Outcome of segmental colonic resection for slow-transit constipation

Surgery for chronic idiopathic constipation: pediatric and adult patients - a systematic review

BACKGROUND

Chronic idiopathic constipation (CIC) is a substantial problem in pediatric and adult patients with similar symptoms and workup; however, surgical management of these populations differs. We systematically reviewed the trends and outcomes in the surgical management of CIC in pediatric and adult populations.

METHODS

A literature search was performed using Ovid MEDLINE, Embase, Scopus, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov between January 1, 1995 and June 26, 2020. Clinical trials and retrospective and prospective studies of patients of any age with a diagnosis of CIC with data of at least 1 outcome of interest were selected. The interventions included surgical resection for constipation or antegrade continence enema (ACE) procedures. The outcome measures included bowel movement frequency, abdominal pain, laxative use, satisfaction, complications, and reinterventions.

RESULTS

Adult patients were most likely to undergo resection (94%), whereas pediatric patients were more likely to undergo ACE procedures (96%) as their primary surgery. Both ACE procedures and resections were noted to improve symptoms of CIC; however, ACE procedures were associated with higher complication and reintervention rates.

CONCLUSION

Surgical management of CIC in pediatric and adult patients differs with pediatric patients receiving ACE procedures and adults undergoing resections. The evaluation of resections and long-term ACE data in pediatric patients should be performed to inform patients and physicians whether an ACE is an appropriate procedure despite high complication and reintervention rates or whether resections should be considered as an initial approach for CIC.

Diverting Loop Ileostomy in the Management of Medically Refractory Constipation Cases Not Falling Into Classical Categories

BACKGROUND

The approach to constipation refractory to medical management does not necessarily follow classical teaching and is challenging. Although the role of surgery is unclear, diverting loop ileostomy may be offered to gauge symptom response followed by colectomy for appropriate patients.

OBJECTIVE

Our goal was to examine outcomes in patients with constipation not falling into classical subtypes who underwent diverting loop ileostomy creation as the initial surgical intervention. Our secondary aim was to offer patients colectomy and anastomosis and examine their outcome if they improved after ileostomy.

DESIGN

The study design was a retrospective review.

SETTINGS

This study was conducted in the pelvic floor center of our colorectal surgery department from January 2006 to December 2018.

PATIENTS

Patients with medically refractory constipation referred for surgical consideration and not falling into classical constipation categories (slow transit, normal transit, or pelvic floor dysfunction) underwent evaluation with transit marker study, cinedefecography, and anal physiology and were offered ileostomy as initial surgical management.

MAIN OUTCOME MEASURES

The primary measures were symptom improvement and self-reported quality of life improvement with increased patient satisfaction.

RESULTS

Eighty-seven patients underwent diverting loop ileostomy as initial surgical therapy. Group 1 had 54 (62%) patients who self-reported symptom improvement, discontinued anticonstipation medication, and had ileostomy output >200 mL/day. Of these 54 patients, 25 had colectomy with anastomosis, 16 (64%) of whom had symptom improvement, stayed off bowel medication, and had >1 bowel movement daily. Group 2 had 33 patients who did not meet the above criteria after initial ileostomy. Nine patients in group 2 elected colectomy with anastomosis after intensive counseling; 6 (66%) reported the same positive results above.

LIMITATIONS

The study limitations included: 1) no objective outcome measures of patient's perceived symptom improvement and satisfaction and 2) retrospective review.

CONCLUSION

Initial creation of diverting loop ileostomy may be offered to a subset of refractory constipation patients not falling into classical categories after thorough workup. Patients who self-report symptom improvement, have ileostomy output >200 mL/day, and do not require bowel medication may have acceptable results with subsequent colectomy and ileorectal anastomosis. See Video Abstract at http://links.lww.com/DCR/B854.

ILEOSTOMA EN ASA DERIVATIVA EN CASOS DE ESTREIMIENTO REFRACTARIOS AL TRATAMIENTO MDICO, QUE NO PERTENECEN A LAS CATEGORAS CLSICAS

ANTECEDENTES:El enfoque del estreñimiento refractario al tratamiento médico, que no siempre se presenta como las formas descritas clasicamente, es un desafío. Si bien el papel de la cirugía no está claro, se puede ofrecer una ileostomía en asa para medir la respuesta de los síntomas, seguida de colectomía en pacientes seleccionados.OBJETIVO:Evaluar los resultados de pacientes con estreñimiento, que no pertenecen a las formas clásicas de presentación, que se les realizó una ileostomía en asa de derivación, como intervención quirúrgica inicial. El objetivo secundario fue ofrecer a los pacientes una colectomía con anastomosis primaria y evaluar si mejoraban sus resultados después de la ileostomía.DISEÑO:El diseño del estudio fue una revisión retrospectiva.MARCO:Este estudio se realizó en el centro del piso pélvico de nuestro departamento de cirugía colorrectal, e incluyo los pacientes atendidos entre enero de 2006 y diciembre de 2018.PACIENTES:Se incluyeron los pacientes con estreñimiento refractario al tratamiento médico, derivados para evaluación quirúrgica, que no presentaban las formas clásicas de presentación (tránsito lento, tránsito normal, disfunción del suelo pélvico). Estos se sometieron a evaluación con estudio de tránsito colónico, cinedefecografía y fisiología anal, y se les ofreció una ileostomía en asa como tratamiento quirúrgico inicial.PRINCIPALES MEDIDAS DE RESULTADO:Las primeras medidas fueron la mejora de los síntomas y la calidad de vida informado por el paciente.RESULTADOS:Ochenta y siete pacientes fueron sometidos a ileostomía en asa como tratamiento quirúrgico inicial. El grupo 1 tenía 54 (62%) pacientes que informaron mejoría de los síntomas, interrumpieron la medicación proquinética y tuvieron un débito por la ileostomía >200 cc/día. De estos 54 pacientes, 25 se sometieron a colectomía más anastomosis primaria y 16 (64%) tuvieron una mejoría de los síntomas, dejaron de tomar medicamentos proquinéticos y tuvieron más de una evacuación al día. El grupo 2 tenía 33 pacientes que no cumplían con los criterios de mejoría de los síntomas después de la ileostomía inicial. Nueve pacientes del grupo 2 eligieron colectomía con anastomosis después de un asesoramiento intensivo, 6 (66%) informaron resultados positivos de mejoría de los síntomas.LIMITACIONES:Las limitaciones del estudio incluyeron 1) ninguna medida de resultado objetiva de la mejora y satisfacción de los síntomas percibidos por el paciente 2) revisión retrospectiva.CONCLUSIÓNES:La creación inicial de una ileostomía en asa de derivación se puede ofrecer a un subgrupo de pacientes con estreñimiento refractario que no entran en las categorías clásicas después de un estudio exhaustivo. La mejoría de los síntomas, informado por los pacientes, producción de ileostomía >200 cc/día y que no requieren medicación proquinética, pueden tener resultados aceptables con colectomía y anastomosis ileorrectal. Consulte Video Resumen en http://links.lww.com/DCR/Bxxx. (Traducción-Dr. Rodrigo Azolas).

