Effect of subtotal colectomy on gastric emptying of a solid meal in slow-transit constipation

BACKGROUND

Idiopathic slow-transit constipation is considered a panenteral disease in which patients may have delayed gastric emptying. The effects of total abdominal colectomy and ileorectal anastomosis on upper gut motility are unknown. The aim of this study was to evaluate gastric emptying in patients with idiopathic slow-transit constipation before and after subtotal colectomy.

METHODS

Gastric emptying of a solid meal was studied by scintigraphic technique in 11 patients with idiopathic slow-transit constipation. The total colonic transit time was more than 72 hours in all patients studied, with delay in transit in all segments of the colon. The gastric emptying test was repeated 3 to 6 months after total abdominal colectomy and ileorectal anastomosis in ten of these patients. Before and after surgery, patients filled out a questionnaire to record upper gut symptoms.

RESULTS

Solid gastric emptying was delayed (T1/2 > upper limit of normal) in 7 of 11 patients with idiopathic slow-transit constipation. Gastric emptying T1/2 was almost similar before and after surgery. Mean +/- standard deviation was 142 +/- 91 minutes before surgery and 146 +/- 67 minutes after surgery. Symptoms of vomiting and belching improved significantly after surgery. Symptoms of nausea, bloating, and pyrosis also decreased, but these changes failed to reach statistical significance.

CONCLUSION

Despite a reduction in upper gut symptoms, total abdominal colectomy and ileorectal anastomosis does not improve delayed gastric emptying in patients with idiopathic slow-transit constipation.

Colectomy for slow-transit constipation: preoperative functional evaluation is important but not a guarantee for a successful outcome

PURPOSE

This study was designed to assess the results of preoperative functional evaluation of patients with severe slow-transit constipation in relation to functional outcome.

METHODS

Four hundred thirty-nine patients with chronic intractable constipation were evaluated by marker studies. Twenty-one patients underwent colectomy and ileorectal anastomosis for slow-transit constipation. Mean colorectal transit time was 156 hours (normal, <45 hours). Small-bowel transit time was normal in ten patients and delayed in five patients. Six were nonresponders. Morbidity was 33 percent. Small-bowel obstruction occurred in six patients; relaparotomy was done in four patients. Follow-up varied from 14 to 153 (mean, 62) months.

RESULTS

After three months, defecation frequency was increased in all. Mean stool frequency improved from one bowel movement per 5.9 days to 2.8 times per day. Sixteen patients felt improved after surgery. Seventeen continued to experience abdominal pain, and 13 still used laxatives and enemas. Satisfaction rate was 76 percent (16 patients). After one year, defecation frequency was back at the preoperative level in five patients. An ileostomy was created in two more patients because of incontinence and persistent diarrhea. Eleven patients (52 percent) still felt improved. A relation between small-bowel function and functional results could not be demonstrated.

CONCLUSIONS

Preoperative evaluation is important but not a guarantee for, successful outcome. Colectomy remains an ultimate option for patients with disabling slow-transit constipation, but patients should be informed that, despite an increased defecation frequency, abdominal symptoms might persist. Any promiscuous use of colectomy to treat constipation should be discouraged.

Plasma cholecystokinin, plasma peptide YY and gallbladder motility in patients with slow transit constipation: effect of intestinal stimulation

BACKGROUND/AIM

Because cholecystokinin and peptide YY are gut hormones with potent effects on gastrointestinal motility, we determined whether abnormalities of cholecystokinin and peptide YY exist in slow transit constipation.

METHODS

Plasma concentrations of these hormones before, during and after intraduodenal infusion of a liquid meal in 21 patients with slow transit constipation were compared with the results in 8 healthy controls.

RESULTS

Fasting levels of plasma cholecystokinin (3.1+/-0.2 vs. 2.4+/-0.2 pM; p = 0.02) were higher in patients. Basal plasma peptide YY (11.4+/-1.4 vs. 8.9+/-0.7 pM; p = 0.1) tended to be higher in patients. After the meal (60-90 min), incremental cholecystokinin (p<0.05), but not peptide YY, was significantly higher in patients. During intraduodenal infusion of the meal (0-60 min), incremental plasma cholecystokinin (251+/-20 pM.min) and peptide YY (1,146+/-186 pM. min) in patients were almost similar to control values (262+/-22 and 901+/-166 pM. min). Gallbladder volumes before, during and after the meal were not different between the 2 groups. Gastric emptying of a solid meal was delayed in the majority of patients (12 of 18). Abnormalities of plasma cholecystokinin were observed only in patients with delayed gastric emptying.

