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Chaichanavichkij P, Vollebregt PF, Tee SZY, Scott SM, Knowles CH. Slow-transit constipation and criteria for colectomy: a cross-sectional study of 1568 patients. BJS Open 2021; 5:6289804. [PMID: 34052848 PMCID: PMC8164778 DOI: 10.1093/bjsopen/zrab049] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 04/26/2021] [Indexed: 12/13/2022] Open
Abstract
Background Colectomy remains a treatment option for a minority of patients with slow-transit constipation (STC) refractory to conservative treatment. However careful patient selection is essential to maximize benefits and minimize risk of adverse outcome. This study determined the proportion of patients with chronic constipation that would meet criteria for colectomy based on recent European graded practice recommendations derived by expert consensus. Methods Retrospective application of graded practice recommendations was undertaken on a prospectively maintained data set of consecutive adult patients with chronic constipation who underwent whole-gut transit studies using radio-opaque markers. Primary analysis applied contraindications achieving high level of expert consensus (normal whole-gut transit as an absolute contraindication and faecal incontinence as a relative contraindication for colectomy). Secondary analysis applied contraindications with less certain consensus. Results Primary analysis of 1568 patients undergoing a whole-gut transit study between January 2004 and March 2016 found 208 (13.3 per cent) met published criteria to be selected for colectomy, with 974 excluded for normal whole-gut transit and 386 for faecal incontinence. Secondary analysis demonstrated high prevalence of other relative contraindications to colectomy: 165 concomitant upper gastrointestinal symptoms, 216 abdominal pain (including 126 irritable bowel syndrome), and 446 evacuation disorder. The majority of patients (416 of 594) had two or more relative contraindications. If these patients were excluded, only 26 (1.7 per cent) chronically constipated patients retrospectively met selection criteria for colectomy. Conclusions The retrospective application of selection criteria is a limitation. However, the data highlight the high prevalence of factors associated with poor postoperative outcome and provide further caution to surgeons undertaking colectomy for STC.
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Affiliation(s)
- P Chaichanavichkij
- National Bowel Research Centre and GI Physiology Unit, Blizard Institute, Centre for Neuroscience, Surgery & Trauma, Queen Mary University of London, London, UK
| | - P F Vollebregt
- National Bowel Research Centre and GI Physiology Unit, Blizard Institute, Centre for Neuroscience, Surgery & Trauma, Queen Mary University of London, London, UK
| | - S Z Y Tee
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - S M Scott
- National Bowel Research Centre and GI Physiology Unit, Blizard Institute, Centre for Neuroscience, Surgery & Trauma, Queen Mary University of London, London, UK
| | - C H Knowles
- National Bowel Research Centre and GI Physiology Unit, Blizard Institute, Centre for Neuroscience, Surgery & Trauma, Queen Mary University of London, London, UK
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Patton V, Balakrishnan V, Pieri C, Doherty P, Phan-Thien KC, King DW, Lubowski DZ. Subtotal colectomy and ileorectal anastomosis for slow transit constipation: clinical follow-up at median of 15 years. Tech Coloproctol 2020; 24:173-179. [PMID: 31907721 DOI: 10.1007/s10151-019-02140-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 12/13/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Slow transit constipation is characterised by prolonged colonic transit and reliance on laxatives. The pathophysiology is poorly understood and in its most severe form, total colectomy with ileorectal anastomosis is the final treatment option. We present a follow-up study of the long-term function in patients who had surgery for laxative-resistant slow transit constipation. METHODS A postal survey was sent to assess bowel frequency, abdominal pain, St Mark's continence score, satisfaction with procedure, likelihood to choose the procedure again, and long-term rates of small bowel obstruction and ileostomy. Longitudinal data from a subgroup studied 23 years previously are reported. RESULTS Forty-two patients (male = 2) were available for follow-up out of an initial cohort of 102. Mean time since surgery was 15.9 years (range 1.7-29.7) years. Fifty percent had < 4 bowel motions per day, most commonly Bristol stool 6, mean St Mark's score 7.45. Twenty-one percent had severe incontinence. Satisfaction and likelihood to choose surgery were high (median 10/10). There was a high rate of small bowel obstruction, suggesting pan-intestinal dysmotility in some cases. Conversion to ileostomy occurred in 8 patients. In the longitudinal follow-up in 15 subjects, continence deteriorated (p < 0.01), stool consistency softened (p < 0.01), and stool frequency fell (p < 0.01). CONCLUSIONS Satisfactory stool frequency was achieved in the long term, and although 21% had incontinence scores > 12, patient satisfaction was high. This is the longest reported follow-up of colectomy for slow transit constipation, with longitudinal outcomes reported. There was considerable attrition of patients, so larger, longitudinal studies are required to better ascertain the functional outcomes of these patients.
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Affiliation(s)
- V Patton
- Department Colorectal Surgery, St George Clinical School, St George Hospital, University of New South Wales, Kogarah, NSW, Sydney, 2217, Australia. .,School of Nursing and Midwifery, Edith Cowan University, Perth, WA, Australia.
| | - V Balakrishnan
- Department Colorectal Surgery, St George Clinical School, St George Hospital, University of New South Wales, Kogarah, NSW, Sydney, 2217, Australia
| | - C Pieri
- Department Colorectal Surgery, St George Clinical School, St George Hospital, University of New South Wales, Kogarah, NSW, Sydney, 2217, Australia
| | - P Doherty
- Department Colorectal Surgery, St George Clinical School, St George Hospital, University of New South Wales, Kogarah, NSW, Sydney, 2217, Australia
| | - K C Phan-Thien
- Department Colorectal Surgery, St George Clinical School, St George Hospital, University of New South Wales, Kogarah, NSW, Sydney, 2217, Australia
| | - D W King
- Department Colorectal Surgery, St George Clinical School, St George Hospital, University of New South Wales, Kogarah, NSW, Sydney, 2217, Australia
| | - D Z Lubowski
- Department Colorectal Surgery, St George Clinical School, St George Hospital, University of New South Wales, Kogarah, NSW, Sydney, 2217, Australia
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Yang Y, Cao YL, Wang WH, Zhang YY, Zhao N, Wei D. Subtotal colonic bypass plus colostomy with antiperistaltic cecoproctostomy for the treatment of slow transit constipation in an aged population: A retrospective control study. World J Gastroenterol 2018; 24:2491-2500. [PMID: 29930470 PMCID: PMC6010946 DOI: 10.3748/wjg.v24.i23.2491] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 04/05/2018] [Accepted: 05/18/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To compare the efficacy, improved quality of life, and prognosis in patients undergoing either subtotal colonic bypass with antiperistaltic cecoproctostomy (SCBAC) or subtotal colonic bypass plus colostomy with antiperistaltic cecoproctostomy (SCBCAC) for the treatment of slow transit constipation.
METHODS Between October 2010 and October 2014, aged patients with slow transit constipation who were hospitalized and underwent laparoscopic surgery in our institute were divided into two groups: the bypass group, 15 patients underwent SCBAC, and the bypass plus colostomy group, 14 patients underwent SCBCAC. The following preoperative and postoperative clinical data were collected: gender, age, body mass index, operative time, first flatus time, length of hospital stay, bowel movements (BMs), Wexner fecal incontinence scale, Wexner constipation scale (WCS), gastrointestinal quality of life index (GIQLI), numerical rating scale for pain intensity (NRS), abdominal bloating score (ABS), and Clavien-Dindo classification of surgical complications (CD) before surgery and at 3, 6, 12, and 24 mo after surgery.
RESULTS All patients successfully underwent laparoscopic surgery without open surgery conversion or surgery-related death. The operative time and blood loss were significantly less in the bypass group than in the bypass plus colostomy group (P = 0.007). No significant differences were observed in first flatus time, length of hospital stay, or complications with CD > 1 between the two groups. No patients had fecal incontinence after surgery. At 3, 6, and 12 mo after surgery, the number of BMs was significantly less in the bypass plus colostomy group than in the bypass group. The parameters at 3, 6, 12, and 24 mo after surgery in both groups significantly improved compared with the preoperative conditions (P < 0.05), except NRS at 3, 6 mo after surgery in both groups, ABS at 12, 24 mo after surgery and NRS at 12, 24 mo after surgery in the bypass group. WCS, GIQLI, NRS, and ABS significantly improved in the bypass plus colostomy group compared with the bypass group at 3, 6, 12, and 24 mo after surgery (P < 0.05) except WCS, NRS at 3, 6 mo after surgery and ABS at 3 mo after surgery. At 1 year after surgery, a barium enema examination showed that the emptying time was significantly better in the bypass plus colostomy group than in the bypass group (P = 0.007).
CONCLUSION Laparoscopic SCBCAC is an effective and safe procedure for the treatment of slow transit constipation in an aged population and can significantly improve the prognosis. Its clinical efficacy is more favorable compared with that of SCBAC. Laparoscopic SCBCAC is a better procedure for the treatment of slow transit constipation in an aged population.
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Affiliation(s)
- Yang Yang
- Institute of Anal-Colorectal Surgery, No. 150 Central Hospital of PLA, Luoyang 471000, Henan Province, China
| | - Yong-Li Cao
- Institute of Anal-Colorectal Surgery, No. 150 Central Hospital of PLA, Luoyang 471000, Henan Province, China
| | - Wen-Hang Wang
- Institute of Anal-Colorectal Surgery, No. 150 Central Hospital of PLA, Luoyang 471000, Henan Province, China
| | - Yuan-Yao Zhang
- Institute of Anal-Colorectal Surgery, No. 150 Central Hospital of PLA, Luoyang 471000, Henan Province, China
| | - Nan Zhao
- Institute of Anal-Colorectal Surgery, No. 150 Central Hospital of PLA, Luoyang 471000, Henan Province, China
| | - Dong Wei
- Institute of Anal-Colorectal Surgery, No. 150 Central Hospital of PLA, Luoyang 471000, Henan Province, China
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Knowles CH, Grossi U, Chapman M, Mason J. Surgery for constipation: systematic review and practice recommendations: Results I: Colonic resection. Colorectal Dis 2017; 19 Suppl 3:17-36. [PMID: 28960923 DOI: 10.1111/codi.13779] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
AIM To assess the outcomes of colectomy in adults with chronic constipation (CC). METHOD Standardised methods and reporting of benefits and harms were used for all CapaCiTY reviews that closely adhered to PRISMA 2016 guidance. Main conclusions were presented as summary evidence statements (SES) with a summative Oxford Centre for Evidence-Based Medicine (2009) level. RESULTS Forty articles were identified, providing data on outcomes in 2045 patients. Evidence was derived almost exclusively from observational studies, the majority of which concerned colectomy and ileorectal anastomosis (CIRA) rather than other procedural variations. Average length of stay (LOS) ranged between 7-15 days. Although inconsistent, laparoscopic surgery may be associated with longer mean operating times (210 vs 167 min) and modest decreases in LOS (10-8 days). Complications occurred in approximately 24% of patients. Six (0.4%) procedure-related deaths were observed. Recurrent episodes of small bowel obstruction occurred in about 15% (95%CI: 10-21%) of patients in the long-term, with significant burden of re-hospitalisation and frequent recourse to surgery. Most patients reported a satisfactory or good outcome after colectomy but negative long-term functional outcomes persist in a minority of patients. The influence of resection extent, anastomotic configuration and method of access on complication rates remains uncertain. Available evidence weakly supports selection of patients with an isolated slow-transit phenotype. CONCLUSION Colectomy for CC may benefit some patients but at the cost of substantial short- and long-term morbidity. Current evidence is insufficient to guide patient or procedural selection.