Slow-transit constipation and criteria for colectomy: a cross-sectional study of 1568 patients

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.

The Usefulness of Preoperative Evaluation for Intractable Slow Transit Constipation by Computed Tomography

Objectives:

Total colectomy with ileorectal anastomosis is the gold standard surgical procedure for patients with slow transit constipation (STC). This operation's outcomes are highly variable; however, predictors of postoperative outcomes after surgical treatment of intractable STC remain unclear. This study aimed to clarify the usefulness of preoperative evaluation for intractable STC by computed tomography (CT) in predicting postoperative outcomes.

Methods:

From January 2011 to December 2018, 22 patients with intractable STC underwent laparoscopic total colectomy with ileorectal anastomosis at the Kashiwa Hospital, Jikei University. They were divided into two groups, eighteen patients in the colonic inertia type (CI) group, and four patients in the spastic constipation type (SC) group, by preoperative CT according to specific criteria.

Results:

There were no significant differences in the mean age, gender, mean operation time, or mean intraoperative blood loss. The SC group's postoperative hospital stay was significantly longer than that of the CI group. Postoperative gastric outlet obstruction occurred in two patients (11%) who underwent distal partial gastrectomy with R-Y reconstruction after the surgery in the CI group but no patients in the SC group. Postoperative pelvic outlet obstruction occurred in all four patients who underwent ileostomy within a year after surgery in the SC group but no patients in the CI group.

Conclusions:

The outcomes of total colectomy in the treatment of intractable STC are highly variable. Preoperative evaluation for intractable STC by CT seems to be a useful predictor of postoperative outcomes.

Megadolicocolon de presentación poco usual en un paciente de edad avanzada: a propósito de un caso

El megadolicocolon es una patología inusual, de etiología no bien esclarecida, tal parece ser de origen congénito, se presenta con frecuencia en recién nacidos y lactantes con vólvulos de colon. Su incidencia es variable y se encuentra entre 1,9 y 28,5 %. Este reporte de caso es excepcional debido a que se presenta con una evolución y comportamiento agresivo de la enfermedad, pues se trata de un paciente de edad avanzada, con antecedente de sigmoidopexia y cuadro clínico de 7 meses de evolución consistente en estreñimiento crónico y exacerbación difusa de dolor abdominal incapacitante, quién requirió procedimiento quirúrgico de emergencia para su manejo.

Comparison of laparoscopic selective colectomy based on barium-strip examination and subtotal colectomy for adult slow-transit constipation

BACKGROUND

Surgical management of adult slow-transit constipation (ASTC) can be effective for patients with intractable symptoms. This study aimed to evaluate whether barium-strip examination and selective colectomy improved post-operative outcomes in ASTC patients in comparison with subtotal colectomy.

METHODS

A retrospective cohort study of 53 cases with refractory ASTC was conducted between June 2008 and June 2014. Patients were evaluated by the barium-strip technique, colonoscopy, defecography and anorectal manometry. Patients in the standard group underwent laparoscopic subtotal colectomy and patients in the laparoscopic selective colectomy (LSC) group underwent LSC at the precise location identified by barium strip. Spontaneous bowel movements, the Wexner Constipation Scale and the Gastrointestinal Quality of Life Index (GIQLI) were assessed post-operatively at 3, 6, 12 and 24 months.

RESULTS

A total of 49 patients were included in the analysis. The median follow-up was 37 months (range, 26-60 months). The mean post-operative hospital stay was 12 days and similar between groups (P = 0.071). The length of colon resection, operative time and intra-operative blood loss were reduced in the LSC group (all P < 0.05). No major complications occurred. A similar number of patients (24 in the standard group and 25 in the LSC group) exhibited hypoganglionosis or aganglionosis in the colon-wall muscle layer (P = 0.986). Although there were no significant differences in post-operative spontaneous bowel movements and the Wexner Constipation Scale between the two groups, the mean GIQLI of the LSC group was significantly higher at 3, 6 and 24 months post-operatively (all P < 0.05).

CONCLUSIONS

LSC based on barium-strip examination is an appropriate modality for treating ASTC.

Long-term outcome after segmental colonic resection for slow transit constipation

PURPOSE

Colectomy with ileorectal anastomosis (IRA) is the most common surgical procedure for slow transit constipation (STC). A hemicolectomy has been suggested as an alternative to IRA with good short-term results. However, long-term results are unknown. The aim of this study was to evaluate the long-term results after hemicolectomy as a treatment for STC.

METHODS

Fifty patients with STC were selected for right- or left-sided hemicolectomy after evaluation with colonic scintigraphy from 1993 to 2008. Living patients (n = 43) received a bowel function questionnaire and a questionnaire about patient-reported outcome.

RESULTS

After a median follow-up of 19.8 years, 13 patients had undergone rescue surgery (n = 12) or used irrigation (n = 1) and were classified as failures. In all, 30 were evaluable for functional outcome and questionnaire data for 19 patients (due to 11 non-responding) could be analysed. Two reported deterioration after several years and were also classified as failures. Median stool frequency remained increased from 1 per week at baseline to 5 per week at long-term follow-up (p = 0.001). Preoperatively, all patients used laxatives, whereas 12 managed without laxatives at long-term follow-up (p = 0.002). There was some reduction in other constipation symptoms but not statically significant. In the patients' global assessment, 10 stated a very good result, seven a good result and two a poor result.

CONCLUSIONS

Hemicolectomy for STC increases stool frequency and reduces laxative use. Long-term success rate could range between 17/50 (34%) and 35/50 (70%) depending on outcome among non-responders.

