Colectomy for constipation

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Colectomy for constipation

• Juan J. Nogueras, M.D., F.A.C.S., F.A.S.C.R.S.
• Chairman, Division of Surgery
• Cleveland Clinic Florida, Weston

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Constipation

• Definition Less
  than 3 bowel movements per week on a standardized
  diet containing a minimum of 19 grams of dietary
  fiber daily

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Constipation Diagnosis

• Exclusion of organic, anatomic, and extracolonic
  causes
• History
• Physical examination
• Colonoscopy
• Barium enema

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Constipation History

• Illnesses
• NeurologicStroke/Tumor
• Pelvic/Spinal Surgery/Trauma
• Hx of imperforate anus, Hirschprungs disease
• Multiple Sclerosis
• Paraplegia
• Autonomic Neuropathy (Diabetes)
• Chagas Disease
• Hypothyroid
• Multiple endocrine Neoplasia
• Hypercalcemia
• Uremia
• Pregnancy
• Psychiatric

• Medications
• Anticholinergics
• Anticonvulsants
• Antiparkinsonian
• Anesthetics
• Diuretics
• Iron
• Opiates
• MAOI
• Antidepressant
• Antacids
• Antipsychotic

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CONSTIPATION History

• What does the patient mean by constipation
• Frequency, Duration of symptoms (chronic,
  lifelong, progressive, Urge/sensation, difficulty
  evacuating, Straining, digitation,
• Associated Symptoms
• Pain, Bloating, IBS, cramps, gas, bleeding
• Anorectal Surgery
• Hemorrhoids, Fissures, Fistula, Abscess,
  Stricture, Stenosis
• Diet, Fiber, Fluids,
• Activity, Lifestyle
• Psychiatric-
• Sense tension in the room.
• Difficult, demanding patients
• Stressful office sessions.

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Constipation Diagnosis

• Basic physiologic evaluation
• Anorectal manometry
• Electromyography
• Cinedefecography
• Pancolonic transit study

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Transit studies

• Colonic transit
• Small bowel transit
• Gastric motility

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Colonic transit History

• Hertz 1907 Bismuth
• Burnett 1923 Millett seeds
• Alvarez 1924 Colored glass beads
• Mulinos 1935 Carmine
• Connell 1960 Radiotelemetering capsule
• Hansky 1962 Radioactive chromium
• Hinton 1969 Radioactive pellets
• Rosswick 1967 Radioisotope capsule

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Colonic TransitRadiopaque markers

• Variety of techniques
• Types of markers
• Frequency of x-rays

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Colonic Transit Radiopaque markersCCF Technique

• Refrain from laxatives, enemas, suppositories day
  prior to ingestion
• May continue psyllium, high fiber diet, exercise
• Ingest capsule with 24 markers (SitzmarksTM) on
  Sunday at 9AM (Day 0)
• Plain film of abdomen Wed (Day 3) and
  Friday (Day 5)

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Colonic Inertia
Day 3
Day 5
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Obstructed Defecation
Day 5
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Colonic inertia Diagnosis

• Diffuse marker delay during transit study without
  paradoxical puborectalis contraction during
  cinedefogram or electromyography

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Reproducibility of Colonic Transit Study in
Constipation

• 51 patients with constipation
• Two separate colonic transit studies
• 35 of 51 pts identical results
• 16 pts disparate results

Nam, et al. DCR 20014486-92
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Reproducibility of Colonic Transit Study in
Constipation
Nam, et al. DCR 20014486-92
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Reproducibility of Colonic Transit Study in
Constipation

• Correlation is best for patients with idiopathic
  constipation and worst for patients with colonic
  inertia
• Success rate for colectomy higher in those
  patients with reproducible colonic transit study

Nam, et al. DCR 20014486-92
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Colonic inertia Management

• Conservative- medical
• Surgical
• Total abdominal colectomy with ileorectal
  anastomosis
• Segmental resections
• Cecorectal anastomosis
• Ileosigmoid anastomosis
• Stoma

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Historical

• Colectomy for intestinal stasis
• Lane 1908
• POOR RESULTS

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Colectomy for constipation

• St Marks Hospital 1972-1987
• 44 F
• Mean age 343 years (18-74 yrs)
• BM median 1-4 / month
• Range daily q 3 months

Kamm, et al GUT 1988
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Colectomy for constipation

• Prolonged transit study 97
• Failed balloon expulsion 72
• Paradoxical PR 65
• Frequent psychiatric evaluation and analgesic
  abuse

Kamm, et al GUT 1988
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Colectomy for constipation

• Normal bowel function 50
• Diarrhea 39
• Constipation 11
• Incontinence 14
• Pain 71

Kamm, et al GUT 1988
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Colectomy for constipation

• Effective treatment
• Sustained benefit
• Residual and new problems
• Liberal preoperative psychiatric consult

Kamm, et al GUT 1988
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Colectomy for constipation

• 59 patients
• Mean age 42.3 years
• Ileoproctostomy
• 52 patients follow up 42 months
• 69 lt 4 BM/day

Lubowski et al. DCR 1996
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Colectomy for constipation

• Small bowel obstruction 17
• Antidiarrheals 10
• Incontinent 11
• Stoma 1 patient
• Satisfaction 90

Lubowski et al. DCR 1996
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Colectomy for constipation