CONCLUSION

Plasma levels of cholecystokinin are elevated in the fasting state and decrease more slowly after stimulation, but maximum release in response to intestinal nutrients is not altered in patients with slow transit constipation. The abnormality seems to be confined to a subgroup of patients with delayed gastric emptying.

Effect of rectal distension on gallbladder emptying and circulating gut hormones

BACKGROUND

Abnormalities of upper gut motility, including a delay of gastric emptying and small bowel transit, found in patients with constipation may be secondary to factors originating in the colon or rectum as a result of faecal stasis. The aim was to determine if stimulation of mechanosensory function by rectal distension affects postprandial gallbladder emptying and release of gastrointestinal peptides participating in control of upper gut motility.

MATERIALS AND METHODS

Eight healthy volunteers were studied with an electronic barostat and a plastic bag positioned in the rectum. Intrabag pressure was maintained at minimal distension pressure + 2 mmHg on one occasion and on a pressure that induced a sensation of urge on the other. Gallbladder volume and plasma concentrations of cholecystokinin (CCK), pancreatic polypeptide (PP) and peptide YY (PYY) were measured before and after ingestion of a 450-kcal mixed liquid meal.

RESULTS

Rectal distension enhanced maximum gallbladder emptying from 66 +/- 7% to 78 +/- 5% (P < 0.05). Distension tended to increase integrated plasma PYY from 77 +/- 30 pM min to 128 +/- 40 pM min in the first hour after the meal (P = 0.08) and it suppressed integrated plasma PP from 1133 +/- 248 pM min to 269 +/- 284 pM min in the second hour (P < 0.05). Integrated plasma CCK concentrations were not significantly affected.

CONCLUSION

Mechanosensory stimulation of the rectum enhances postprandial gallbladder emptying and influences postprandial release of gut hormones involved in the regulation of gastrointestinal motility in healthy subjects. These mechanisms may play a role in the pathogenesis of the upper gastrointestinal motor abnormalities observed in constipated patients.

Effects of rectal mobilization and lateral ligaments division on colonic and anorectal function

PURPOSE

Colonic and anorectal function are altered after posterior rectopexy. The aim of this randomized, prospective study was to evaluate the effects of rectal mobilization and division of the lateral ligaments on colonic and anorectal function.

METHODS

Posterior rectopexy was performed in 18 patients with complete rectal prolapse. Anal manometry and measurement of rectal compliance, total and segmental colonic transit time, constipation score, and defecation frequency were performed preoperatively and three months postoperatively. Ligaments were divided in ten patients.

RESULTS

Mean preoperative total transit time was similar between the two patient groups and doubled postoperatively (P = 0.03). Mean postoperative segmental transit time increased by a factor of 1.7 in segments I (ascending colon) and II (descending colon) and by a factor of 2.3 in segment III (rectosigmoid). The same pattern was found in both groups. Mean resting pressure decreased after division of the lateral ligaments and increased after preservation. Mean rectal compliance decreased after division of the ligaments and increased when they were preserved. Mean postoperative constipation score differed little from the preoperative score. Mean defecation frequency was decreased in the group with the ligaments preserved and increased in the group with the ligaments divided. None of the effects of rectal mobilization or division of the lateral ligaments on anorectal function reached statistical significance.

CONCLUSION

Rectal mobilization had a statistically significant effect on colonic function. Total and segmental colonic transit times doubled. The effects on anorectal function were not significant. Division of the lateral ligaments did not significantly influence postoperative functional outcome.

Abnormalities of upper gut motility in patients with slow-transit constipation

OBJECTIVE

To further delineate motor activity of the upper gastrointestinal tract in patients with slow-transit constipation.

DESIGN

A prospective study comparing healthy volunteers with patients with a clinical diagnosis of slow-transit constipation.

METHODS

Eighteen patients with clinical diagnosis of slow-transit constipation and 10 healthy controls were included in the study. Fasting antroduodenal motility was measured by perfusion manometry for at least one complete cycle of the migrating motor complex or a maximum of 300 min. Oesophageal manometry, gastric emptying and orocaecal transit time measurements were also performed.

