimens confirmed the partial obstruction. CONCLUSIONS: The "triple suture" technique is a new, robust, reliable, and inexpensive technique for experimental long-standing partial SBO, with very low mortality.

Association of decreased variation of coefficient R-R interval with ischemic colitis and small bowel obstruction.

BACKGROUND: The parasympathetic nervous system exerts and controls intestinal tone. Several studies have suggested that the coefficient of the R-R intervals (CVRR) is useful for evaluating the parasympathetic nervous system. OBJECTIVES: This study aimed to evaluate the relationship between gastrointestinal emergencies, specifically ischemic colitis (IC) and small bowel obstruction (SBO), and the autonomic nervous system. METHODS: In this retrospective study, a total of 13 patients with IC or SBO aged ≧65 years were analyzed. CVRR was measured in patients with IC and SBO and controls. RESULTS: CVRR averaged to 8.8% ± 2.5% in controls, 1.4% ± 0.4% in patients with IC, and 2.4% ± 1.0% in SBO groups (p < 0.001). CVRR was significantly lower in patients with IC and SBO than that in controls. CONCLUSION: The results of this study demonstrate the possibility that CVRR may serve as a clinical index for assessing the functioning of the parasympathetic nervous system in patients with IC or SBO.

Standard stapled transanal rectal resection versus stapled transanal rectal resection with one high-volume stapler to prevent complications in the elderly.

BACKGROUND: The causes of obstructed defecation syndrome (ODS) can actually be either functional or mechanical (primary or secondary deficit of the sensitivity, slow bowel transit, pelvic floor dyssynergia, internal and external rectal prolapse, recto-anal intussusceptions, anterior or posterior rectocele and pelvic prolapse of the bladder, uterus, bowel or sigma). The aim of our study was to evaluate the safety, efficacy and feasibility of stapled transanal rectal resection (STARR) procedure performed by a single or double stapler through clinical and functional outcomes for transanal stapled surgery. METHODS: From January 2016 to October 2017, ninety patients with ODS secondary to rectal prolapse, anal-rectal intussusception and anterior rectocele, that underwent to a STARR procedure were enrolled. Thirty of these underwent a STARR procedure with double circular stapler PPH-01 (Group A); 30 with single circular stapler CPH34HV with a purse string suture (Group B); and 30 with single circular stapler CPH34HV with a "parachute technique" (Group C). All patients were selected with clinical examination, Wexner score for fecal incontinence and ODS score for constipation. Patients also underwent a Defeco RMN for an anatomical and dynamic evaluation of the pelvic floor. RESULTS: No recurrence rates were observed in the three groups. The mean operative time was 46.3 minutes in group A; 34.5 minutes in group B; and 37.6 minutes in Group C. The volume of the resected specimen was 17 mL in group A; 15 mL in group B; and 16 mL in Group C. Complications were bleeding (3.3% in group A); fecal urgency (6.6% in group A, 10% in group B and 3.3% in group C); rectal hematoma (3.3% in group A). all symptoms significantly improved after the operation without differences between groups. CONCLUSIONS: The STARR technique performed with a single stapler CPH34HV is safe, faster and less expensive than the STARR performed by a double PPH01. Besides, with the parachute technique, it is possible to resect asymmetric prolapses.