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Affiliation(s)
- C H Knowles
- National Bowel Research Centre, Blizard Institute, Queen Mary University London, London, UK
| | - U Grossi
- National Bowel Research Centre, Blizard Institute, Queen Mary University London, London, UK
| | - M Chapman
- Good Hope Hospital, Heart of England NHS Trust, Birmingham, UK
| | - J Mason
- University of Warwick, Coventry, UK
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- National Institute for Health Research: Chronic Constipation Treatment Pathway
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- Affiliate section of the Association of Coloproctology of Great Britain and Ireland
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A prospective comparison of short term results and functional recovery after laparoscopic subtotal colectomy and antiperistaltic cecorectal anastomosis with short colonic reservoir vs. long colonic reservoir. BMC Gastroenterol 2015; 15:30. [PMID: 25887580 PMCID: PMC4367911 DOI: 10.1186/s12876-015-0257-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2013] [Accepted: 02/26/2015] [Indexed: 12/12/2022] Open
Abstract
Background To observe and compare the short term results and functional recovery of laparoscopic subtotal colectomy with antiperistaltic cecorectal anastomosis (LSCACRA) in the treatment of Adult slow transit constipation (STC) with two different reservoir length: short colonic reservoir and long colonic reservoir. Methods All STC patients treated with LSCACRA between April 2007 and December 2011 at our institution were followed up. Patients with 2 cm to 3 cm ascending colon preserved above the ileocecal junction were designated as observation group, whereas those preserved by 10 cm to 15 cm were classified as control group. 41 cases in the observation group and 40 cases in the control group were enrolled. Preoperative and outcome parameters of patients were collected, including gender, age, body mass index, operative time , blood loss, first flatus time, hospital stay, postoperative complications, Wexner constipation scale(WCS), Wexner incontinence scale, gastrointestinal quality of life index(GIQLI), abdominal pain intensity scale(APIS), abdominal pain frequency scale(APFS) and abdominal bloating scale(ABS). Results Laparoscopic surgeries were successfully carried out for all patients, without any case transferred to laparotomy or death related to surgery. The operative time, blood loss, first flatus time, and days of hospital stay of the two groups did not show significant differences. We found no significant differences on complications (Clavien–Dindo grade > I) between the two groups. No patient exhibited anastomotic leak. No fecal incontinence occurred in both groups. On the 3rd, 6th and 12th month after operation, the parameters of both groups significantly improved compared with the preoperative conditions (P < 0.05) except the APIS at 3rd and 6th month in control group. On the 3rd, 6th and 12th month after operation, the Functional Recovery outcomes of WCS、GIQLI、APIS、APFS and ABS in the observation group were superior to those in the control group (P < 0.05). Conclusion LSCACRA has a significant effect in the treatment of STC in adult. Postoperative outcomes can be optimized by shortening the length of the preserved ascending colon above the ileocecal junction, which promise better life quality of patients. Trial registration: Chinese Clinical Trial Registry ChiCTR-OPC-14005280, 2014-09-29. Electronic supplementary material The online version of this article (doi:10.1186/s12876-015-0257-7) contains supplementary material, which is available to authorized users.
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Bove A, Bellini M, Battaglia E, Bocchini R, Gambaccini D, Bove V, Pucciani F, Altomare DF, Dodi G, Sciaudone G, Falletto E, Piloni V. Consensus statement AIGO/SICCR diagnosis and treatment of chronic constipation and obstructed defecation (part II: treatment). World J Gastroenterol 2013. [PMID: 23049207 DOI: 10.3748/wjg.v] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The second part of the Consensus Statement of the Italian Association of Hospital Gastroenterologists and Italian Society of Colo-Rectal Surgery reports on the treatment of chronic constipation and obstructed defecation. There is no evidence that increasing fluid intake and physical activity can relieve the symptoms of chronic constipation. Patients with normal-transit constipation should increase their fibre intake through their diet or with commercial fibre. Osmotic laxatives may be effective in patients who do not respond to fibre supplements. Stimulant laxatives should be reserved for patients who do not respond to osmotic laxatives. Controlled trials have shown that serotoninergic enterokinetic agents, such as prucalopride, and prosecretory agents, such as lubiprostone, are effective in the treatment of patients with chronic constipation. Surgery is sometimes necessary. Total colectomy with ileorectostomy may be considered in patients with slow-transit constipation and inertia coli who are resistant to medical therapy and who do not have defecatory disorders, generalised motility disorders or psychological disorders. Randomised controlled trials have established the efficacy of rehabilitative treatment in dys-synergic defecation. Many surgical procedures may be used to treat obstructed defecation in patients with acquired anatomical defects, but none is considered to be the gold standard. Surgery should be reserved for selected patients with an impaired quality of life. Obstructed defecation is often associated with pelvic organ prolapse. Surgery with the placement of prostheses is replacing fascial surgery in the treatment of pelvic organ prolapse, but the efficacy and safety of such procedures have not yet been established.
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Affiliation(s)
- Antonio Bove
- Gastroenterology and Endoscopy Unit, Department of Gastroenterology, AORN "A. Cardarelli", 80131 Naples, Italy.
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7
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Bove A, Bellini M, Battaglia E, Bocchini R, Gambaccini D, Bove V, Pucciani F, Altomare DF, Dodi G, Sciaudone G, Falletto E, Piloni V. Consensus statement AIGO/SICCR diagnosis and treatment of chronic constipation and obstructed defecation (Part II: Treatment). World J Gastroenterol 2012; 18:4994-5013. [PMID: 23049207 PMCID: PMC3460325 DOI: 10.3748/wjg.v18.i36.4994] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2011] [Revised: 11/17/2011] [Accepted: 08/15/2012] [Indexed: 02/06/2023] Open
Abstract
The second part of the Consensus Statement of the Italian Association of Hospital Gastroenterologists and Italian Society of Colo-Rectal Surgery reports on the treatment of chronic constipation and obstructed defecation. There is no evidence that increasing fluid intake and physical activity can relieve the symptoms of chronic constipation. Patients with normal-transit constipation should increase their fibre intake through their diet or with commercial fibre. Osmotic laxatives may be effective in patients who do not respond to fibre supplements. Stimulant laxatives should be reserved for patients who do not respond to osmotic laxatives. Controlled trials have shown that serotoninergic enterokinetic agents, such as prucalopride, and prosecretory agents, such as lubiprostone, are effective in the treatment of patients with chronic constipation. Surgery is sometimes necessary. Total colectomy with ileorectostomy may be considered in patients with slow-transit constipation and inertia coli who are resistant to medical therapy and who do not have defecatory disorders, generalised motility disorders or psychological disorders. Randomised controlled trials have established the efficacy of rehabilitative treatment in dys-synergic defecation. Many surgical procedures may be used to treat obstructed defecation in patients with acquired anatomical defects, but none is considered to be the gold standard. Surgery should be reserved for selected patients with an impaired quality of life. Obstructed defecation is often associated with pelvic organ prolapse. Surgery with the placement of prostheses is replacing fascial surgery in the treatment of pelvic organ prolapse, but the efficacy and safety of such procedures have not yet been established.
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8
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Bove A, Bellini M, Battaglia E, Bocchini R, Gambaccini D, Bove V, Pucciani F, Altomare DF, Dodi G, Sciaudone G, Falletto E, Piloni V. Consensus statement AIGO/SICCR diagnosis and treatment of chronic constipation and obstructed defecation (part II: treatment). World J Gastroenterol 2012. [PMID: 23049207 PMCID: PMC3460325 DOI: 10.3748/wjg.v18.i36.4994;] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The second part of the Consensus Statement of the Italian Association of Hospital Gastroenterologists and Italian Society of Colo-Rectal Surgery reports on the treatment of chronic constipation and obstructed defecation. There is no evidence that increasing fluid intake and physical activity can relieve the symptoms of chronic constipation. Patients with normal-transit constipation should increase their fibre intake through their diet or with commercial fibre. Osmotic laxatives may be effective in patients who do not respond to fibre supplements. Stimulant laxatives should be reserved for patients who do not respond to osmotic laxatives. Controlled trials have shown that serotoninergic enterokinetic agents, such as prucalopride, and prosecretory agents, such as lubiprostone, are effective in the treatment of patients with chronic constipation. Surgery is sometimes necessary. Total colectomy with ileorectostomy may be considered in patients with slow-transit constipation and inertia coli who are resistant to medical therapy and who do not have defecatory disorders, generalised motility disorders or psychological disorders. Randomised controlled trials have established the efficacy of rehabilitative treatment in dys-synergic defecation. Many surgical procedures may be used to treat obstructed defecation in patients with acquired anatomical defects, but none is considered to be the gold standard. Surgery should be reserved for selected patients with an impaired quality of life. Obstructed defecation is often associated with pelvic organ prolapse. Surgery with the placement of prostheses is replacing fascial surgery in the treatment of pelvic organ prolapse, but the efficacy and safety of such procedures have not yet been established.
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Affiliation(s)
- Antonio Bove
- Gastroenterology and Endoscopy Unit, Department of Gastroenterology, AORN "A. Cardarelli", 80131 Naples, Italy.