Use of high-resolution colonic manometry to establish etiology and direct treatment in patients with constipation: Case series with correlation to histology

BACKGROUND AND AIM

Different clinical treatments are available to treat patients with constipation. We aimed to study the etiology and direct treatment in a case series of patients with constipation by the use of high-resolution colonic manometry (HRCM).

METHODS

High-resolution colonic manometry was used to record the colorectal peristaltic contractions of the entire colon in patients. Based on the results of HRCM, 151 patients with constipation were classified into groups and received different clinical treatment such as a total or subtotal colectomy, local excision, or conservative treatment. Paraffin-embedded samples obtained after resection were studied using hematoxylin and eosin, as well as immunohistochemical staining.

RESULTS

All patients underwent HRCM over 24 h. Based on the amplitude, intensity, and trends in peristaltic contractions recorded by HRCM, we observed 117 patients with slow-transit constipation and 34 with functional outlet obstruction constipation. After an overall evaluation of the results of HRCM and anorectal function, 26, 23, 27, and 75 patients were treated with total colectomy, subtotal colectomy, local excision, and conservative treatment, respectively. Furthermore, histological examination of surgical samples showed vacuolar degeneration of nerve plexuses as well as of the muscularis propria, which also showed fibrosis in its outer layers in patients with constipation.

CONCLUSION

Different types of constipation showed different colonic motility patterns and morphological changes in the colonic wall. HRCM plays an important role in the diagnosis and classification of patients with constipation. Furthermore, HRCM can accurately identify the diseased colonic segments and help to choose the appropriate treatment.

Dolichocolon revisited: An inborn anatomic variant with redundancies causing constipation and volvulus

The objective of this review is to examine whether a redundant colon gives rise to symptoms like constipation and volvulus. In 1820, Monterossi made drawings of colons with displacements and elongation of the colon found during autopsy. In 1912, Kienböeck first visualized a redundant colon using bismuth, and Lardennois and Auborg named the anatomic variant dolichocolon in 1914. The criteria were later: A sigmoid loop rising over the line between the iliac crests, a transverse colon below the same line and extra loops at the flexures. The incidence of dolichocolon is 1.9%-28.5%. Dolichocolon seems to be congenital, as fetuses, newborns, and infants exhibit colonic redundancies. Studies have identified a triade of constipation, abdominal pain, and distension. Colon transit time was recently shown to increase significantly with increased number of redundancies, which increases abdominal pain, bloating and infrequent defecation. The diagnosis of dolichocolon is established by barium enema or CT-colonography. Treatment is conservative, or surgical in case of volvulus or refractory constipation.

Isobaric tags for relative and absolute quantification-based proteomic analysis that reveals the roles of progesterone receptor, inflammation, and fibrosis for slow-transit constipation

BACKGROUND AND AIM

Progesterone receptor, inflammation, neurotransmitter expression, and fibrosis are involved in slow-transit constipation. The aim of the present study was to examine whether patients with slow-transit constipation have an overexpression of progesterone receptor and serotonin, which may impair the fibrosis of muscularis propria in colorectal wall.

METHODS

High-resolution colon manometry was used to record the colorectal peristaltic contractions of the proximal ascending and sigmoid colon in patients. Protein samples prepared from frozen sigmoid colon tissue and the proximal margin of the ascending colon of four female patients were compared using isobaric tags for relative and absolute quantification labeling technique coupled to 2D liquid chromatography-tandem mass spectrometry analysis. Immunohistochemical staining of progesterone receptor, serotonin, and fibronectin was performed in paraffin-embedded sigmoid colon tissues and the proximal margin of the ascending colon or ileum from 43 patients with slow-transit constipation.

RESULTS

Among these differentially regulated proteins based on isobaric tags for relative and absolute quantification and liquid chromatography-tandem mass spectrometry analysis, 56 proteins involved in the response to progesterone, inflammation, matrix remodeling, fibrosis, and muscle metabolism. Immunohistochemical staining confirmed that there was significantly higher expression of progesterone receptor (t = 19.19, P = 0.000) and serotonin (t = 13.52, P = 0.004) in sigmoid colon than in the proximal margin of the ascending colon and ileum. Progesterone receptor and fibronectin expression in the outer layer of muscularis propria were higher than in the middle layer.

CONCLUSIONS

These results demonstrate that progesterone receptor, along with inflammation and fibrosis, may take part in slow-transit constipation development.

Surgery for constipation: systematic review and practice recommendations: Results I: Colonic resection

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.

慢传输型便秘外科治疗进展

近年来, 慢性便秘呈缓慢上升趋势, 慢传输型便秘(slow transit constipation, STC)是慢性便秘最常见的一种类型, 外科治疗是STC治疗的重要手段. 由于目前对于STC的发病原因及发病机制尚未完全明确, 及术前缺乏精确定位病变结肠的检查方法, 导致治疗STC手术方法的多样性. 近三十年来, 随着医学技术的不断进步, STC的外科治疗不断发展, 手术方法不断创新; 手术方法经历了从简单到复杂再到个体化选择, 从单一手术方法到多种手术方法选择, 从经腹开放手术到腹腔镜微创手术. 本文从STC的术式产生和发展过程来阐述STC外科治疗疗效和进展.

Functional Disorders: Slow-Transit Constipation

Constipation is a very common complaint, with slow-transit constipation (STC) accounting for a significant proportion of cases. Old age, female gender, psychiatric illness, and history of sexual abuse are all associated with STC. The exact cause of STC remains elusive; however, multiple immune and cellular changes have been demonstrated. Diagnosis requires evidence of slowed colonic transit which may be achieved via numerous modalities. While a variety of medical therapies exist, these are often met with limited success and a minority of patients ultimately require operative intervention. When evaluating a patient with STC, it is important to determine the presence of concomitant obstructed defecation or other forms of enteric dysmotility, as this may affect treatment decisions. Although a variety of surgical procedures have been reported, subtotal colectomy with ileorectal anastomosis is the most commonly performed and well-studied procedure, with the best track record of success.

