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Swanson KA, Phelps HM, Chapman WC, Glasgow SC, Smith RK, Joerger S, Utterson EC, Shakhsheer BA. Surgery for chronic idiopathic constipation: pediatric and adult patients - a systematic review. J Gastrointest Surg 2024; 28:170-178. [PMID: 38445940 DOI: 10.1016/j.gassur.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 11/25/2023] [Accepted: 12/08/2023] [Indexed: 03/07/2024]
Abstract
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.
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Affiliation(s)
- Kerry A Swanson
- Department of Surgery, Washington University in St. Louis, St. Louis, Missouri, United States.
| | - Hannah M Phelps
- Department of Surgery, Washington University in St. Louis, St. Louis, Missouri, United States
| | - William C Chapman
- Department of Surgery, Washington University in St. Louis, St. Louis, Missouri, United States
| | - Sean C Glasgow
- James H. Quillen Veterans Affairs Medical Center, Mountain Home, Tennessee, United States; Eastern Tennessee State University, Johnson City, Tennessee, United States
| | - Radhika K Smith
- Advent Health Medical Center, Orlando, Florida, United States
| | - Shannon Joerger
- Division of Pediatric Gastroenterology, Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri, United States
| | - Elizabeth C Utterson
- Division of Pediatric Gastroenterology, Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri, United States
| | - Baddr A Shakhsheer
- Section of Pediatric Surgery, Department of Surgery, Comer Children's Hospital, The University of Chicago, Chicago, Illinois, United States
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Ragg J, McDonald R, Hompes R, Jones OM, Cunningham C, Lindsey I. Isolated colonic inertia is not usually the cause of chronic constipation. Colorectal Dis 2011; 13:1299-302. [PMID: 20958908 DOI: 10.1111/j.1463-1318.2010.02455.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
AIM Chronic constipation is classified as outlet obstruction, colonic inertia or both. We aimed to determine the incidence of isolated colonic inertia in chronic constipation and to study symptom pattern in those with prolonged colonic transit time. METHODS Chronic constipation patients were classified radiologically by surgeon-reported defaecating proctography and transit study into four groups: isolated outlet obstruction, isolated colonic inertia, outlet obstruction plus colonic inertia, or normal. Symptom patterns were defined as stool infrequency (twice weekly or less) or frequent unsuccessful evacuations (more than twice weekly). RESULTS Of 541 patients with chronic constipation, 289 (53%) were classified as isolated outlet obstruction, 26 (5%) as isolated colonic inertia, 159 (29%) as outlet obstruction plus colonic inertia and 67 (12%) as normal. Of 448 patients (83%) with outlet obstruction, 35% had additional colonic inertia. Only 14% of those with prolonged colonic transit time had isolated colonic inertia. Frequent unsuccessful evacuations rather than stool infrequency was the commonest symptom pattern in all three disease groups (isolated outlet obstruction 86%, isolated colonic inertia 54% and outlet obstruction plus colonic inertia 63%). CONCLUSION Isolated colonic inertia is an unusual cause of chronic constipation. Most patients with colonic inertia have associated outlet obstruction. These data question the clinical significance of isolated colonic inertia.
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Affiliation(s)
- J Ragg
- Oxford Pelvic Floor Centre, Surgery and Diagnostics, Churchill Hospital, Oxford, UK
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Abstract
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.
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Affiliation(s)
- Dennis Raahave
- Department of Surgery, Copenhagen University North Sealand Hospital, Helsingore, Denmark.
