Surgery for Constipation

Ed Kiff

Powerpoint File

Constipation is a symptom not a disease

Defaecation is an extrusion process.

Having excluded all the other causes of constipation, there remain 3 groups. Those who never learnt to defaecate properly, those with dysmotility, that stops stool getting to the rectum and those with a mechanical / connective tissue problem in the pelvis and pelvic floor that prevents extrusion.

The tests are not perfect. There is overlap of these groups.

Patients, largely women, who have longstanding constipation – going once a week or less – who have tried all conservative treatments, where all other causes have been excluded, who do not want to carry on with their symptoms, who can accept that surgery only treats some symptoms not the cause, who have normal small bowel transit, and delayed colonic transit, who do not have an evacuatory disorder and who have adequate anal sphincters MAY be helped by colectomy and IRA but I would want them to have an ileostomy first.

Women who cannot easily defaecate and are aware of a bulge into the vagina when straining and who find that defaecation is easier if they press against the bulge may be helped by rectocoele repair.

Treat people not proctograms.

If you operate on these people you have to be prepared to cope with their disease and not just fix their symptom.

References: Surgery for constipation. Who When Why. M62. 2006

Locke. Pemberton Phillips. Gastroenterology 2000 119

AGA Technical review on constipation

A useful 21 page overview of investigation and treatment

Hirst et al Colorectal Disease 2005; 7:159-163

The role of rectocoele repair in targeted patients with obstructed defaecation

82 cases notes reviewed. All tests normal except proctogram showing rectocoele 77% pleased. 31% had further surgery.

Mellgren et al. DCR 1995; 38: 7-13

Results of rectocele repair A prospective study.

25 patients, 21 improved ; Digitalisation not necessary for good outcome.

Maher et al. Obster Gynecol 2004; 104: 685-9

Midline rectovaginal fascial plication for repair of rectocoele and obstructed defaecation.

38 patients, 12 month follow up, 97% satisfied.

Boccasanta et al. DCR 2004; 47:1285-96

Stapled transanal rectal resection for outlet obstruction: a prospective, multicentre trial.

90 patients, 16 month follow up. Results excellent 48, Good 33. Both intussusception and rectocele disappeared.

Stojkovic et al. Colorectal disease 2003; 5:169-72

Does the need to self digitate or the presence of a large or nonemptying rectocoele on proctography influence the outcome of transanal rectocoele repair?

No. 75% success in 55 patients with 6 months follow up.

Nyam et al. DCR 1997;40:529

Long term results of surgery for chronic constipation

1009 patients at Mayo Clinic, 52 with STC had TAC+IRA and 22 with STC and pelvic floor dysfunction had retraining and then TAC+IRA. So 74 patients, 68 women and 5 year follow up. 90% improved QOL.

Fitzllarris et al. DCR 2003;46:433-40

Quality of life after subtotal colectomy for slow transit constipation: both quality and quantity count. 112 patients in Minnesota, 109 female reviewed by questionnaire, 41% abdo pain, 21% incontinence, 46% diarrhoea, 93% would do it again.

Lubowski et al. 1996;39:28-9

Results of colectomy for severe slow transit constipation.

59 patients in Sydney, 42 month follow up after TAC+IRA. 6 incontinent, 14 difficult evacuations, 27 persistent abdo pain, 47 satisfied with outcome.

Platell et al. Aust NZJSurg 1997;66:525-9

A long term follow up of patients undergoing colectomy for chronic idiopathic constipation.

96 patients had 5 year FU after TAC. 3%leak, 11% pelvic abscess, 51% still suain, 50% some incontinence, 55% abdo pain, 76% bloating, 35% reoperation, 9% had ileostomy.

Lees et al. Colorectal Disease 2004;6:362-8

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

36 month FU of 32 patients. 88% required one or more further procedures, 59% reversed, 47% eventually satisfactory.