Diagnosis and management of chronic constipation in adults

Constipation is a heterogeneous, polysymptomatic, multifactorial disease. Acute or transient constipation can be due to changes in diet, travel or stress, and secondary constipation can result from drug treatment, neurological or metabolic conditions or, rarely, colon cancer. A diagnosis of primary chronic constipation is made after exclusion of secondary causes of constipation and encompasses several overlapping subtypes. Slow-transit constipation is characterized by prolonged colonic transit in the absence of pelvic floor dysfunction. This subtype of constipation can be identified using either the radio-opaque marker test or wireless motility capsule test, and is best treated with laxatives such as polyethylene glycol or newer agents such as linaclotide or lubiprostone. If unsuccessful, subspecialist referral should be considered. Dyssynergic defecation results from impaired coordination of rectoanal and pelvic floor muscles, and causes difficulty with defecation. The condition can be identified using anorectal manometry and balloon expulsion tests and is best managed with biofeedback therapy. Opioid-induced constipation is an emerging entity, and several drugs including naloxegol, methylnaltrexone and lubiprostone are approved for its treatment. In this Review, we provide an overview of the burden and pathophysiology of chronic constipation, as well as a detailed discussion of the available diagnostic tools and treatment options.

Use of Antegrade Continence Enema for the Treatment of Fecal Incontinence and Functional Constipation in Adults: A Systematic Review

BACKGROUND

Antegrade continence enema is a proximal colonic stoma that allows antegrade lavage of the colon for the treatment of fecal incontinence and functional constipation. Its role in the treatment of these conditions in adults has not been established.

OBJECTIVE

This review aimed to evaluate the clinical response and complications of antegrade continence enema in the adult population.

DATA SOURCES

A systematic literature search of MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases from January 1980 to October 2013 was conducted.

STUDY SELECTION

Studies reporting clinical outcomes of antegrade continence enema in adult patients were considered. Only studies with participants aged 16 years and older were selected.

INTERVENTION(S)

Use of the antegrade continence enema for the treatment of constipation and incontinence in adults was investigated.

MAIN OUTCOME MEASURES

The primary outcome was the number of patients irrigating their stoma. Secondary outcomes included the incidence of stoma stenosis, assessment of functional outcome, and evaluation of quality of life.

RESULTS

Overall, 15 studies were selected, describing outcomes in 374 patients. All of the reports were observational cross-sectional studies, and 4 were prospective. The number of participants still using their stoma ranged from 47% to 100% over a follow-up period of 6 to 55 months. Eleven studies reported achievement of full continence in 33% to 100% of patients. Four studies described functional outcomes, and 7 studies reported a wide range of patient satisfaction. The rate of stoma stenosis varied from 8% to 50%.

LIMITATIONS

There were considerable heterogeneities within and across studies. Most studies were of poor quality, as reflected in the Methodological Index for Nonrandomized Studies score.

CONCLUSIONS

Antegrade continence enema has been reported as an acceptable treatment of both functional constipation and fecal incontinence in adults across several analyses. There is wide variation regarding outcome measures. Larger prospective studies are required to assess the role of antegrade continence enema in the adult population.

Results after sacral nerve stimulation for chronic constipation

BACKGROUND

Sacral nerve stimulation is an established treatment for fecal incontinence and initial reports describe successful results also in subjects with chronic constipation.

METHODS

Consecutive patients with slow transit or outlet obstruction type constipation were offered external stimulation through a test electrode inserted in a sacral foramen during a 3-week period. The symptomatic evaluation was based on the number of bowel movements and a validated obstructed defecation score (ODS). A permanent implant was performed provided an overall 50% decrease in symptoms was observed.

KEY RESULTS

In total, 44 patients with chronic constipation were treated with a 3-week test stimulation. Fifteen experienced a 50% reduction of symptoms and received a permanent implant. Four of the 15 with permanent implants were explanted during the course of the study. Five subjects (11% of original group) reported sustained symptom relief at final follow-up after a mean of 24 months (range 4-81). Mean ODS score did not change during the treatment. Patients with predominantly slow transit constipation or outlet obstruction did not differ concerning success rate.

CONCLUSIONS & INFERENCES

Sacral nerve stimulation has limited efficacy in unselected patients with chronic constipation and cannot be recommended for treatment on routine basis.

Constipation and pelvic outlet obstruction

Caring for patients with constipation and pelvic outlet obstruction can be challenging, requiring skill, patience, and empathy on the part of the medical professional. The mainstay of treatment is behavioral with surgery reserved for a select group of patients. The evaluation, diagnostic, and treatment modalities of both constipation and pelvic outlet with a focus on current advancements and technology are explored in depth.

Management of pediatric patients with refractory constipation who fail cecostomy

BACKGROUND

Antegrade continence enema (ACE) is a recognized therapeutic option in the management of pediatric refractory constipation. Data on the long-term outcome of patients who fail to improve after an ACE-procedure are lacking.

PURPOSE

To describe the rate of ACE bowel management failure in pediatric refractory constipation, and the management and long term outcome of these patients.

METHODS

Retrospective analysis of a cohort of patients that underwent ACE-procedure and had at least 3-year-follow-up. Detailed analysis of subsequent treatment and outcome of those patients with a poor functional outcome was performed.

RESULTS

76 patients were included. 12 (16%) failed successful bowel management after ACE requiring additional intervention. Mean follow-up was 66.3 (range 35-95 months) after ACE-procedure. Colonic motility studies demonstrated colonic neuropathy in 7 patients (58%); abnormal motility in 4 patients (33%), and abnormal left-sided colonic motility in 1 patient (9%). All 12 patients were ultimately treated surgically. Nine patients (75%) had marked clinical improvement, whereas 3 patients (25%) continued to have poor function issues at long term follow-up.

CONCLUSIONS

Colonic resection, either segmental or total, led to improvement or resolution of symptoms in the majority of patients who failed cecostomy. However, this is a complex and heterogeneous group and some patients will have continued issues.

Consensus statement AIGO/SICCR diagnosis and treatment of chronic constipation and obstructed defecation (part II: treatment)

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.

Consensus statement AIGO/SICCR diagnosis and treatment of chronic constipation and obstructed defecation (Part II: Treatment)

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.

Consensus statement AIGO/SICCR diagnosis and treatment of chronic constipation and obstructed defecation (part II: treatment)

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.

The impact of transcutaneous electrical stimulation therapy on appendicostomy operation rates for children with chronic constipation--a single-institution experience

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.

Laparoscopic subtotal colectomy with antiperistaltic cecorectal anastomosis: a new step in the treatment of slow-transit constipation

BACKGROUND

Subtotal colectomy with antiperistaltic cecorectal anastomosis (SCCRA) has proved to be an effective alternative to total colectomy for the treatment of severe slow-transit constipation. The laparoscopic approach has made this procedure even more attractive. This is the first controlled trial on laparoscopic SCCRA. The study compares the laparoscopic and the open approach.