RESULTS

At least one complete cycle of the migrating motor complex was observed in all controls, but in only nine patients (P < 0.01 versus control). The migrating motor complex cycle was incomplete (n = 5) or phase 3 activity was absent (n = 4) in the other patients. The incidence of clustered contractions was significantly increased in slow-transit constipation (P = 0.05 versus controls). The area under the contraction curve during late phase 2 (1509+/-296 mmHg x s) in patients with a complete cycle was significantly smaller than that in controls (2997+/-614 mmHg x s; P = 0.05). Orocaecal transit time was not significantly different among patients and controls, but oesophageal motility was abnormal in five of 18 patients and gastric emptying was abnormal in eight of 15 patients.

CONCLUSION

Abnormalities of upper gut motility occur frequently in patients with slow-transit constipation. Interdigestive antroduodenal motility is characterized by (i) absence or prolonged duration of the migrating motor complex, (ii) an increased number of clustered contractions, or (iii) a decreased motility during late phase 2 of the migrating motor complex.

[Bilateral traumatic dissection of the carotid artery]

Bilateral carotid artery dissection is a rare and unusual complication of blunt cervicofacial trauma. The diagnosis of a carotid injury is rarely suspected in trauma patients with neurological deficits. Neurological symptoms may develop in a delayed fashion. Angiography should be considered in trauma patients with hemiplegia and a normal mental status and in patients with blunt cervical trauma with an abnormal neurological examination. Initial heparinisation can prevent arterial thrombosis and neurological deterioration.

The guide wire dilating forceps technique of percutaneous tracheostomy

BACKGROUND

Prospective evaluation of the percutaneous tracheostomy by the guide wire dilating forceps (GWDF) technique.

METHODS

In 50 selected patients percutaneous tracheostomy with fiberscopic control was performed and evaluated.

RESULTS

Most percutaneous tracheostomies were performed without any adverse effect. No life-threatening complications or deaths were related to the procedure. The procedure was successful in 49 of 50 patients (98%). In 1 patient the procedure was converted to an open tracheostomy because significant bleeding occurred. Five perioperative complications, including this significant bleeding and four minor complications, occurred in 50 patients (10%). Early complications occurred in 6 of 48 patients (13%), including one significant bleeding and five minor complications. A subglottic stenosis occurred in 2 of 36 successfully decannulated patients (6%). In one case this was certainly due to prolonged endotracheal intubation.

CONCLUSIONS

The GWDF technique is a safe and efficient bedside alternative to open tracheostomy. Fiberscopic control is recommended to increase the safety of the procedure. Although studies of late complications are necessary, it appears to be justifiable to consider percutaneous tracheostomy for patients who require tracheostomy.

The effects of biofeedback on rectal sensation and distal colonic motility in patients with disorders of rectal evacuation: evidence of an inhibitory rectocolonic reflex in humans?

OBJECTIVE

Abnormalities of descending colon motility reported in a subset of patients with rectal evacuation disorders are consistent with a rectocolonic inhibitory reflex. Our aims were to evaluate distal colon motor function and rectal sensation in such patients and assess effects of biofeedback (BF) training on these functions.

METHODS

Seven patients (five women, two men; mean age 36 yr) with rectal evacuation disorders were studied before and after 10-days biofeedback training; six healthy volunteers (five women, one man; mean age 30 yr) were studied once. Colonic compliance, motility, sensation thresholds, and perception scores during standardized rectal distentions were measured using two barostat-manometry assemblies inserted into the cleansed colon with the aid of flexible sigmoidoscopy.

RESULTS

Sigmoid compliance, fasting, and postprandial motility index, and perception thresholds were similar in controls and patients before and after biofeedback training. Postprandial sigmoid tone tended (p = 0.09) to be lower in patients than controls; after biofeedback, postprandial tone was comparable to that in controls. Rectal urgency scores at 24 mm Hg distention were greater in patients than in controls (p = 0.02 for both). After biofeedback, there were trends for lower perceptions of urgency to defecate (7.6 +/- 1.1 cm pre- vs 5.3 +/- 1.5 post-; p = 0.04) at 24 mm Hg; conversely, gas sensation at 12 mm Hg was higher (1.2 +/- 0.5 cm pre- vs 3.3 +/- 0.6 post-; p = 0.05).

CONCLUSIONS

Normalization of rectal evacuation and postprandial sigmoid tone in patients with evacuation disorders by biofeedback training supports the presence of a rectocolonic inhibitory reflex. Effect of biofeedback on rectal sensation in these patients requires further study.