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9
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Yik YI, Leong LCY, Hutson JM, Southwell BR. The impact of transcutaneous electrical stimulation therapy on appendicostomy operation rates for children with chronic constipation--a single-institution experience. J Pediatr Surg 2012; 47:1421-6. [PMID: 22813807 DOI: 10.1016/j.jpedsurg.2012.01.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2011] [Revised: 01/13/2012] [Accepted: 01/15/2012] [Indexed: 12/27/2022]
Abstract
PURPOSE Appendicostomy for antegrade continence enema is a minimally invasive surgical intervention that has helped many children with chronic constipation. At our institution, since 2006, transcutaneous electrical stimulation (TES) has been trialed to treat slow-transit constipation (STC) in children. This retrospective audit aimed to determine if TES use affected appendicostomy-formation rates and to monitor changes in practice. We hypothesized that appendicostomy rates have decreased for STC but not for other indications. METHODS Appendicostomy-formation rate was determined for the 5 years before and after 2006. Children were identified as STC or non-STC from nuclear transit scintigraphy and patient records. RESULTS Since 1999, 317 children were diagnosed with STC using nuclear transit scintigraphy with 121 during 2001 to 2005 (24.2/year) and 147 during 2006 to 2010 (29.4/year). Seventy-four children had appendicostomy formation. For 2001 to 2005, appendicostomy-formation rates for STC and non-STC children were similar: 5.4 per year (n = 27) and 4.8 per year (n = 24), respectively. For 2006 to 2010, appendicostomy-formation rates were 1.2 per year (n = 6) for STC and 3.2 per year (n = 16) for non-STC (χ(2), P = .04). CONCLUSION Since 2006, appendicostomy-formation rates have significantly reduced in STC but not in non-STC children at our institute, coinciding with the introduction of TES as an alternative treatment for STC. Transcutaneous electrical stimulation has not been tested on non-STC children in this period.
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Affiliation(s)
- Yee Ian Yik
- F Douglas Stephens Surgical Research and Gut Motility Laboratories, Murdoch Children's Research Institute, Melbourne, Australia
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10
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Arebi N, Kalli T, Howson W, Clark S, Norton C. Systematic review of abdominal surgery for chronic idiopathic constipation. Colorectal Dis 2011; 13:1335-43. [PMID: 20969711 DOI: 10.1111/j.1463-1318.2010.02465.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
AIM Constipation is a common problem which increases in prevalence with age. Chronic constipation is complex and difficult to treat. Some patients will not respond to pharmacological therapy and therefore surgery may be considered. A systematic review of the literature was performed to determine the outcome of surgery. METHOD Published papers were identified by a search of The Cochrane Library, MEDLINE, CINAHL and EMBASE. They were reviewed and the data were extracted. RESULTS Forty-eight papers were identified, including 1443 patients. Eleven different procedures were described. There was inconsistency in reporting. In 65% of patients the mean frequency of defaecation increased from 1.1 to 19.7 evacuations per week. Where laxative usage was reported (971 patients), it was found that 88% of patients did not need them postoperatively. Early complications included ileus (0-16%), infection (0-13%) and anastomotic leakage (0-22%). Patient satisfaction and quality of life scores were high. Only 30% of studies included data on preoperative psychological assessment. CONCLUSION Surgery improves constipation and is associated with a higher degree of patient satisfaction, but the quality of studies was very variable. Future controlled trials should examine the ideal therapeutic approach for different patient groups.
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Affiliation(s)
- N Arebi
- St Mark's Hospital, London, UK.
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11
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Knowles CH, Farrugia G. Gastrointestinal neuromuscular pathology in chronic constipation. Best Pract Res Clin Gastroenterol 2011; 25:43-57. [PMID: 21382578 PMCID: PMC4175481 DOI: 10.1016/j.bpg.2010.12.001] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2010] [Accepted: 12/15/2010] [Indexed: 01/31/2023]
Abstract
Some patients with chronic constipation may undergo colectomy yielding tissue appropriate to diagnosis of underlying neuromuscular pathology. The analysis of such tissue has, over the past 40 years, fueled research that has explored the presence of neuropathy, myopathy and more recently changes in interstitial cells of Cajal (ICC). In this chapter, the data from these studies have been critically reviewed in the context of the significant methodological and interpretative issues that beset the field of gastrointestinal neuromuscular pathology. On this basis, reductions in ICC appear to a consistent finding but one whose role as a primary cause of slow-transit constipation requires further evaluation. Findings indicative of significant neuropathy or myopathy are variable and in many studies subject to considerable methodological bias. Methods with practical diagnostic utility in the individual patient have rarely been employed and require further validation in respect of normative data.
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Affiliation(s)
| | - Gianrico Farrugia
- Enteric NeuroScience Program, Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA
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12
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Landmann RG, Wexner SD. Paradoxical puborectalis contraction and increased perineal descent. Clin Colon Rectal Surg 2010; 21:138-45. [PMID: 20011410 DOI: 10.1055/s-2008-1075863] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Paradoxical puborectalis contraction and increased perineal descent are two forms of functional constipation presenting as challenging diagnostic and treatment dilemmas to the clinician. In the evaluation of these disorders, the clinician should take special care to exclude anatomic disorders leading to constipation. Physical examination is supplemented by additional diagnostic modalities such as cinedefecography, electromyography, manometry, and pudendal nerve tefninal motor latency. Generally, these investigations should be used in combination with the two playing the more relied upon techniques. Treatment is typically conservative with biofeedback playing a principal role with favorable results when patient compliance is emphasized. When considering paradoxical puborectalis contraction, failure of biofeedback is usually augmented with botulinum toxin injection. Increased perineal descent is generally treated with biofeedback and perineal support maneuvers. Surgery has little or no role in these conditions. The patient who insists on surgical intervention for either of these two conditions should be offered a stoma.
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Affiliation(s)
- Ron G Landmann
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL 33331, USA
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13
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Pescatori M, Milito G, Fiorino M, Cadeddu F. Complications and reinterventions after surgery for obstructed defecation. Int J Colorectal Dis 2009; 24:951-9. [PMID: 19165491 DOI: 10.1007/s00384-009-0639-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/08/2009] [Indexed: 02/04/2023]
Abstract
PURPOSE Functional results following surgery for obstructed defecation (OD) have been widely investigated, but there are few reports aimed to analyze postoperative complications and re-interventions. This study investigates the adverse events requiring retreatment for obstructed defecation. METHODS We retrospectively analyzed the records of 203 patients operated on by a single surgeon, 20 transabdominally and 183 transperineally (159 manual and 24 stapled). Postoperative complications requiring retreatment and outcome of reinterventions were analyzed. RESULTS Adverse events requiring retreatment occurred in 14.3% more frequently after abdominal than after perineal procedures (20% vs. 13.7%), but the sample size of the two arms is different. Rectal bleeding and strictures were the most common adverse events (6.9%). Major complications, i.e., ischemic colitis requiring hemicolectomy and pelvic sepsis requiring colostomy also occurred (1%). The overall reintervention rate was 7.5%, (5% after abdominal and 7.6% after perineal surgery). Overall, 59% of the reoperated patients were still constipated at a median follow up of 2 years. CONCLUSIONS Complications requiring retreatment are not uncommon after surgery for OD and reinterventions are often unsuccessful. A careful preoperative evaluation and selection of patients should be undertaken in order to minimize adverse events.
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Affiliation(s)
- Mario Pescatori
- Coloproctology Unit, Ars Medica and Villa Flaminia Hospitals, Rome, Italy
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Clarke MCC, Chase JW, Gibb S, Hutson JM, Southwell BR. Improvement of quality of life in children with slow transit constipation after treatment with transcutaneous electrical stimulation. J Pediatr Surg 2009; 44:1268-72; discussion 1272. [PMID: 19524752 DOI: 10.1016/j.jpedsurg.2009.02.031] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2009] [Accepted: 02/17/2009] [Indexed: 11/19/2022]
Abstract
BACKGROUND Slow transit constipation (STC) causes intractable symptoms not responsive to medical treatment. Children have irregular bowel motions, colicky abdominal pain, and frequent soiling. Transcutaneous electrical stimulation using interferential current (interferential therapy [IFT]) is a novel treatment of STC. This study assessed quality of life (QOL) in STC children before and after IFT treatment. METHODS Eligible STC children were randomized to receive either real or placebo IFT (12 sessions for 4 weeks). Questionnaires (Pediatric Quality of Life Inventory) were administered before and 6 weeks after treatment, with parallel parent and child self-report scales. Higher scores indicate better QOL. Holschneider and Templeton scores were also obtained. The QOL scores were compared using paired t tests. RESULTS Thirty-three children (21 male), with a mean age of 11.8 years (range, 7.4-16.5 years), were recruited; 16 received real IFT. Child-perceived QOL was improved after real IFT compared with baseline (81.1 vs 72.9, P = .005) but not after placebo IFT (78.1 vs 74.9, P = .120). The Holschneider score improved after real IFT (10 vs 8, P = .015) but not after placebo IFT (9 vs 8, P = .112). Parentally perceived QOL was similar after real IFT (70.1 vs 70.3, P = .927) and placebo IFT (70.2 vs 69.8, P = .899). There were no differences in Templeton scores. CONCLUSION Interferential therapy is a novel therapy for children with STC that improves their self-perceived QOL.
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Affiliation(s)
- Melanie C C Clarke
- Department of General Surgery, Royal Children's Hospital, Parkville, Melbourne, Victoria 3052, Australia
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15
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Marchesi F, Sarli L, Percalli L, Sansebastiano GE, Veronesi L, Di Mauro D, Porrini C, Ferro M, Roncoroni L. Subtotal colectomy with antiperistaltic cecorectal anastomosis in the treatment of slow-transit constipation: long-term impact on quality of life. World J Surg 2008; 31:1658-64. [PMID: 17541684 DOI: 10.1007/s00268-007-9111-6] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The aim of the study was to evaluate the effectiveness of subtotal colectomy with cecorectal anastomosis (SCCA) in the treatment of slow-transit constipation, not just in terms of symptom resolution but also the overall impact on patients' quality of life. METHODS Between 1991 and 2005, 43 patients underwent SCCA at our institution, 22 for slow-transit constipation (STC) and 21 for other types of colic diffuse disease (non-slow-transit constipation: NSTC), the latter being considered controls. A total of 29 patients (17 affected by STC) were administered a 50-item telephonic questionnaire, including the Gastrointestinal Quality of Life Index (GIQLI), the Wexner constipation and incontinence scale (WC, WI), and individual willingness to repeat the procedure. Questionnaire data and other parameters such as age, sex, length of follow-up, complications, and length of hospital stay were analyzed and compared, in order to evaluate possible correlations between the parameters and their related impact on quality of life, procedural effectiveness in terms of symptomatic regression, qualitative differences related to pathology (constipation versus non-constipation), and surgical approach (laparotomy versus video-laparo-assisted procedure). RESULTS There were no procedure-related deaths in this series (mortality: 0%); however, we found two complications in the STC group (9.1%), one requiring reoperation. The GIQLI mean score for the STC group was 115.5 +/- 20.5 (mean score for healthy people 125.8 +/- 13), and the WC mean score passed from a preoperative value of 20.3 to a postoperative value of 2.6. Regression analysis revealed a significant correlation between GIQLI and urgency and abdominal pain, and abdominal pain correlated significantly with pathology (STC). A high number of patients (88.2% in STC) expressed a willingness to repeat the procedure given the same preoperative conditions. CONCLUSIONS Comparing our results to those of the most homogeneous literature data, SCCA does not appear to be inferior to subtotal colectomy with ileorectal anastomosis (IRA) in terms of therapeutic effectiveness, postoperative mortality and morbidity, or overall impact on quality of life.