METHODS

Since 2001, all SCCRAs have been performed laparoscopically at our institution. Only severely symptomatic patients are offered surgery, after stringent patient selection. Laparoscopic SCCRA was performed following the same steps that we first described for the open approach, by utilizing a five-trocar technique. Outcome parameters were prospectively collected every 3 and 6 months. Wexner constipation and incontinence scales (WCS, WI) and gastrointestinal quality of life index (GIQLI) were adopted for functional results. We conducted a case-control study of 15 consecutive patients who underwent laparoscopic SCCRA (VL) and 15 patients previously operated on by the open approach (Op) to compare postoperative and functional outcomes.

RESULTS

The VL group had better postoperative outcomes (pain, ileus) while complication rates were similar. Resolution of constipation was impressive in both groups, with no significant difference at follow-up. The VL group presented with a higher number of bowel movements at 3 months (3.8 vs. 2.8, p = 0.039), resulting in a significantly higher incontinence rate at 3 months (WI 6.4 vs. 2.73, p = 0.004), although the difference was no longer significant at 1-year follow-up. The quality of life was good for both groups; the VL group showed a significant improvement at 1-year follow-up (64.18 vs. 114.79, p < 0.01).

CONCLUSIONS

Laparoscopic SCCRA confirmed the good functional results of the open approach, with no increase in morbidity rate and a faster postoperative recovery. An early higher incontinence rate did not affect quality of life.

Systematic review of abdominal surgery for chronic idiopathic constipation

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.

Surgical treatment for constipation in children and adults

Functional constipation is one of the most common gastrointestinal disorders. In both children and adults, most patients are managed conservatively with good results. In this review, we focus on the surgical approach to constipation. Patients who lack the capacity to consistently have voluntary bowel movements may need mechanical emptying of the colon through an enema program; for them, surgery to allow for antegrade enemas, (via the appendix or using a button device) is useful. Those patients with severe constipation not responsive to intense medical treatment may be candidates for other surgical interventions, such as resection of the dysfunctional colonic segment (rectosigmoid or whole colon), or plication, -pexy, and STARR techniques for evacuatory disorders secondary to obstructive anatomical features. Permanent stomas are an option of last resort.

Colectomy for refractory constipation

OBJECTIVE

This study evaluated the type of colectomy, postoperative complications, functional results, and satisfaction in patients with constipation refractory to conservative therapy. Further, colonic transit time (CTT), faecal load (coprostasis), and colon length (redundancies) were compared between operated and non-operated patients.

MATERIAL AND METHODS

Out of 281 patients, 30 women and 5 men underwent surgery. All patients were evaluated by clinical and physiological investigations. Forty-four randomly selected healthy persons constituted the control group.

RESULTS

Twenty-one patients had at hemicolectomy, 11 patients a subtotal colectomy and 3 patients an ileostomy. Two patients had an anastomotic leak and one died. In 11 patients, further surgery was necessary, because of recurrent constipation. Abdominal pain disappeared and defecation patterns improved significantly to 1-4 per day after a colectomy with no uncontrolled diarrhoea. The mean CTT was 65.0 h for patients operated, 37.9 h in non-operated patients and 24.75 h in controls (p < 0.05). Abdominal bloating and pain and defecation parameters correlated significantly positively with CTT and faecal loading, which were significantly increased in operated patients (p < 0.05). The colon was significantly longer in operated patients compared to non-operated, which significantly increased CTT and aggravated symptoms. The histology of the removed colon revealed degenerative changes.

CONCLUSIONS

A segmental or a subtotal colectomy reduced bloating and pain and improved defecation patterns significantly. Although patient satisfaction was rather high, there are significant risks of postoperative complications and future operations. The operated patients had a significant increased CTT, faecal load and colon length, compared to non-operated patients.

Antegrade colonic enemas and intestinal diversion are highly effective in the management of children with intractable constipation

PURPOSE

Intractable constipation in children is an uncommon but debilitating condition. When medical therapy fails, surgery is warranted; but the optimal surgical approach has not been clearly defined. We reviewed our experience with operative management of intractable constipation to identify predictors of success and to compare outcomes after 3 surgical approaches: antegrade continence enema (ACE), enteral diversion, and primary resection.

METHODS

A retrospective review of pediatric patients undergoing ACE, diversion, or resection for intractable, idiopathic constipation from 1994 to 2007 was performed. Satisfactory outcome was defined as minimal fecal soiling and passage of stool at least every other day (ACE, resection) or functional enterostomy without abdominal distension (diversion).

RESULTS

Forty-four patients (range = 1-26 years, mean = 9 years) were included. Sixteen patients underwent ACE, 19 underwent primary diversion (5 ileostomy, 14 colostomy), and 9 had primary colonic resections. Satisfactory outcomes were achieved in 63%, 95%, and 22%, respectively. Of the 19 patients diverted, 14 had intestinal continuity reestablished at a mean of 27 months postdiversion, with all of these having a satisfactory outcome at an average follow-up of 56 months. Five patients underwent closure of the enterostomy without resection, whereas the remainder underwent resection of dysmotile colon based on preoperative colonic manometry studies. Of those undergoing ACE procedures, age younger than 12 years was a predictor of success, whereas preoperative colonic manometry was not predictive of outcome. Second manometry 1 year post-ACE showed improvement in all patients tested. On retrospective review, patient noncompliance contributed to ACE failure.

CONCLUSIONS

Antegrade continence enema and enteral diversion are very effective initial procedures in the management of intractable constipation. Greater than 90% of diverted patients have an excellent outcome after the eventual restoration of intestinal continuity. Colon resection should not be offered as initial therapy, as it is associated with nearly 80% failure rate and the frequent need for additional surgery.

Standard medical therapies do not alter colonic transit time in children with treatment-resistant slow-transit constipation

BACKGROUND

Slow transit constipation (STC) is a form of chronic constipation characterised by prolonged passage of faecal matter through the colon. It is diagnosed by demonstrating delayed colonic transit on gastrointestinal transit studies. Traditionally, radio-opaque marker studies are performed. Recently, radioisotope nuclear transit studies (NTS) have been used in our centre to assess gastrointestinal transit time. This study aimed to evaluate if there are changes in colonic transit in STC children resistant to standard medical treatment over a prolonged period.