[Measurement of colon transit time useful in the evaluation of functional constipation]

OBJECTIVE

To determine the colon transit time (CTT) in patients complaining of functional constipation and the correlation between abnormal transit times and the types of constipation and of the symptoms.

DESIGN

Retrospective, descriptive.

SETTING

Department of Surgery, University Hospital, Nijmegen, the Netherlands.

METHOD

The signs and symptoms of 112 patients with infrequent or difficult defaecation, 93 (83%) of them women, with a median age of 42 years (range: 16-72), were recorded by means of a questionnaire. After ingestion of radiopaque markers per day for 10 days, an abdominal survey X-ray was made on day 11. The numbers of markers in the X-ray and per segment (right and left hemicolon and rectosigmoid) were counted; the CTT in hours was calculated by multiplying this number by 2.4. Slowness was defined as more than 45 h for the total CTT and as more than 15 h for the segmental CTT.

RESULTS

The total CTT was normal in 33 patients (29%) and prolonged in 79 (71%). The CTT was prolonged only in the rectosigmoid in 14 patients with a normal CTT (42%) and in 50 patients with a prolonged total CTT (63%). Of the patients with a normal total CTT, 13 (39%) had a normal segmental CTT. No statistically significant correlation could be demonstrated between the presence of any symptom and a prolonged CTT.

CONCLUSION

Functional constipation may be associated with a normal CTT. Disorders of colonic motility and of rectal evacuation could be distinguished by measuring the total and the segmental colonic transit times.

Local recurrence and survival in patients with rectal cancer, diagnosed 1981-86: a community hospital-based study in the south-east Netherlands

We carried out a population-based audit of local recurrence rates in curatively resected patients with rectal cancer, diagnosed between 1981 and 1986. The study comprises 372 patients treated for rectal cancer in five community hospitals in the south-east of the Netherlands. The follow-up period was 7-12 years. We studied the medical records of these patients in the Eindhoven Cancer Registry, and by checking the endoscopical, surgical and pathological reports, we traced the following events: local recurrence, distant metastasis and (cause of) death. Curative resection was carried out in 232 of the 372 cases (62%); post-operative radiotherapy was administered to 27% of stage B2 and 50% of stage C (Astler-Coller) patients. Crude and net 5-year survival rates were 45% and 58%, respectively. Local recurrence rates were 18%, without much variation per hospital. After adjustment for age, gender, tumour site and type of surgery, local recurrence was primarily determined by tumour penetration of the muscularis propria and lymph node infiltration, the relative risks being 2.5 and 3.1, respectively (90% confidence intervals: 1.1-5.9 and 1.5-6.4). Although patients with cancer of the distal segment (0-6 cm) had shorter survival times than with proximal tumours, tumour site only weakly influenced local recurrence rates. These results confirm that the risk of recurrence for stage B2 and C patients can be reduced by more extensive surgical procedures. This study has contributed to the growing awareness of improved surgical treatment in rectal cancer.

The evaluation and treatment of functional constipation

Constipation and defecation may be considered as the last taboo. The inability to defecate or to achieve this only by digital evacuation has never been a popular topic among patients and doctors. Application of tests from the colorectal laboratory has made it possible to study the function of the different parts of the colon and the mechanism of continence. We consider transit studies, defecography, EMG, and anal manometry, all useful as diagnostic procedures for functional constipation. Several causes of functional constipation can be distinguished in slow transit and difficult evacuation or colonic inertia, spastic pelvic floor syndrome, rectocele and intussusception. This article presents our view of the assessment and management of functional constipation.

Does selective decontamination of the gastrointestinal tract prevent multiple organ failure? An experimental study

Gut bacteria have been incriminated as causing or contributing to generalized sepsis with multiple organ failure in severely ill patients, and selective decontamination of the gastrointestinal tract of Enterobacteriaceae has been claimed to decrease septic complications in these patients. We studied the effects of selective decontamination of the gastrointestinal tract on survival and organ function in an experimental model of sepsis with multiple organ failure. Wistar rats were inoculated intraperitoneally with zymosan and randomized into control or treatment groups (trimethoprim or streptomycin sulfate). Selective decontamination effectively prevented bacterial translocation of Enterobacteriaceae. However, only early mortality was decreased, and only so in the streptomycin-treated rats. Selective decontamination did not result in a significantly better condition of the surviving animals on day 12.