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Affiliation(s)
- Federico Marchesi
- Department of Surgical Sciences, Section of General Surgical Clinics and Surgical Therapy, Parma University Medical School, Parma, Italy.
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Abstract
Slow-transit constipation is characterized by delay in transit of stool through the colon, caused by either myopathy or neuropathy. The severity of constipation is highly variable, but may be severe enough to result in complete cessation of spontaneous bowel motions. Diagnostic tests to assess colonic transit include radiopaque marker or radioisotope studies, and intraluminal tests (colonic and small bowel manometry). Most patients with functional constipation respond to laxatives, but a small proportion are resistant to this treatment. In some patients biofeedback is helpful although the mechanism by which this works is still uncertain. Other patients are resistant to all conservative modes of therapy and require surgical intervention. Extensive clinical and physiological preoperative assessment of patients with slow colonic transit is essential before considering surgery, including an assessment of small bowel motility and identification of coexistent obstructed defecation. The psychological state of the patient should always be taken into account. When surgery is indicated, subtotal colectomy and ileorectal anastomosis is the operation of choice. Segmental colonic resection has been reported in a few patients, but methods of identifying the affected segment need to be developed further. Less invasive and reversible surgical options include laparoscopic ileostomy, antegrade colonic enema and sacral nerve stimulation.
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Affiliation(s)
- Shing Wai Wong
- Department of Surgery, Prince of Wales Hospital, Sydney, NSW, Australia
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17
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Abstract
Patients with intractable chronic constipation should be evaluated with physiologic tests after structural disorders and extracolonic causes have been excluded. Conservative treatment options should be tried excessively. If surgery is indicated subtotal colectomy with IRA is the treatment method of choice. However, segmental resection may be a good option for isolated megasigmoid, sigmoidocele or recurrent sigmoid volvulus. In general patients with GID should not be offered any surgical options because of their anticipated poor results. Moreover, patients with psychiatric disorders should be actively discouraged from resection as they tend to have poorer prognosis. Patients must be counseled that preoperative pain and/or bloating will likely persist even if surgery normalizes bowel frequency. Patients with associated problems may be better served by having a stoma without resection as both a therapeutic maneuver and a diagnostic trial. Colectomy is no option to treat pain and/or abdominal bloating.
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Affiliation(s)
- Johann Pfeifer
- Department of General Surgery, Medical University of Graz, Austria
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18
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Zmora O, Colquhoun P, Katz J, Efron J, Weiss EG, Nogueras JJ, Vernava AM, Wexner SD. Small bowel transit does not correlate with outcome of surgery in patients with colonic inertia. Surg Innov 2006; 12:215-8. [PMID: 16224641 DOI: 10.1177/155335060501200305] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Colonic inertia is a motility disorder that may involve dysfunction of the entire intestinal tract. The aim of this study was to assess whether small bowel transit time is associated with the outcome of total abdominal colectomy in patients with colonic inertia. A retrospective review of the medical records of patients who underwent total abdominal colectomy for colonic inertia was performed to identify those individuals who had a preoperative small bowel transit study. The outcome of surgery was correlated with the results of the small bowel transit study. Fifty-two female patients underwent total abdominal colectomy for colonic inertia between 1988 and 2000, of whom 17 (33%) had a preoperative small bowel transit study. The small bowel transit time was normal in 11 patients (65%), and the time was abnormally prolonged in 6 (35%). At a mean follow-up of 37 months, there was no significant difference in the outcome of surgery between the two groups. A good result was achieved in 36% of the normal small bowel transit time group compared with 33% in the abnormal group; the result was fair in 63% and 33%, and poor in 0% and 33%, respectively (P=NS). The small bowel transit study does not reliably predict the outcome of total abdominal colectomy in patients with colonic inertia.
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Affiliation(s)
- Oded Zmora
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL 33331, USA
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19
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Gladman MA, Scott SM, Lunniss PJ, Williams NS. Systematic review of surgical options for idiopathic megarectum and megacolon. Ann Surg 2005; 241:562-74. [PMID: 15798457 PMCID: PMC1357059 DOI: 10.1097/01.sla.0000157140.69695.d3] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE A subgroup of patients with intractable constipation has persistent dilatation of the bowel, which in the absence of an organic cause is termed idiopathic megabowel (IMB). The aim of this systematic review was to evaluate the published outcome data of surgical procedures for IMB in adults. METHODS Electronic searches of the MEDLINE (PubMed) database, Cochrane Library, EMBase, and Science Citation Index were performed. Only peer-reviewed articles of surgery for IMB published in the English language were evaluated. Studies of all surgical procedures were included, providing they were performed on 3 or more patients, and overall success rates were documented. Studies were critically appraised in terms of design and methodology, inclusion criteria, success, mortality and morbidity rates, and functional outcomes. RESULTS A total of 27 suitable studies were identified, all evidence was low quality obtained from case series, and there were no comparative studies. The studies involved small numbers of patients (median 12, range 3-50), without long-term follow-up (median 3 years, range 0.5-7). Inclusion of subjects, methods of data acquisition, and reporting of outcomes were extremely variable. Subtotal colectomy was successful in 71.1% (0%-100%) but was associated with significant morbidity related to bowel obstruction (14.5%, range 0%-29%). Segmental resection was successful in 48.4% (12.5%-100%), and recurrent symptoms were common (23.8%). Rectal procedures achieved a successful outcome in 71% to 87% of patients. Proctectomy, the Duhamel, and pull-through procedures were associated with significant mortality (3%-25%) and morbidity (6%-29%). Vertical reduction rectoplasty (VRR) offered promising short-term success (83%). Pelvic-floor procedures were associated with poor outcomes. A stoma provided a safe alternative but was only effective in 65% of cases. CONCLUSIONS Outcome data of surgery for IMB must be interpreted with extreme caution due to limitations of included studies. Recommendations based on firm evidence cannot be given, although colectomy appears to be the optimum procedure in patients with a nondilated rectum, restorative proctocolectomy the most suitable in those with dilatation of the colon and rectum, and VRR in those patients with dilatation confined to the rectum. Appropriately designed studies are required to make valid comparisons of the different procedures available.
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Affiliation(s)
- Marc A Gladman
- Centre for Academic Surgery (Gastrointestinal Physiology Unit), Barts, London, UK
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20
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Gladman MA, Williams NS, Scott SM, Ogunbiyi OA, Lunniss PJ. Medium-term results of vertical reduction rectoplasty and sigmoid colectomy for idiopathic megarectum. Br J Surg 2005; 92:624-30. [PMID: 15810056 DOI: 10.1002/bjs.4918] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Abstract
Background
Vertical reduction rectoplasty (VRR) was devised specifically to address the physiological abnormalities present in the rectum of patients with idiopathic megarectum (IMR). This study evaluated the medium-term clinical and physiological results of VRR.
Methods
VRR and sigmoid colectomy was performed in ten patients with IMR and constipation (six women). Patients were evaluated before and a median of 60 (range 28–74) months after surgery by assessment of symptoms using scoring systems and anorectal physiological measurements. Independent, detailed postoperative evaluation of rectal diameter, compliance, and sensory and evacuatory function was performed.
Results
There were no deaths or late complications. Symptoms recurred necessitating permanent ileostomy formation in two patients. Median (range) constipation scores improved from 22 (18–27) before to 10 (0–24) after surgery (P = 0·016). Median (range) bowel frequency increased from 1·5 (0·2–7) to 7 (0·5–21) per week (P = 0·016). Rectal diameter, compliance and sensory function were normal in seven of eight patients after surgery. Evacuatory function and colonic transit were each normalized in two of eight patients after VRR.
Conclusion
VRR corrected rectal diameter, compliance and sensory function in most patients, and clinical benefit was sustained in the medium term. The procedure was associated with a low morbidity, and no mortality and should be considered in the surgical management of IMR.
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Affiliation(s)
- M A Gladman
- Centre for Academic Surgery (Gastrointestinal Physiology Unit), St Bartholomew's and The Royal London Hospital, Queen Mary's School of Medicine and Dentistry, Whitechapel, London, UK
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21
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Lundin E, Karlbom U, Westlin JE, Kairemo K, Jung B, Husin S, Påhlman L, Graf W. Scintigraphic assessment of slow transit constipation with special reference to right- or left-sided colonic delay. Colorectal Dis 2004; 6:499-505. [PMID: 15521943 DOI: 10.1111/j.1463-1318.2004.00694.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Subtotal colectomy and ileorectal anastomosis for slow transit constipation has several side-effects. The motor abnormality in some patients may be segmental which could motivate a limited resection of the colon. Therefore a diagnostic tool to identify a segmental colonic motor dysfunction is needed. The aim of this study was to evaluate a scintigraphic method to assess colonic transit with special reference to right- or left-sided delay. METHODS Twenty-three constipated patients (19 women, mean age 50 years) with slow colonic transit on radio-opaque marker studies and 13 healthy individuals (11 women, mean age 46 years) were studied. All subjects were examined with oral (111)Indium-DTPA scintigraphy. The scintigraphic results for patients and controls were presented as geometric centre of radioactivity and percent activity over time in the right, the left and the recto-sigmoid colon. The inter-observer variation in the interpretation of the scans was also evaluated. RESULTS There was no difference in transit time between the groups of patients and controls in the right colon whereas the patients had a significant delay in the left colon (P < 0.05). Two patients had a marked delay in the right colon followed by relatively rapid transit in the left colon. The inter-observer correlation was good comparing the right, the left and the recto-sigmoid colon (r = 0.58-0.98, P < 0.01-0.001). CONCLUSION The results indicate that colonic scintigraphy with oral (111)Indium-DTPA may help to select patients for a left or, in a few cases, a right hemicolectomy for slow transit constipation.