METHODS

Children with STC resistant to standard medical therapy for > or =2 years who had undergone two separate NTS to assess their colonic transit (where the first study had identified slow colonic transit without anorectal retention) were identified after ethical approval. The geometric centre (GC) of radioisotope activity at 6, 24, 30 and 48 h was compared in the two transit studies to determine if changes occurred.

RESULTS

Seven children (4 males) with proven STC resistant to standard medical therapy and two transit studies performed at different times were identified. Mean age was 7.0 years (5.4-10.8 years) at first study, and 11.4 years (9.7-14.2 years) at second study, with a mean of 4.4 years (1-8.5 years) between studies. There was no significant difference in colonic transit at any timepoint in the two tests (paired t test).

CONCLUSIONS

We conclude that nuclear transit studies are reproducible in assessing slow colonic transit in children with treatment-resistant STC and demonstrate that conventional medical treatment over many years has no effect on underlying colonic motility.

Surgery and sacral nerve stimulation for constipation and fecal incontinence

Fecal continence is a complex bodily function, which requires the interplay of sensation, rectal capacity, and anal neuromuscular function. Fecal incontinence affects approximately 2% of the population and has a prevalence of 15% in elderly patients. Constipation is one of the most common gastrointestinal disorders. The variety of symptoms and risk factors suggest a multifactorial origin. Before any invasive intervention, the surgeon should have a thorough understanding of the etiology of these conditions. Appropriate medical management can improve symptoms in the majority of patients. Surgery is indicated when all medical possibilities are exhausted. This review discusses the most used surgical procedures emphasizing the latest experiences. Sacral nerve stimulation (SNS) is a promising option for patients with fecal incontinence and constipation. The procedure affords patients improved continence and quality of life. The mechanism of action is still poorly understood. This treatment has been used before in other more invasive surgical procedures or even after their failure to improve patients' symptoms and avoid a definitive stoma. Before any invasive intervention, the surgeon should have a thorough understanding of the etiology of these conditions. Appropriate medical management can improve symptoms in the majority of patients. Surgery is indicated when all medical possibilities are exhausted. This review discusses the most used surgical procedures emphasizing the latest experiences. Sacral nerve stimulation (SNS) is a promising option for patients with fecal incontinence and constipation. The procedure affords patients improved continence and quality of life. The mechanism of action is still poorly understood. This treatment has been used before in other more invasive surgical procedures or even after their failure to improve patients' symptoms and avoid a definitive stoma.

Subtotal colectomy with antiperistaltic cecoproctostomy for selected patients with slow transit constipation-from Chinese report

BACKGROUND AND AIMS

Total abdominal colectomy with ileorectal anastomosis (TAC-IRA) is recommended widely for the patients with severe, refractory slow transit constipation (STC). Subtotal colectomy with end-to-end antiperistaltic cecorectal anastomosis (Sarli procedure), an alternative for STC, has been paid particular attention. The purpose of this study was to retrospectively compare alterations of clinical functions and qualities of life between TAC-IRA and Sarli procedure.

METHODS

Seventeen patients with STC who underwent Sarli procedure and 20 patients with STC who underwent TAC-IRA were chosen for this study. Patient characteristics, operative data, postoperative data, alterations of clinical function, and quality of life were compared. The gastrointestinal quality of life index (GIQLI) survey was used to evaluate postoperative qualities of life.

RESULTS

At the mean 4-year follow-up (range 2-6 years), the frequency of daily bowel movement in the Sarli group was significantly less than that in the TAC-IRA group (2.4 +/- 0.9 vs. 3.4 +/- 0.8; P = 0.0014), and the Wexner continence scores were significantly lower in the Sarli group compared to the TAC-IRA group (4.3 +/- 1.8 vs. 5.8 +/- 1.9; P = 0.0223). However, the GIQLI score in Sarli group was higher than the TAC-IRA group (119.8 +/- 7.5 vs. 111.1 +/- 12.0, P = 0.0455). Post subtotal colectomy barium enema showed a sign of "reservoir" at the residual ascending colon and cecum.

CONCLUSIONS

Compared to the TAC-IRA, subtotal colectomy with end-to-end antiperistaltic cecoproctostomy for appropriately selected patients with STC resulted in relief of constipation, satisfactory functional outcome, and improved qualities of life.

Surgical treatment of patients with constipation and fecal incontinence

Patients with constipation and fecal incontinence usually come to the attention of the surgeon when conservative measures have failed to alleviate sufficiently severe symptoms. Following detailed clinical and physiologic assessment, the surgeon should tailor the procedure to specific underlying physiologic abnormalities to restore function. This article describes the rationale, indications (including patient selection), results, and current position controversies of surgical procedures for constipation and fecal incontinence, dividing these into those regarded as historical, contemporary, or evolving. Reported surgical outcome data must be interpreted with caution because for most studies the evidence is of low quality, making comparison of different procedures problematic and emphasizing the need for better designed and conducted clinical trials.

Slow transit constipation: a review of a colonic functional disorder

Constipation is a common gastrointestinal complaint that can cause significant physical and psychosocial problems. It has been categorized as slow transit constipation, normal transit constipation, and obstructed defecation. Both the definition and pathophysiology of constipation are unclear, but attempts to describe each of the three types have been made. Slow transit constipation, a functional colonic disorder represents approximately 15 to 30% of constipated patients. The theorized etiologies are disorders of the autonomic and enteric nervous system and/or a dysfunctional neuroendocrine system. Slow transit constipation can be diagnosed with a complete history, physical exam, and a battery of specific diagnostic studies. Once the diagnosis is affirmed and medical management has failed, there are several treatment options. Biofeedback, sacral nerve stimulation, segmental colectomy, and subtotal colectomy with various anastomoses have all been used. Of those treatment options, a subtotal colectomy with ileorectal anastomosis is the most efficacious with the data to support its use.

Laparoscopic total colectomy for colonic inertia: surgical and functional results

BACKGROUND

Total colectomy is the surgery of choice for colonic inertia (CI) when medical treatment has failed. Laparoscopic total colectomy has demonstrated to be a feasible technique.

OBJECTIVE

Present our experience in patients with CI who underwent laparoscopic total colectomy (TC) + ileorectoanastomosis (IRA) and evaluate the functional results and medium-term follow-up after this surgery.

MATERIAL AND METHODS

All patients with CI were included in a prospective laparoscopic surgical protocol, from 2002 to 2007. These patients had a complete work-up for chronic constipation (clinical records, barium enema, colonic transit time, defecography, anorectal manometry, small bowel follow through). All patients were evaluated with Wexner's score for constipation pre- and postoperatively, asked if they would recommend surgery to other patients, and if they were satisfied with the procedure (on a scale from 1 to 10). Statistical analysis was carried out using Student's T-test.

