• Percent change in ODS symptom composite score from baseline at 1 month, 6 months, 2 years, 3 years, 4 years and 5 years
• Change in patient condition scores from baseline at 1 month, 6 months and 1 year; to be assessed as patient-reported assessment of symptom severity and frequency (PAC-SYM), and quality of life (PAC-QOL and SF-12)
• Change from baseline in urge to defecate
• Change from baseline in dynamic defecography parameters (including anterior rectocele depth, anteroposterior diameter of rectum) at rest and during evacuation at 6 months postoperative
• Global assessment of change in bowel condition by both the investigator and the subject
• Patient surgery satisfaction assessment at 1 month, 6 months, and 1 year postoperative
• Change from baseline in anorectal pain at onset of defecation at 1 month postoperative
• Incidence of dyspareunia at baseline, 1 month, 6 months, and 1 year postoperative

• - Percent change in ODS symptom composite score from baseline at 1-month, 6-month, 2-year, 3 year, 4-year and 5 years.
• - Change in patient condition scores from baseline at 1-month, 6-months, 1-year, 2-year, 3-year, 4 year and 5-years, to be assessed as patient-reported assessment of symptom severity and frequency (PAC-SYM), and quality of life (PAC-QOL and SF-12).
• - Change from baseline in urge to defecate.
• - Change from baseline in dynamic defecography parameters (including anterior rectocele depth, anteroposterior diameter of rectum) at rest and during evacuation at 6-months postoperative.
• - Global assessment of change in bowel condition by both the investigator and the subject.
• - Patient Surgery Satisfaction Assessment at 1-month, 6-months, and 1-year postoperative.
• - Change from baseline in anorectal pain at onset of defecation at 1-month postoperative.
• -Incidence of dyspareunia at baseline, 1-month, 6-month, and 1 year postoperative.

The primary purpose of this study is to determine how effective and how durable STARR (stapled transanal rectal resection) surgery is in relieving symptoms of intractable constipation associated with obstructive defecation syndrome (ODS).

Rectocele and rectal intussusception are frequent findings in women but are often asymptomatic apart from anatomical defects, which can be seen on vaginal examination. They can be associated, however, with refractory constipation that may be best described by the terms "Outlet Obstruction" or "Obstructive Defecation Syndrome (ODS)". ODS is characterized by a symptom complex, including the feeling of incomplete evacuation associated with the need to strain excessively and for external assistance (digital, mechanical or positional maneuvers, enemas or suppositories) to aid defecation. Abdominal or rectal pain is also a common complaint. Obstetric trauma is also recognized as a contributing factor. However, none of these symptoms/factors can be singled out to be pathognomonic for this problem. ODS has a prevalence of approximately 12% in the general population.

For individuals with ODS and related intussusception/rectocele, a variety of surgical techniques including abdominal, vaginal, transanal and perineal approaches have been devised. The impact of clinical studies to evaluate these techniques has been limited by variability of results and lack of comparators. Recently, a new surgical approach was developed by an Italian surgeon, A. Longo, and has been evaluated in several European centers. These early studies and observations indicate that this new procedure may in fact provide significantly better symptom resolution in ODS patients than other available treatments, and warrants further study. The procedure is referred to as "Stapled Transanal Rectal Resection (STARR)" and this study will assess its effectiveness in a United States population.

• Obstructive Defecation Syndrome
• Chronic Constipation
• Rectocele
• Intussusception