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Affiliation(s)
- E Lundin
- Department of Nuclear Medicine, University Hospital, SE-751 85 Uppsala, Sweden.
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22
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El-Tawil AM. Reasons for creation of permanent ileostomy for the management of idiopathic chronic constipation. J Gastroenterol Hepatol 2004; 19:844-6. [PMID: 15242484 DOI: 10.1111/j.1440-1746.2003.03309.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
The aim of the present study was to examine the reasons for initiation of end ileostomy for management of intractable constipation over the last 35 years. A total of 62 patients with intractable constipation, on whom an end ileostomy was created during the period from 1966 to 2001, were recorded. The incidence of initiating a terminal ileostomy as a further surgical intervention to the total number of managed patients in examined studies varied from 2 to 25%. Preoperative unevaluated anal and rectal abnormalities formed the highest proportion compared with other reasons (65%, 40/62). A better understanding of the functional colonic and anorectal abnormalities may facilitate changes in surgical therapy.
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Affiliation(s)
- A M El-Tawil
- Department of Gastroenterology, City Hospital, Dudley Road, Birmingham B18 7QH, UK.
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23
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Lundin E, Karlbom U, Påhlman L, Graf W. Outcome of segmental colonic resection for slow-transit constipation. Br J Surg 2002; 89:1270-4. [PMID: 12296895 DOI: 10.1046/j.1365-2168.2002.02213.x] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The standard surgical treatment for slow-transit constipation (STC) is subtotal colectomy and ileorectal anastomosis. A segmental resection may serve the same purpose, but with a reduced risk of side-effects such as diarrhoea or incontinence. The aim of this study was to evaluate the functional results following segmental resection in a consecutive series of patients with STC. METHODS Selection criteria included prolonged segmental transit on oral 111In-labelled diethylene triamine penta-acetic acid scintigraphic transit study, and disabling symptoms resistant to medical therapy and treatment of outlet obstruction. Twenty-eight patients (26 women, median age 52 years) were treated with segmental resection and followed prospectively with a validated questionnaire. RESULTS After a median of 50 (range 16-78) months, 23 patients were pleased with the outcome. The median (range) stool frequency increased from 1 (0-7) to 7 (0-63) per week (P < 0.001). The number of patients passing hard stools and straining excessively decreased (P = 0.016 and P = 0.041, respectively). The median incontinence score was unchanged. Rectal sensory thresholds were higher in patients in whom the treatment failed (P < 0.001). CONCLUSION With a symptomatic relief comparable to that after ileorectal anastomosis and less severe side-effects, segmental colectomy may be a better alternative for selected patients with STC. Thorough preoperative evaluation is important and impaired rectal sensation may predict a poor outcome.
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Affiliation(s)
- E Lundin
- Department of Surgery, University Hospital, S-751 85 Uppsala, Sweden.
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Verne GN, Hocking MP, Davis RH, Howard RJ, Sabetai MM, Mathias JR, Schuffler MD, Sninsky CA. Long-term response to subtotal colectomy in colonic inertia. J Gastrointest Surg 2002; 6:738-44. [PMID: 12399064 DOI: 10.1016/s1091-255x(02)00022-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The purpose of this study was to determine the long-term outcome of patients who had previously undergone subtotal colectomy for severe idiopathic constipation at the University of Florida between 1983 and 1987. In addition, we aimed to determine whether preoperative motility abnormalities of the upper gastrointestinal tract are more common among those patients who have significant postoperative complications after subtotal colectomy. We evaluated 13 patients who underwent subtotal colectomy for refractory constipation between 1983 and 1987 at the University of Florida. Preoperatively, all patients exhibited a pattern consistent with colonic inertia as demonstrated by means of radiopaque markers. Each patient was asked to quantitate the pain intensity and frequency of their bowel movements before and after surgery. In seven patients an ileosigmoid anastomosis was performed, whereas in six patients an ileorectal anastomosis was used. Abdominal pain decreased after subtotal colectomy. Patients with abnormal upper gastrointestinal motility preoperatively experienced greater postoperative pain than those with normal motility regardless of the type of anastomosis. In addition, the number of postoperative surgeries was similar in those patients with abnormal upper motility compared to those with normal motility. Overall, the total number of bowel movements per week increased from 0.5 +/- 0.03 preoperatively to 15 +/- 4.5 (P < 0.007) postoperatively. The results of our study suggest that patients with isolated colonic inertia have a better long-term outcome from subtotal colectomy than patients with additional upper gastrointestinal motility abnormalities associated with their colonic inertia.
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Affiliation(s)
- G Nicholas Verne
- Malcom Randall Veterans Affairs Medical Center, Gastroenterology Section, Department of Medicine, University of Florida, Gainesville, Florida 32608, USA.
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Aldulaymi BH, Rasmussen OØ, Christiansen J. Long-term results of subtotal colectomy for severe slow-transit constipation in patients with normal rectal function. Colorectal Dis 2001; 3:392-5. [PMID: 12790936 DOI: 10.1046/j.1463-1318.2001.00283.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE The outcome of subtotal colectomy for severe constipation may be difficult to predict. One factor, which probably is of major importance for the functional outcome, is rectal function. The aim of the study has been to evaluate long-term results after subtotal colectomy with ileo-rectal anastomosis in a group of patients with severe slow-transit constipation but without evidence of impaired rectal emptying. PATIENTS AND METHODS Of 273 patients with constipation referred for surgical evaluation 18 (7%) fulfilled our criteria for subtotal colectomy. Slow-transit was confirmed by radio-opaque marker studies and normal rectal function by emptying of viscous fluid and normal emptying at defecography. RESULTS At follow up between 3 and 9 years 15 patients had a bowel frequency between 2 and 6 daily. One patient, who had an ileostomy because of anastomotic leak, had not wanted bowel continuity restored. One patient with opiate abuse became less constipated with 2-3 bowel movements a week. One patient was still constipated one year after the operation and subsequently had an ileal pouch-anal anastomosis. This patient who had normal rectal emptying had a very high volume tolerability with a maximum tolerable volume of 700 ml. In 4 of 7 patients abdominal pain persisted after the operation, and 3 developed diarrhoea, which required daily intake of loperamide. CONCLUSION Subtotal colectomy for severe slow-transit constipation is justified provided anorectal function is normal. In spite of normal rectal emptying very high rectal volume tolerability may be an indicator of functional megarectum and impaired rectal emptying postoperatively.
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Affiliation(s)
- B H Aldulaymi
- Department of Surgery, D Herlev Hospital, University of Copenhagen
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27
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Sarli L, Costi R, Sarli D, Roncoroni L. Pilot study of subtotal colectomy with antiperistaltic cecoproctostomy for the treatment of chronic slow-transit constipation. Dis Colon Rectum 2001; 44:1514-20. [PMID: 11598483 DOI: 10.1007/bf02234608] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Functional results of total colectomy with ileorectal anastomosis for the treatment of chronic constipation caused by colonic inertia are often considered unsatisfactory because of the frequency of postoperative diarrhea and the high rate of postoperative small-bowel obstruction. Patients affected by severe colonic inertia underwent a subtotal colectomy with a novel antiperistaltic cecorectal anastomosis. The aim of the study was to assess the functional results after preservation of the cecorectal junction. METHODS Eight females affected by isolated colonic inertia and two females with both paradoxical puborectalis contraction and colonic inertia, of a median age of 40 years, underwent subtotal colectomy with antiperistaltic cecorectal anastomosis. Before antiperistaltic cecorectal anastomosis all ten patients were laxative-dependant, with a mean bowel frequency of ten days; eight of them (80 percent) had distention, seven (70 percent) bloating, and three (30 percent) abdominal pain. RESULTS There was no mortality or major postoperative morbidity. One month after antiperistaltic cecorectal anastomosis, bowel frequency was a mean of 2.2 (range, 1-4) per day, with a semiliquid stool consistency. After one year, bowel frequency was a mean of 1.3 (range, 0.5-3) per day, with a solid stool consistency; the same results were recorded at last follow-up. Although no patients used antidiarrheal medicine, laxatives continued to be used by both patients with paradoxical puborectalis contraction. All ten (100 percent) of the patients reported a good or improved quality of life. CONCLUSION This preliminary experience seems to show that antiperistaltic cecorectal anastomosis is safe and effective for patients with colonic inertia. It results in prompt and prolonged relief from constipation for patients with isolated colonic inertia.
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Affiliation(s)
- L Sarli
- Institute of General Surgery, University of Parma, School of Medicine, Parma, Italy
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Nylund G, Oresland T, Fasth S, Nordgren S. Long-term outcome after colectomy in severe idiopathic constipation. Colorectal Dis 2001; 3:253-8. [PMID: 12790968 DOI: 10.1046/j.1463-1318.2001.00249.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The specific aim of the investigation was to assess the long-term results of subtotal colectomy with ileorectal anastomosis in patients with severe idiopathic constipation. PATIENTS AND METHODS 40 patients with severe idiopathic constipation were operated on between 1981 and 1993. Patients were accepted for a colectomy and an ileo-rectal anatomosis after a thorough gastro-intestinal investigation. Pre-operative bowel frequency was less than 2 movements per week, and slow transit was documented. Postoperative complications occurred in eight patients. Early re-operation was performed in 2 patients for small bowel obstruction. RESULTS Mean follow-up was 11 (range 5-16) years. The defaecation frequency at follow-up was 3.0 +/- 1.9 per day. Twenty-nine patients stated that they were satisfied and 11 were dissatisfied with the procedure. The outcome did not correlate with observed signs of outlet obstruction, blunted rectal sensation or presence of a psychiatric diagnosis. At 5-16 years after the procedure 33 patients still retain the ileo-rectal anastomosis. Seven patients have had further procedures: Five patients have an ileo-anal pouch, one has a continent ileostomy and one has a conventional ileostomy. Small bowel obstruction was encountered in 17 patients, in 10 of these surgical treatment was necessary. CONCLUSION It is concluded that colectomy and ileorectal anastomosis for the treatment of severe idiopathic constipation causes an increase in the number of bowel motions, but is deemed successful only by 3 out of 4 patients. Secondary morbidity is considerable.