RESULTS

In this period 20 patients were operated with diagnosis of CI. All patients were females with an average age of 41.5 years (range 18-52 years). Mean operative time was 248 min (range 170-360 min). One (5%) patient was converted to open surgery. The medium time to flatus per anum and feeding was 2 (range 1-6) and 3 (range 2-6) days, respectively. The medium postoperative stay was 7 days. Seven patients (35%) presented surgical postoperative complications (three postoperative ileus, one portal thrombosis, one rectal hemorrhage, one anastomotic leakage, and one hemoperitoneum). There was no postoperative mortality. The average follow-up was 25 months (range 1-60 months). Preoperative Wexner's constipation score was 22.3 (range 19-29 months) pre surgery and at the end of follow-up was 1.8 (range 0-6) (p < 0.01). The medium level of satisfaction was 8 (range 2-10) and only one patient would not recommend surgery to other patients.

CONCLUSION

The laparoscopic access is a safe technique with satisfactory functional results after medium-term follow-up.

Subtotal colectomy with antiperistaltic cecorectal anastomosis in the treatment of slow-transit constipation: long-term impact on quality of life

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.

Anorectal manovolumetry in the decision making before surgery for slow transit constipation

BACKGROUND

Colectomy with ileorectal anastomosis for slow transit constipation (STC) is being challenged by other operations, such as segmental resections. The importance of preoperative anorectal physiology testing may therefore be increased. The aim of this study was to identify anorectal abnormalities in patients with STC, which may influence the surgical approach.

METHODS

Fifty consecutive patients with STC (43 women; median age, 49 years) and 28 controls (23 women; median age, 50 years) were examined with anorectal manovolumetry. Anal pressures and rectal volumes were recorded, at stepwise rectal distension.

RESULTS

Anal resting pressure was lower in patients (median, 54 cm H(2)O; range, 22-130) than in controls (median, 68 cm H(2)O; range, 35-100) (p<0.05). Squeeze pressure tended to be lower in patients (median, 147 cm H(2)O; range, 53-382) than in controls (median, 177 cm H(2)O; range, 65-423) (p=0.09). Rectal sensory thresholds did not differ significantly between patients and controls, although 10 patients had a threshold for filling above the 95(th) percentile of controls. Rectal compliance was increased in patients in the pressure interval 5-35 cm H(2)O (p<0.05-0.01). The threshold and amplitude of the recto-anal inhibitory reflex did not differ significantly, but the recovery of resting pressure after eliciting the reflex was lower in patients than in controls in the pressure interval 10-50 cm H(2)O (p<0.05-0.001).

CONCLUSIONS

More than half of the patients with STC deviated in some parameter. An impaired internal sphincter function and increased rectal compliance were seen. One fifth of the patients had impaired rectal sensation.

Slow-transit constipation: evaluation and treatment

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.

Long-term results of subtotal colectomy with cecorectal anastomosis for isolated colonic inertia

AIM: To evaluate the results of sub total colectomy with cecorectal anastomosis (STC-CRA) for isolated colonic inertia (CI).

METHODS: Fourteen patients (mean age 57.5 ± 16.5 year) underwent surgery for isolated CI between January 1986 and December 2002. The mean frequency of bowel motions with the aid of laxatives was 1.2 ± 0.6 per week. All subjects underwent colonoscopy, anorectal manometry, cinedefaecography and colonic transit time (CTT). CI was defined as diffuse markers delay on CTT without evidence of pelvic floor dysfunction. All patients underwent STC-CRA. Long-term follow-up was obtained prospectively by clinical visits between October 2005 and February 2006 at a mean of 10.5 ± 3.6 years (range 5-16 years) during which we considered the number of stool emissions, the presence of abdominal pain or digitations, the use of pain killers, laxatives and/or fibers. Patients were also asked if they were satisfied with the surgery.

RESULTS: There was no postoperative mortality. Postoperative complications occurred in 21.4% (3/14). At the end of follow-up, bowel frequency was significantly (P < 0.05) increased to a mean of 4.8 ± 7.5 per day (range 1-30). One patient reported disabling diarrhea. Two patients used laxatives less than three times per month without complaining of what they called constipation. Overall, 78.5% of patients would have chosen surgery again if necessary.

CONCLUSION: STC-CRA is feasible and safe in patients with CI achieving 79% of success at a mean follow-up of 10.5 years. A prospective controlled evaluation is warranted to verify the advantages of this surgical approach in patients with CI.

Segmental colonic transit studies: comparison of a radiological and a scintigraphic method

OBJECTIVE

Colonic transit studies are used to diagnose slow transit constipation (STC) and to evaluate segmental colonic transit before segmental or subtotal colectomy. The aim of the study was to compare a single X-ray radio-opaque marker method with a scintigraphic technique to assess total and segmental colonic transit in patients with STC.

METHOD

Thirty-one female patients (median age 46 years) with severe constipation and a prolonged or borderline prolonged colonic transit time on radio-opaque marker study were included in the study. They were subsequently investigated with (111)Indium-DTPA colonic transit scintigraphy, with a median time between the investigations of 4(range 1-27) months. Normal values of healthy female controls were used for comparison.

RESULTS

There was no difference between the two methods in terms of prolonged or normal total colonic transit time. Twenty-nine of 31 female patients had a prolonged transit time only in one or two segments on the marker study. On scintigraphy, the transit time was prolonged for patients in the left (P < 0.05 to P < 0.001), but not in the right colon. With respect to prolonged or normal segmental transit time, there was a significant difference between the two methods only in the descending colon (P = 0.02). However, the results varied considerably for individual patients.

CONCLUSION

Segmental colonic delay was a common finding. The two methods gave similar results for groups of patients, except in the descending colon. The variation of the results for individuals suggests that a repeated transit test may improve the assessment of total and segmental transit.

Surgery for constipation

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.

Colonic exclusion and combined therapy for refractory constipation

AIM: To investigate the therapeutic effectiveness of colonic exclusion and combined therapy for refractory constipation.