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Pinto RA, Sands DR. Surgery and sacral nerve stimulation for constipation and fecal incontinence. Gastrointest Endosc Clin N Am 2009; 19:83-116, vi-vii. [PMID: 19232283 DOI: 10.1016/j.giec.2008.12.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Rodrigo A Pinto
- Department of Colorectal Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Boulevard, Weston, FL 33331, USA
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Iannelli A, Piche T, Dainese R, Fabiani P, Tran A, Mouiel J, Gugenheim J. Long-term results of subtotal colectomy with cecorectal anastomosis for isolated colonic inertia. World J Gastroenterol 2007; 13:2590-5. [PMID: 17552007 PMCID: PMC4146820 DOI: 10.3748/wjg.v13.i18.2590] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Antonio Iannelli
- Service de Chirurgie Digestive, Université de Nice-Sophia-Antipolis, Faculté de Médicine, Nice, France
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bin Mohd Zam NA, Tan KY, Ng C, Chen CM, Wong SK, Chng HC, Tay KH, Eu KW. Mortality, morbidity and functional outcome after total or subtotal abdominal colectomy in the asian population. ANZ J Surg 2005; 75:840-3. [PMID: 16176220 DOI: 10.1111/j.1445-2197.2005.03552.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE This study reviews the functional outcome and satisfaction of patients after subtotal or total colectomy (STTC). METHODS A retrospective review of patients who underwent STTC between June 1999 and September 2003 was performed. A standardized questionnaire was formulated and phone interviews were conducted with these patients. RESULTS There were 50 patients who underwent STTC during this period. The most common indications were bleeding diverticular disease, patients with synchronous colorectal cancers or polyps and left-sided colonic obstruction. The presence of ischaemic heart disease and the development of perioperative acute coronary syndrome were found to be statistically significant predictors of 30 day mortality with P = 0.01 and 0.05, respectively. Phone interviews were successfully conducted in 33 patients. The patients interviewed were between 4 and 54 months postsurgery. Ninety-four percent reported that they were either happy or satisfied. Cleveland Clinic Incontinence Score (CCIS) revealed good or perfect continence in 94% of patients. Less than one-quarter of those interviewed had five or more bowel movements in a day while most had either two or three bowel movements a day. Patient satisfaction after STTC correlated strongly with the severity of CCIS and number of bowel movements a day (P < 0.01). Also, those with less than five bowel movements a day were more likely to report a better satisfaction (P < 0.01). CONCLUSION Subtotal or total colectomy is associated with a good functional outcome and most patients were satisfied with their bowel function on follow-up.
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Bosshard W, Dreher R, Schnegg JF, Büla CJ. The treatment of chronic constipation in elderly people: an update. Drugs Aging 2005; 21:911-30. [PMID: 15554750 DOI: 10.2165/00002512-200421140-00002] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Constipation is a common problem in elderly persons, with prevalence ranging from 15% to 20% in the community-dwelling elderly population and up to 50% in some studies of nursing home residents. In these patients, constipation results from a combination of risk factors, such as reduced fibre and fluid intake, decreased physical activity resulting from chronic diseases and multiple medications. Despite the high prevalence of constipation, there is surprisingly little evidence available on which to base management decisions of this common condition. Increased fluid intake, regular physical activity and high fibre intake are usually proposed as first step nonpharmacological measures. However, adherence to these measures is limited and pharmacological treatment is frequently required. Data are too limited, especially in elderly persons, to formally recommend one class of laxatives over another or one agent over another within each class. However, bulk-forming and osmotic laxatives are usually recommended as first-line agents, even though data on their effectiveness are limited. The need to maintain good hydration is a limitation in the use of bulk-forming laxatives, in particular, in frail elderly patients. In these patients, polyethylene glycol, an osmotic agent, is an attractive alternative. In addition, it has been shown to relieve faecal impaction in frail patients with neurological disease. Its cost and potential danger in patients at high risk for aspiration is, however, a limitation. Stimulant laxatives are considered mainly as an intermittent treatment in patients who do not respond to bulk-forming or osmotic laxatives. Several promising compounds such as the new serotonin 5-HT4 receptor agonists (tegaserod, prucalopride) and neurotrophin-3 (NT3) have not been adequately tested in older individuals. They are not routinely used and their role in the management of constipation in these patients will be more precisely defined in the future. Other treatment options are available (acupuncture, biofeedback, botulinum toxin and surgery), but experience with these interventions in elderly patients is limited and their indications in this population remain to be clarified. Management of constipation in elderly persons depends largely on experience and beliefs. Several new compounds seem promising but will need to be specifically tested in this population before being recommended.
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Affiliation(s)
- Wanda Bosshard
- Division of Geriatric Medicine and Geriatric Rehabilitation, Department of Internal Medicine, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
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Alves A, Coffin B, Panis Y. [Surgical management for slow-transit constipation]. ACTA ACUST UNITED AC 2005; 129:400-4. [PMID: 15388366 DOI: 10.1016/j.anchir.2004.07.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
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.
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Affiliation(s)
- A Alves
- Service de chirurgie digestive, hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris, France.
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