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Affiliation(s)
- G Nylund
- Colorectal Unit, Sahlgrenska Universitetssjukhuset, University of Göteborg, S-416 85 Göteborg, Sweden
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Mollen RM, Kuijpers HC, Claassen AT. Colectomy for slow-transit constipation: preoperative functional evaluation is important but not a guarantee for a successful outcome. Dis Colon Rectum 2001; 44:577-80. [PMID: 11330586 DOI: 10.1007/bf02234332] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE This study was designed to assess the results of preoperative functional evaluation of patients with severe slow-transit constipation in relation to functional outcome. METHODS Four hundred thirty-nine patients with chronic intractable constipation were evaluated by marker studies. Twenty-one patients underwent colectomy and ileorectal anastomosis for slow-transit constipation. Mean colorectal transit time was 156 hours (normal, <45 hours). Small-bowel transit time was normal in ten patients and delayed in five patients. Six were nonresponders. Morbidity was 33 percent. Small-bowel obstruction occurred in six patients; relaparotomy was done in four patients. Follow-up varied from 14 to 153 (mean, 62) months. RESULTS After three months, defecation frequency was increased in all. Mean stool frequency improved from one bowel movement per 5.9 days to 2.8 times per day. Sixteen patients felt improved after surgery. Seventeen continued to experience abdominal pain, and 13 still used laxatives and enemas. Satisfaction rate was 76 percent (16 patients). After one year, defecation frequency was back at the preoperative level in five patients. An ileostomy was created in two more patients because of incontinence and persistent diarrhea. Eleven patients (52 percent) still felt improved. A relation between small-bowel function and functional results could not be demonstrated. CONCLUSIONS Preoperative evaluation is important but not a guarantee for, successful outcome. Colectomy remains an ultimate option for patients with disabling slow-transit constipation, but patients should be informed that, despite an increased defecation frequency, abdominal symptoms might persist. Any promiscuous use of colectomy to treat constipation should be discouraged.
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Affiliation(s)
- R M Mollen
- Department of Surgery, Gelderse Vallei Hospital, Bennekom, The Netherlands
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30
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Abstract
Fecal incontinence is a disabling and distressing condition. Many patients are reluctant to discuss the condition with a physician. A thorough history, good physical examination, and detailed anorectal physiologic investigations can help in the therapeutic decision-making algorithm. Patients with isolated anterior sphincter defects are candidates for overlapping repair. In the presence of unilateral or bilateral pudendal neuropathy, the patient should be counseled preoperatively regarding a [table: see text] lower anticipation of success. If the injury occurred shortly before the planned surgery and neuropathy is present, it may be prudent to wait because neuropathy sometimes can resolve within 6 to 24 months of the injury. Pudendal nerve study may help determine surgical timing. An anterior sphincter defect combined with a rectovaginal fistula can be approached by overlapping sphincter repair and a concomitant transanal advancement flap. Patients who had undergone multiple such procedures may benefit from concomitant fecal diversion at the time of repeat sphincter repair. Patients with global or multifocal sphincter injury may be candidates for a neosphincter procedure. The stimulated graciloplasty and artificial bowel sphincter are reasonable options. In the absence of the availability of these techniques or because of financial constraints, consideration could be given to bilateral gluteoplasty or unilateral or bilateral nonstimulated graciloplasty. The postanal repair still serves a role in patients with isolated decreased resting pressures with or without neuropathy or external sphincter injury with minimal degrees of incontinence. Biofeedback and the Procon device may play a role in these patients. Lastly, fecal diversion must be considered as a means of improving the quality of life because the patient can participate in the activities of daily living without the fear of fecal incontinence.
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Affiliation(s)
- N A Rotholtz
- Department of Colorectal Surgery, Cleveland Clinic Florida, Fort Lauderdale, Florida, USA
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31
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Pikarsky AJ, Singh JJ, Weiss EG, Nogueras JJ, Wexner SD. Long-term follow-up of patients undergoing colectomy for colonic inertia. Dis Colon Rectum 2001; 44:179-83. [PMID: 11227933 DOI: 10.1007/bf02234290] [Citation(s) in RCA: 92] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE Total abdominal colectomy with ileorectal anastomosis has been the procedure of choice for patients with the established diagnosis of colonic inertia. Previous studies with a limited follow-up of only one to two years have shown acceptable results and a high rate of patient satisfaction. The aim of this study was to evaluate the long-term results of total abdominal colectomy in these patients in terms of complications, bowel function, and overall patient satisfaction. METHODS Access to the colorectal registry at the Cleveland Clinic Florida identified all patients who underwent total abdominal colectomy for colonic inertia between 1988 and 1993, with a minimum of five-year follow-up. Telephone interviews were designed to assess bowel function, concomitant use of any antidiarrheal medications, postoperative complications, persistence or development of preoperative symptoms such as pain or bloating, and overall satisfaction. Patients were asked to rate their outcome as excellent, good, fair, or poor. RESULTS Fifty patients underwent total abdominal colectomy for the diagnosis of colonic inertia. Three patients died of unrelated causes and 30 (60 percent) were available for follow-up. The mean follow-up was 106 months, ranging from 61 to 122 months. All 30 patients reported the outcome of surgery as "excellent." The average frequency of spontaneous bowel movements was 2.5 (range, 1-6) per day. During the period of follow-up, six patients (20 percent) required admission for small-bowel obstruction, three of whom (10 percent) required laparotomy. Four patients complained of mild pelvic pain, only one of whom had the onset of pelvic pain postoperatively that persisted until the time of interview. In the other three patients the pain was present preoperatively but had decreased in intensity since the operation. Two patients (6 percent) still required assistance with bowel movements, one by laxatives and the other by enemas. Only two patients (6 percent) needed antidiarrheal medications to reduce bowel frequency. CONCLUSION This long-term follow-up revealed a high degree of patient satisfaction and very good bowel habits, with an acceptable long-term rate of bowel obstruction. Based on these results, total abdominal colectomy can be recommended to patients with well-established colonic inertia with expectations of sustained benefit up to ten years after surgery.
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Affiliation(s)
- A J Pikarsky
- Department of Colorectal Surgery, Cleveland Clinic Florida, Fort Lauderdale 33309, USA
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32
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Nam YS, Pikarsky AJ, Wexner SD, Singh JJ, Weiss EG, Nogueras JJ, Choi JS, Hwang YH. Reproducibility of colonic transit study in patients with chronic constipation. Dis Colon Rectum 2001; 44:86-92. [PMID: 11805568 DOI: 10.1007/bf02234827] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Major therapeutic decisions are rendered based on a single colonic transit study. Therefore, the aim of this study was to assess the reproducibility of colonic transit time in patients with chronic constipation. MATERIALS AND METHODS Fifty-one patients with chronic idiopathic constipation were randomly selected to undergo two separate colonic transit tests. All clinical conditions, methodology, and patients' instructions were identical on both occasions. The gamma rate (linear correlation analysis) was undertaken between the first and second colonic transit times. Groups were divided according to the diagnoses of colonic inertia (slow-transit constipation), paradoxical puborectalis contraction, and chronic idiopathic constipation (normal-transit constipation). RESULTS In 35 of 51 patients (69 percent), the results were identical between the two studies; however, in 16 patients (31 percent), the results were disparate (gamma correlation coefficient = 0.53; P < 0.01). The specific correlation coefficients for patients with colonic inertia, paradoxical puborectalis contraction, and chronic idiopathic constipation were 0.12, 0.21, and 0.60 (P < 0.01), respectively. Moreover, the success rate of colectomy for colonic inertia was significantly higher in patients who underwent a repeat transit study confirming inertia than in patients who underwent colectomy based on a single study. CONCLUSIONS Overall, colonic transit time is reproducible in patients with chronic constipation. The correlation coefficient is best for patients with idiopathic constipation and worst for patients with colonic inertia. This new finding suggests that suboptimal surgical outcome may be attributable to inaccurate diagnosis. Because of this poor correlation coefficient, in patients with colonic inertia, consideration should be given to repeating the colonic transit study before colectomy to help secure the diagnosis and improve outcome.
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Affiliation(s)
- Y S Nam
- Department of Colorectal Surgery, Cleveland Clinic Florida, Fort Lauderdale, Florida 33309-1743, USA
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33
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Knowles CH, Martin JE. Slow transit constipation: a model of human gut dysmotility. Review of possible aetiologies. Neurogastroenterol Motil 2000; 12:181-96. [PMID: 10877606 DOI: 10.1046/j.1365-2982.2000.00198.x] [Citation(s) in RCA: 91] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Slow transit constipation is a severe condition of gut dysmotility that predominantly affects young women and may result in surgical intervention. Current medical treatments for STC are often ineffective, and the outcome of surgery is unpredictable. STC was first described almost a century ago. Since this time, progress in improving therapy for this condition has been complicated by a lack of understanding of the aetiology, and great variation in the methods and criteria used for the study of patients with this debilitating disorder. It is difficult to find unequivocal data, and harder still to give a definitive picture of the cause or causes of STC. Here we consider the evidence for various aetiologies of STC, in the light of the physiological and pathological findings.
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Affiliation(s)
- C H Knowles
- Academic Department of Surgery, Royal London School of Medicine & Dentistry, Whitechapel, London, UK
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34
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Abstract
OBJECTIVE To review the outcome data for colectomy performed for patients with slow transit constipation (STC). BACKGROUND The outcome of surgical intervention in patients with STC is unpredictable. This may be a consequence of the lack of effectiveness of such interventions or may reflect heterogeneity within this group of patients. METHODS The authors reviewed the data of all series in the English language that document the outcome of colectomy in > or = 10 patients in the treatment of STC. RESULTS Thirty-two series fulfilled the entry criteria. There was widespread variability in patient satisfaction rates after colectomy (39% to 100%), reflecting large differences in the incidence of postoperative complications and in long-term functional results. Outcome was dependent on several clinical and pathophysiologic findings and on the type of study, the population studied, and the surgical procedure used. CONCLUSIONS It may be possible to predict outcome on the basis of preoperative clinical and pathophysiologic findings. This review suggests a rationale for the selection of patients for colectomy.