METHODS: Thirty-two patients with refractory constipation were randomly divided into treatment group (n = 14) and control group (n = 18). Fourteen patients in treatment group underwent colonic exclusion and end-to-side colorectal anastomosis. Eighteen patients in control group received subtotal colectomy and end-to-end colorectal anastomosis. The therapeutic effects of the operations were assessed by comparing the surgical time, incision length, volume of blood losses, hospital stay, recovery rate and complication incidence. All patients received long-term follow-up.

RESULTS: All operations were successful and patients recovered fully after the operations. In comparison of treatment group and control group, the surgical time (h), incision length (cm), volume of blood losses (mL), hospital stay (d) were 87 ± 16 min vs 194 ± 23 min (t = 9.85), 10.4 ± 0.5 cm vs 21.2 ± 1.8 cm (t = 14.26), 79.5 ± 31.3 mL vs 286.3 ± 49.2 mL (t = 17.24), and 11.8 ± 2.4 d vs 18.6 ± 2.6 d (t = 6.91), respectively (P < 0.001 for all). The recovery rate and complication incidence were 85.7% vs 88.9% (P = 0.14 > 0.05), 21.4% vs 33.3% (P = 0.73 > 0.05), respectively.

CONCLUSION: Colonic exclusion has better therapeutic efficacy on refractory constipation. It has many advantages such as shorter surgical time, smaller incision, fewer blood losses and shorter hospital stay.

Is total colectomy the right choice in intractable slow-transit constipation?

BACKGROUND

The aim of the study was to evaluate the functional results of surgical treatment for intractable slow-transit constipation and to establish that the importance of correct diagnosis and type of colon resection (total or segmental) is essential to achieve optimal outcome while minimizing side effects.

METHODS

Between 1995 and 2004, of the 450 patients presenting with chronic constipation, we further investigated 33 patients with a diagnosis of slow-transit constipation that had not improved with medical or rehabilitative treatment. Preoperative evaluation included a daily evacuation diary compiled using Wexner score, psychologic assessment, Medical Outcomes Study 36-item Short Form Health Survey (SF-36), radiologic investigation of colonic transit time, enema radiograph, colpo-cysto-defecography, anal manometry, and, in selected patients, colonoscopy and pudendal nerve terminal motor latency. In 15 cases, the cause of constipation was colonic slow-transit (with a mean Wexner score of 22), which was always associated with dolichocolon. The other 18 patients presented outlet obstruction, and, therefore, these results are not included in the present report. The 15 patients with slow-transit constipation were submitted to total laparoscopic colectomy (2), total open colectomy (6), and left laparoscopic hemicolectomy for left colonic slow-transit (7).

RESULTS

Mean follow-up was 38 months. All patients except 1 presented improvement in symptoms with daily evacuations (P < .01; mean Wexner score, 6). Furthermore, results of the SF-36 test showed an improvement in the perception of physical pain, and the emotional, psychologic, and general health spheres after surgical treatment.

CONCLUSIONS

Meticulous preoperative evaluation of intractable slow-transit constipation may discriminate between the different causes of chronic constipation and thus avoid the well-known "Iceberg syndrome," which is responsible for many treatment failures.

Rectal hyposensitivity

Rectal hyposensitivity (RH) relates to a diminished perception of rectal distension that is diagnosed during anorectal physiologic investigation. There have been few direct studies of this physiologic abnormality, and its contribution to the development of functional bowel disorders has been relatively neglected. However, it appears to be common in patients with such disorders, being most prevalent in patients with functional constipation with or without fecal incontinence. Indeed, it may be important in the etiology of symptoms in certain patients, given that it is the only "apparent" identifiable abnormality on physiologic testing. Currently, it is usually diagnosed on the basis of elevated sensory threshold volumes during balloon distension in clinical practice, although such a diagnosis may be susceptible to misinterpretation in the presence of altered rectal wall properties, and thus it is uncertain whether a diagnosis of RH reflects true impairment of afferent nerve function. Furthermore, the etiology of RH is unclear, although there is limited evidence to support the role of pelvic nerve injury and abnormal toilet behavior. The optimum treatment of patients with RH is yet to be established. The majority are managed symptomatically, although "sensory-retraining biofeedback" appears to be the most effective treatment, at least in the short term, and is associated with objective improvement in the rectal sensory function. Currently, fundamental questions relating to the contribution of this physiologic abnormality to the development of functional bowel disorders remain unanswered. Acknowledgment of the potential importance of RH is thus required by clinicians and researchers to determine its relevance.

[Surgical management for slow-transit constipation]

Less than 10% of patients with slow-transit constipation require surgical management after failure of medical treatment. Preoperative clinical, psychological and colorectal routine investigations (ie colonic transit test, anorectal manometry and defecography) are mandatory in order to highly select the patients. To day, the surgical management of slow-transit constipation consists of subtotal colectomy with ileorectal anastomosis, eventually by laparoscopic approach. Although, surgical management improves slow-transit constipation in two thirds of the patients, small bowel obstruction, abdominal pain and constipation recurrence can occur in 25%, 50%, and 10% of the patients respectively.

Scintigraphic assessment of slow transit constipation with special reference to right- or left-sided colonic delay

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.

Long-term results of the antegrade continent enema procedure for constipation in adults

OBJECTIVE

The aim of this study was to evaluate the long-term results of the Antegrade Continent Enema (ACE) procedure for treating severe constipation in adults.

METHODS

Over 10 years 37 ACE conduits were created in 32 patients (median age 35 years, 26 women) with constipation caused by slow transit, obstructed defaecation or both. Conduits were created from the appendix (n = 20, 54%), ileum (n = 10, 27%), neoappendix caecostomy (n = 5, 14%) or colon (n = 2, 5%). Clinical records were retrospectively reviewed to determine outcome.

RESULTS

After a median follow up of 36 (range 13-140) months, 28 (88%) required at least one further procedure on a primary conduit, including reversal in 19 (59%). Five patients had a second conduit fashioned, two successfully. Conduit type and constipation cause did not significantly influence the rates of ACE reversal or major revision. Ileal conduits were associated with fewer minor revision procedures for stenosis (1 in 7 patients) than appendix conduits (21 in 20 patients). There was one (3%) serious complication. Satisfactory ACE function was ultimately achieved in 47% of patients, at last follow up. After ACE reversal, 9 (28%) patients underwent formation of an end stoma and 3 patients had a colectomy.

CONCLUSIONS

Revision procedures are common, but approximately half of patients can expect satisfactory long-term ACE function. ACE conduit reversal does not preclude subsequent alternative surgical strategies to treat this difficult condition.