• Shorvon PJ, McHugh S, Diamant NE, Somers S, Stevenson GW. Defecography in normal volunteers: results and implications. Gut. 1989 Dec;30(12):1737-49.
• Kenton K, Shott S, Brubaker L. The anatomic and functional variability of rectoceles in women. Int Urogynecol J Pelvic Floor Dysfunct. 1999;10(2):96-9.
• Talley NJ, Weaver AL, Zinsmeister AR, Melton LJ 3rd. Functional constipation and outlet delay: a population-based study. Gastroenterology. 1993 Sep;105(3):781-90.
• Siproudhis L, Dautreme S, Ropert A, Briand H, Renet C, Beusnel C, Juguet F, Rabot AF, Bretagne JF, Gosselin M. Anismus and biofeedback: who benefits? Eur J Gastroenterol Hepatol. 1995 Jun;7(6):547-52.
• van Dam JH, Hop WC, Schouten WR. Analysis of patients with poor outcome of rectocele repair. Dis Colon Rectum. 2000 Nov;43(11):1556-60.
• Fleshman JW, Fry RD, Kodner IJ. The surgical management of constipation. Baillieres Clin Gastroenterol. 1992 Mar;6(1):145-62. Review.
• Altomare DF, Rinaldi M, Veglia A, Petrolino M, De Fazio M, Sallustio P. Combined perineal and endorectal repair of rectocele by circular stapler: a novel surgical technique. Dis Colon Rectum. 2002 Nov;45(11):1549-52.
• 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 Oct;7(3):148-53.
• 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 Aug;47(8):1285-96; discussion 1296-7.
• 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 Jul;19(4):359-69. Epub 2004 Mar 13.
• Pescatori M, Dodi G, Salafia C, Zbar AP. Rectovaginal fistula after double-stapled transanal rectotomy (STARR) for obstructed defaecation. Int J Colorectal Dis. 2005 Jan;20(1):83-5. Epub 2004 Sep 2. No abstract available.
• Grassi R, Romano S, Micera O, Fioroni C, Boller B. Radiographic findings of post-operative double stapled trans anal rectal resection (STARR) in patient with obstructed defecation syndrome (ODS). Eur J Radiol. 2005 Mar;53(3):410-6.
• Mongardini M, Custureri F, Schillaci F, Cola A, Maturo A, Fanello G, Corelli S, Pappalardo G. [Prevention of post-operative pain and haemorrhage in PPH (Procedure for Prolapse and Hemorrhoids) and STARR (Stapled Trans-Anal Rectal Resection). Preliminary results in 261 cases] G Chir. 2005 Apr;26(4):157-61. Italian.
• Binda GA, Pescatori M, Romano G. The dark side of double-stapled transanal rectal resection. Dis Colon Rectum. 2005 Sep;48(9):1830-1; author reply 1831-2. No abstract available.
• Jayne DG, Finan PJ. Stapled transanal rectal resection for obstructed defaecation and evidence-based practice. Br J Surg. 2005 Jul;92(7):793-4. No abstract available.
• Talley NJ, Phillips SF, Wiltgen CM, Zinsmeister AR, Melton LJ 3rd. Assessment of functional gastrointestinal disease: the bowel disease questionnaire. Mayo Clin Proc. 1990 Nov;65(11):1456-79.

Inclusion Criteria:

• Able to comprehend, understand, and speak the English language
• Able to comprehend, follow, and sign an informed consent document (ICD)
• Able to tolerate general or spinal anesthetic
• Often experience excessive straining, sense of incomplete evacuation, and/or prolonged time for complete evacuation when attempting a bowel movement
• Have experienced ODS symptoms for at least 12 months prior to enrollment
• Have a minimum ODS score of 10
• Have rectocele and/or rectal intussusception confirmed by defecography
• Screened for colorectal neoplasia within 7 years of the screening visit (e.g., colonoscopy or barium enema)
• Have an American Society of Anesthesiologists (ASA) score of no more than 3
• Willing to comply with evaluation and management schedule through 5-year follow-up

Exclusion Criteria:

• Fecal incontinence to solid stool
• Full-thickness prolapse
• Perineal infection
• Recto-vaginal fistula
• Enterocele (at rest)
• Any complex pelvic floor prolapse requiring a combined surgical approach
• Prior sigmoid or anterior resection or prior rectal anastomosis
• Presence of foreign material adjacent to the rectum (e.g., vaginal mesh)
• Grade IV hemorrhoids
• Pregnancy
• Chronic narcotic use
• Evidence of colorectal neoplasia, carcinoma, or inflammatory bowel disease
• Physical or psychological condition which would impair study participation
• Unable or unwilling to attend follow-up visits and examinations
• Surgical procedure required concurrently with STARR
• Prior pelvic radiotherapy
• Failure to identify any anatomical or physiological abnormality in the evaluation
• Significant rectal fibrosis
• Anal stenosis precluding insertion of the stapling device
• Participation in any other investigational device or drug study 30 days prior to enrollment
• Presence or history of hepatitis B, hepatitis C, and/or HIV positive test