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Affiliation(s)
- C H Knowles
- Academic Department of Surgery, St Bartholomew's and the Royal London School of Medicine & Dentistry, Whitechapel, London, United Kingdom
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35
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Affiliation(s)
- Keighley
- University Department of Surgery, Queen Elizabeth Hospital, Birmingham, UK
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36
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Bernini A, Madoff RD, Lowry AC, Spencer MP, Gemlo BT, Jensen LL, Wong WD. Should patients with combined colonic inertia and nonrelaxing pelvic floor undergo subtotal colectomy? Dis Colon Rectum 1998; 41:1363-6. [PMID: 9823800 DOI: 10.1007/bf02237050] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Treatment of severe constipation caused by combined colonic inertia and nonrelaxing pelvic floor is controversial. This study is designed to evaluate the outcome of preoperative biofeedback and subtotal colectomy for patients with combined colonic inertia and nonrelaxing pelvic floor. METHODS One hundred six patients who underwent subtotal colectomy for intractable constipation from 1982 through 1995 answered a detailed questionnaire regarding postoperative bowel function, symptoms of abdominal pain and bloating, and degree of satisfaction after the operation. Sixteen of these patients had a combination of colonic inertia and nonrelaxing pelvic floor diagnosed by transit marker study, electromyography, and defecography. These patients completed preoperative biofeedback training. RESULTS Electromyographic relaxation of pelvic floor musculature was demonstrated after the biofeedback treatment in all patients, but symptoms of difficult evacuation persisted. Postoperatively, seven patients (43 percent) had complete resolution of symptoms of constipation or difficult evacuation. Six patients still complained of incomplete evacuation that was severe in two and unresponsive to postoperative biofeedback. Three patients (18 percent) complained of diarrhea (>5 bowel movements per day) and incontinence of liquid stools (at least one episode a week). Nine patients (56 percent) were satisfied despite persistent symptoms. CONCLUSIONS Subtotal colectomy can improve some symptoms in patients with slow transit constipation and nonrelaxing pelvic floor. However, incomplete evacuation persists in a significant number of patients and almost one-half of patients are dissatisfied with their surgery.
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Affiliation(s)
- A Bernini
- Division of Colon and Rectal Surgery, University of Minnesota Medical School, Minneapolis, USA
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37
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The role of internal sphincterotomy in patients with outlet obstruction due to anal stenosis. COLOPROCTOLOGY 1998. [DOI: 10.1007/bf03043706] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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38
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Abstract
BACKGROUND Developments in anorectal physiologic testing have facilitated better understanding of the process of defecation and factors that might cause chronic constipation. AIM Patients with severe idiopathic chronic constipation were evaluated using colonic transit and pelvic floor function in an attempt to identify those patients suitable for aggressive surgical intervention. MATERIALS AND RESULTS Among 1,009 patients studied using either a marker or scintigraphic transit technique and tests of pelvic floor function, 52 with slow-transit constipation (STC) were identified and underwent abdominal colectomy and ileorectostomy (IRA). Twenty-two patients had pelvic floor dysfunction and STC; these patients underwent initial pelvic floor retraining followed by IRA. A total of 249 patients had pelvic floor dysfunction without evidence of slow-transit and were offered pelvic floor retraining alone. The remaining 597 patients had no quantifiable abnormality of colon or pelvic floor dysfunction; these patients had normal transit constipation/irritable bowel syndrome and were treated medically. There were, thus, 74 patients operated on, 68 women, with a mean age of 53 years and a mean follow-up of 56 months. There was no operative mortality, seven patients (9 percent) had small-bowel obstruction, and nine patients (12 percent) had prolonged ileus. All patients were able to pass a stool spontaneously, 97 percent of patients were satisfied with the results of surgery, and 90 percent have a good or improved quality of life. There was no difference in the outcome of surgery in patients with STC alone compared with STC and pelvic floor dysfunction. CONCLUSION Physiologic evaluation reliably identified patients with severe chronic constipation who might benefit from surgery. IRA is safe and effective, resulting in prompt and prolonged relief of constipation.
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Affiliation(s)
- D C Nyam
- Department of Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA
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39
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Christiansen J, Rasmussen OO. Colectomy for severe slow-transit constipation in strictly selected patients. Scand J Gastroenterol 1996; 31:770-3. [PMID: 8858745 DOI: 10.3109/00365529609010350] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Colectomy for severe constipation has in up to 25% of patients given unsatisfactory results. Failure to cure constipation is in most patients due to rectal dysfunction. The aim of the present study was to evaluate the effect of colectomy in a group of patients who fulfil all the criteria which, with our present knowledge, should predict a favourable result. METHODS Twelve patients with long-standing severe constipation incurable by dietary regulation and medical treatment with demonstrable slow-transit constipation and normal rectal function entered the study. RESULTS Ten patients were relieved of their constipation. Two patients continued to be constipated after subtotal colectomy. One had a very highly compliant rectum (preoperatively) with a maximal tolerable volume of 700 ml but normal emptying at defecography and normal emptying of viscous fluid. The patient was subsequently treated with proctectomy and ileo-pouch-anal anastomosis with satisfactory result. One patient with opioid abuse due to abdominal pain was improved by the operation but was still constipated. The opioid abuse continued, however, after the operation owing to continuing abdominal pain. A further three patients complained of abdominal pain, and two developed diarrhoea, one of whom became incontinent. CONCLUSION Subtotal or segmental colectomy should be considered in a small number of patients with severe constipation provided strict criteria are fulfilled. Excessively high rectal volume tolerability may in spite of normal emptying capacity indicate the risk of development of rectal inertia postoperatively and may be a contraindication for surgery.
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Affiliation(s)
- J Christiansen
- Dept. of Surgery D, Herlev Hospital, University of of Copenhagen, Denmark
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40
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Platell C, Scache D, Mumme G, Stitz R. A long-term follow-up of patients undergoing colectomy for chronic idiopathic constipation. THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF SURGERY 1996; 66:525-9. [PMID: 8712985 DOI: 10.1111/j.1445-2197.1996.tb00802.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Chronic idiopathic constipation is a condition that mainly affects young women and is commonly associated with symptoms of abdominal pain and bloating. It has been proposed that patients with severe symptoms who are unresponsive to conservative measures can be managed by colonic resection. The aim of the present study was to assess the long-term outcome of such surgery on patients with a diagnosis of chronic idiopathic constipation. METHODS Ninety-six patients (92 females, 4 males) underwent either a total colectomy and ileorectal anastomosis (n = 86) or subtotal colectomy and caecorectal anastomosis (n = 10) between 1986 and 1994. RESULTS Postoperative mortality was 2.1%, 3.1% suffered from an anastomotic leak and 11.5% developed a pelvic abscess. Follow up was completed in 92.7% of patients at a mean of 5.0 +/- 2.3 years. Following surgery, symptomatic improvement was reported by 81.6% of patients. However, 51.2% still experienced difficulty with straining, 50.6% had some degree of anal incontinence, 55.2% continued to experience abdominal pains and 75.9% continued to be troubled by abdominal bloating. Reoperation was performed on 35.6% of patients (mainly for division of adhesions), and 9.2% of patients required an ileostomy. CONCLUSIONS Colectomy is associated with relief of constipation in a majority of patients with chronic idiopathic constipation. However, it is associated with a considerable morbidity and is less effective in resolving symptoms of abdominal pain and bloating.
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Affiliation(s)
- C Platell
- Department of Surgery, Royal Brisbane Hospital, Queensland, Australia
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41
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de Graaf EJ, Gilberts EC, Schouten WR. Role of segmental colonic transit time studies to select patients with slow transit constipation for partial left-sided or subtotal colectomy. Br J Surg 1996; 83:648-51. [PMID: 8689210 DOI: 10.1002/bjs.1800830520] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
This prospective study investigated the value of segmental colonic transit time studies in the surgical treatment of slow transit constipation. Overall, 346 patients with chronic constipation were analysed; slow transit constipation was diagnosed in 86 (25 per cent). Based on the results of segmental colonic transit time studies, 18 patients underwent partial left-sided colectomy and 24 subtotal colectomy. Recurrent constipation was seen in three of 18 patients and seven of 24 respectively. Severe abdominal discomfort was noted in six of 18 and 15 of 24 respectively. Disabling diarrhoea and faecal incontinence developed in two of 14 and five of 20 patients with an anastomosis respectively. Although these results indicate that segmental colonic transit time studies are useful in selecting patients with slow transit constipation for partial left-sided or subtotal colectomy, both procedures should be performed with prudence.
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Affiliation(s)
- E J de Graaf
- Department of General Surgery, University Hospital Rotterdam, Netherlands
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42
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Abstract
PURPOSE Constipation is related to intestinal motility disorders (colonic inertia (CI)), pelvic floor disturbances (pelvic outlet obstruction), or a combination of both problems. This review summarizes the physiologic and pathophysiologic changes in patients with intractable constipation and gives an overview of surgical treatment options. RESULTS Although subtotal colectomy with ileorectal anastomosis is the best surgery for CI, there are still approximately 10 percent of patients who will complain of pain and constipation. A completion proctectomy and an ileoanal pouch procedure may be a viable option in a highly select group of patients. In patients with megabowel, reported results are mixed. Subtotal colectomy, partial colectomy for megacolon, and the Duhamel procedure for megarectum have all been reported with variable results. In patients with an isolated distended sigmoid colon, sigmoid colectomy has achieved good results. Anorectal myectomy has not been proven to be successful in the long term. However, in patients with adult short segment Hirschsprung's disease, myectomy can be successful. Patients with pelvic outlet obstruction can be successfully treated with biofeedback. In a small group of patients with a rectocele or a third degree sigmoidocele, surgical intervention yields a high success rate. Division or resection of the puborectalis muscle is not recommended. In patients with a mixed pattern of CI and pelvic outlet obstruction, surgical intervention alone is often not successful. These patients achieve better results by conservative treatment of pelvic outlet obstruction, followed by a colectomy. CONCLUSION Surgical intervention for patients with intractable constipation is rarely necessary. However, thorough preoperative physiologic testing is mandatory for a successful outcome.
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Affiliation(s)
- J Pfeifer
- Department of Colorectal Surgery, Cleveland Clinic Florida, Fort Lauderdale 33309, USA
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43
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Abstract
Chronic constipation is common in the general population, especially in women, in its idiopathic form. However, confusion still surrounds its definition, despite recent efforts to standardize it. Constipation can be divided in two large subgroups-normal transit and slow transit. The have different pathophysiological bases still not completely understood. Most patients respond to simple therapeutic measures aimed at correcting dietary fiber intake and lifestyle. Others, however, need more aggressive treatment, including laxatives, psychological therapy, and biofeedback. In a few patients with intractable constipation, surgery might be indicated to give relief.
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Affiliation(s)
- P Velio
- Cattedra di Gastroenterologia, Università degli Studi di Milano, IRCSS-Ospedale Maggiore di Milano, Italy
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44
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Pluta H, Bowes KL, Jewell LD. Long-term results of total abdominal colectomy for chronic idiopathic constipation. Value of preoperative assessment. Dis Colon Rectum 1996; 39:160-6. [PMID: 8620782 DOI: 10.1007/bf02068070] [Citation(s) in RCA: 50] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
PURPOSE A small proportion of patients with chronic idiopathic constipation are incapacitated by the problem. We have assessed 1) the efficacy of total abdominal colectomy, and 2) the predictive value of preoperative testing. METHODS Preoperative testing included complete history and physical examination, appropriate biochemical and hematologic assessment, psychiatric interview, colon transit studies using ingested radiopaque pellets, anorectal manometry, colonic intraluminal manometry, and measurement of colon diameters and length on barium enema examination. All patients were followed for 65 +/- 40 months. RESULTS Seventy-one percent had excellent or very good results. Twenty-one percent were satisfied, had improved the quality of their life, and felt the operation was worthwhile despite frequent residual or new symptoms. Two (8 percent) patients did not improve. Patients with a psychiatric history or physiologic evidence of an afferent nerve defect had poorer results (P < 0.05). CONCLUSIONS Total abdominal colectomy with ileorectal anastomosis is highly effective in alleviating symptoms in patients with chronic idiopathic constipation.
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Affiliation(s)
- H Pluta
- Department of Surgery, University of Alberta, Edmonton, Canada
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45
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Abstract
PURPOSE This study assesses the outcome of a standardized operation performed by two surgeons for severe idiopathic slow transit constipation that was resistant to laxative treatment. METHODS Fifty-nine consecutive patients, 4 men and 55 women, with a mean age of 42.3 years, underwent colectomy with ileorectal anastomosis. Slow colonic transit was demonstrated in each case. Fifty-two patients were available for follow-up, with median time to follow-up being 42 (range, 3-81) months. RESULTS Median bowel frequency was 4 per 24 hours. Sixty-nine percent had four or less bowel movements daily. Ten percent used antidiarrheal medication regularly. One patient had a stoma for recurrent severe constipation. Mean continence score was 1.8 (on a scale of 0-20); six patients were incontinent, and four of these six had normal preoperative anal manometry. Fourteen patients (27 percent) had difficulty with rectal evacuation. Preoperative defecating proctography was a poor predictor of postoperative evacuation difficulties. Twenty-seven patients (52 percent) had persisting abdominal pain, but there was a significant improvement in the degree of pain (P <0.00001). Forty-seven patients (90 percent) were satisfied with the outcome of the operation (and would elect to have it done again). Dissatisfied patients had recurrent constipation or diarrhea and incontinence. CONCLUSION Colectomy with ileorectal anastomosis produces a satisfactory functional outcome in the majority of patients undergoing surgery for severe constipation with proven slow colonic transit.
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Affiliation(s)
- D Z Lubowski
- Colo-Rectal Unit, St. George Hospital, Sydney, Australia
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46
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Mahendrarajah K, Van der Schaaf AA, Lovegrove FT, Mendelson R, Levitt MD. Surgery for severe constipation: the use of radioisotope transit scan and barium evacuation proctography in patient selection. THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF SURGERY 1994; 64:183-6. [PMID: 8117196 DOI: 10.1111/j.1445-2197.1994.tb02174.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Nineteen women aged 19-64 years (median 38) with intractable constipation were assessed by Indium-111 DTPA colonic transit scan and barium evacuation proctogram. Patients were classified as having an isolated (I) or predominant disorder of colonic transit (II), a mixed disorder of colonic transit and rectal evacuation (III), a predominant disorder of rectal evacuation (IV) or normal colorectal emptying (V). Twelve patients fell into categories I and II and were considered suitable for surgery. Three responded to further vigorous aperient therapy and nine (32-55 years, median 38) underwent subtotal colectomy with ileorectal anastomosis at the level of the sacral promontory. Two patients required re-operation for suspected anastomotic leak. One patient required readmission on two occasions for small bowel obstruction. Follow up has been 2-21 months (median 16). Eight of the nine patients no longer take oral aperients. Eight patients have a satisfactory stool frequency of 2-8 per 24 h; the other patient has an ileostomy and incapacitating postprandial abdominal pain. Abdominal pain is troublesome in two other patients. Two patients require antidiarrhoeal therapy but none experience faecal incontinence. In severely constipated patients with a proven disorder of colonic transit but normal or near normal rectal evacuation subtotal colectomy provides excellent symptomatic relief.
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Affiliation(s)
- K Mahendrarajah
- Department of General Surgery, Sir Charles Gairdner Hospital, Western Australia, Australia
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47
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Bassotti G, Chiarioni G, Imbimbo BP, Betti C, Bonfante F, Vantini I, Morelli A, Whitehead WE. Impaired colonic motor response to cholinergic stimulation in patients with severe chronic idiopathic (slow transit type) constipation. Dig Dis Sci 1993; 38:1040-5. [PMID: 8508698 DOI: 10.1007/bf01295719] [Citation(s) in RCA: 68] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Chronic idiopathic constipation, especially the slow transit type, is a troubling problem often afflicting young women. The pathophysiological basis for this entity is unknown, although a defective cholinergic innervation has been postulated. We tested the hypothesis that cholinergic colonic innervation is deranged in this condition by studying colonic motor activity after strong cholinergic stimulation with edrophonium chloride in 14 women complaining of slow transit constipation. Unlike healthy subjects, constipated patients showed minimal or no response to edrophonium injection. It is concluded that in slow transit constipation there is an important alteration of colonic cholinergic activity and that edrophonium chloride may represent a useful test drug for colonic pathophysiological investigations.
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Affiliation(s)
- G Bassotti
- Laboratorio di Motilità Intestinale, Università di Perugia, Italy
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48
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Pezim ME, Pemberton JH, Levin KE, Litchy WJ, Phillips SF. Parameters of anorectal and colonic motility in health and in severe constipation. Dis Colon Rectum 1993; 36:484-91. [PMID: 8482168 DOI: 10.1007/bf02050015] [Citation(s) in RCA: 52] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Anorectal function and colonic transit was assessed in 17 severely constipated patients and 15 age-matched controls. The constipated patients were divided into those who had "immobile perineum" (perineal descent < or = 1.0 cm during attempted defecation) and those who had a normal descent (> 1.0 cm) of the perineum. When constipation was accompanied by an immobile perineum, patients had impaired balloon expulsion, impaired and delayed artificial stool expulsion, decreased straightening of the anorectal angle, decreased descent of the pelvic floor with defecation, and prolonged rectosigmoid colon transit compared with the patients with constipation who had a mobile perineum and with normal controls. The mobile-perineum group differed from controls only in colon transit times, having prolonged total colon transit. Anal sphincter resting pressures, immediate artificial stool expulsion, resting anorectal angles, and electromyography of the external anal sphincter and puborectalis did not differentiate the constipated patients from the controls. We concluded that descent of the perineum of < 1 cm was associated with impaired expulsion, an adynamic anorectal angle, and slowed distal colon transit. This simple sign of pelvic floor function distinguished constipated patients with disordered expulsion from constipated patients with normal pelvic floor function. These patients may respond poorly to surgery and conventional management and would therefore be candidates instead for pelvic floor retraining. Accurate characterization and appreciation of pelvic floor dysfunction in patients with severe chronic constipation may improve the selection for and results of surgical and nonsurgical intervention.
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Affiliation(s)
- M E Pezim
- Gastroenterology Research Unit, Mayo Clinic, Rochester, Minnesota 55905
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Abstract
The motor function of the colon is probably the least understood of the various hollow viscera of the human body. This is partly because of the marked variability of colonic motor function and the short recording periods usually used, generally not exceeding three hours. Most of the data available on human colonic motility originate from investigations conducted in the most distal portions of the viscus, because of technical difficulties in reaching its proximal portions. Although attempts have been made to solve these problems through the ingestion of radiotelemetric pressure sensors, these efforts have been hampered by intermittent signal loss and the inability to control the location of the capsule within the gastrointestinal tract. To overcome these problems, techniques have recently been developed that permit prolonged recordings (24 hours or more) of myoelectrical and contractile activity of the human colon, with both perfused and solid-state manometric systems. The present paper reviews the current experience in 24 hour recording from the human colon, with a primary emphasis on the more forceful propulsive contractile activity associated with the so called mass movements.
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Affiliation(s)
- G Bassotti
- Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, Md
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50
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Turnbull GK, Ritvo PG. Anal sphincter biofeedback relaxation treatment for women with intractable constipation symptoms. Dis Colon Rectum 1992; 35:530-6. [PMID: 1587169 DOI: 10.1007/bf02050531] [Citation(s) in RCA: 57] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Some constipated women have difficulty relaxing the striated muscles of the anal sphincters, sometimes called anismus. This study was developed to provide a biofeedback-based relaxation treatment to teach these patients to relax the "voluntary" anal sphincter muscle in order to assess whether this treatment would be effective in reducing symptomatology. Seven constipated patients who were unresponsive to a high-fiber diet and required persistent laxative dosing to achieve regular bowel frequency were studied. A dual-therapy approach, in which patients were taught to relax the anal sphincter muscles via biofeedback from a manometric anal sphincter probe, was used. Concurrently, patients were instructed in general biofeedback-relaxation techniques. All were treated as outpatients. Complete data were collected on five patients, one patient discontinued therapy, and one patient moved after treatment was completed. Stool frequency improved from a mean of 1.9 per week to a mean of 4.9 per week in six patients (P less than 0.05). In the five patients who completed the entire protocol, pain and bloating symptom levels were compared before and after treatment. Abdominal pain grade was reduced from 12.8 per week to a mean of 4.4 per week (P less than 0.05), and bloating was reduced from a mean of 14.3 per week to a mean of 6.0 per week (P less than 0.06). Follow-up of 2 to 4.5 years posttherapy showed continued improvement in bowel function and abdominal symptomatology. This treatment appears to be effective in improving stool frequency and in reducing the associated abdominal pain and bloating symptoms in constipated women with anismus.
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Affiliation(s)
- G K Turnbull
- Department of Medicine, Camp Hill Medical Centre, Dalhousie University, Halifax, Nova Scotia, Canada
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