• 1009 patients evaluated for constipation
• 52 patients with slow transit constipation
• Abdominal colectomy with IRA
• 22 had associated pelvic floor dysfunction
  initial pelvic floor training prior to colectomy

Nyam DC, Pemberton JH, et al. DCR 1997
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Colectomy for constipation

• 74 patients
• 68 F 6 M
• Mean age 53 years
• Mean follow up 56 months
• No operative mortality

Nyam DC, Pemberton JH, et al. DCR 1997
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Colectomy for constipation

• Small bowel obstruction 9
• All patients pass stool spointaneously
• Satisfied with results 97
• Good or improved QOL 90
• No difference between STC and STC and pelvic
  floor dysfunction group

Nyam DC, Pemberton JH, et al. DCR 1997
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Colectomy for constipation

• Physiologic evaluation reliably identified
  patients with severe constipation who might
  benefit from surgery
• IRA is safe and effective

Nyam DC, Pemberton JH, et al. DCR 1997
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Colectomy

• 346 patients evaluated
• Slow transit constipation 86 patients (25)
• Left sided colectomy 18 patients
• Subtotal colectomy 24 patients

De Graaf EJ, et al. BJS 1996
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Colectomy

• Left Subtotal
• n 18 24
• Success () 67 33
• Recurrence () 17 29
• Severe abd discomfort () 33 63
• Diarrhea or incontinence () 14 25

De Graaf EJ, et al. BJS 1996
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Colectomy

• Although these results indicate that segmental
  colonic transit time studies are useful in
  selecting patients with slow transit constipation
  for partial left-sided or subtotal colectomy,
  both procedures should be performed with
  prudence.

De Graaf EJ, et al. BJS 1996
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Total abdominal colectomy with ileorectal
anastomosis

• Preferred approach
• How much sigmoid should we leave behind?

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Surgery for Constipation Long term
follow-up after total abdominal colectomy

• AJ Pikarsky, JJ Singh, EG Weiss, JJ
  Nogueras, SD Wexner
• Cleveland Clinic Florida

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Aim

• To prospectively assess the long term results of
  total abdominal colectomy with ileorectal
  anastomosis for colonic inertia
• Complications
• Bowel function
• Patient satisfaction

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Methods

• March 1988- December 1993
• Prospective study
• All patients who underwent total abdominal
  colectomy for colonic inertia
• Telephone questionnaire

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Results

• March 1988- December 1993
• Colonic transit study 403
• Colonic inertia 50(12.4)
• Females 39 (78)
• Males 11(22)
• Mean Age, years (range) 49 (17-78)

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Results

• Preoperative
• Bowel movement (range) 1/8days
  (3/week-1/month)
• Laxatives (number50) (range) 1/day
  (3/day-3/week)
• Abdominal pain 9 (18)
• Bloating 31 (62)

Pikarsky, et al. Dis Colon Rectum 2001
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Results

• 27 months 106 months (range
  2-51) (range 61-122)
• Bowel obstruction 5 (10) 6 (20)
• Conservative 3 (6) 3 (10)
• Surgical 2 (4) 3 (10)
• Mortality 2 (4) 3 (6)
• (not related to TAC-IRA)

Pikarsky, et al. Dis Colon Rectum 2001
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Results

• 27 months 106 months (range
  2-51) (range 61-122)
• Bowel frequency 3.7/day (1/day-10/day)
  2.5/day (1/day-6/day)
• Incontinence episodes
• lt1 episode/month 9 (16.7) 5 (16.7)
• lt1 episode/week 3 (5.5) 0
• gt1 episode/week 1 (1.8) 0
• Antidiarrheal agents 9 (17) 2 (6)

Pikarsky, et al. Dis Colon Rectum 2001
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Results

• Postoperative pain preoperative9/50 (18)
• 4 (13) patients
• Dull pelvic pain
• Decreased intensity
• 3/4 had pain prior to surgery
• Bloating preoperative 31/50 (62)
• 7 (23) patients

Pikarsky, et al. Dis Colon Rectum 2001
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Conclusion

• Long term follow-up reveals high degree of
  patient satisfaction and improvement of bowel
  function after total abdominal colectomy with
  ileorectal anastomosis for colonic inertia

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Conclusion

• Total abdominal colectomy with ileorectal
  anastomosis for colonic inertia is safe and
  recommended for patients with well-established
  colonic inertia

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Colectomy for constipation

• SF-36 scores lower than general population
• Postoperative pain and functional impairment
  predictors of lower QOL scores

Thaler F, Dinnewitzer A, et al. Tech Coloproctol
2005
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Colectomy for constipation

• 69 patients
• 67 F 2 M
• Colectomy with IRA
• 1983-1998
• Median f/u 10.8 years (5.1-18.6 yrs)
• 5 Deceased

Zutshi M, Hull TL, et al. Int J Colorect Dis 2006
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Colectomy for constipation

• Response rate 55
• 35 / 64 patients
• Surgery Beneficial 77
• Semi solid stool 64
• Liquid stool 35

Zutshi M, Hull TL, et al. Int J Colorect Dis 2006
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Colectomy for constipation

• Long term complications 46
• Persistent constipation 9
• Small bowel obstruction 20
• Incontinence 1.5
• Diarrhea 7

Zutshi M, Hull TL, et al. Int J Colorect Dis 2006
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Colectomy for constipation

• SF-36 questionnaire
• Physical component comparable to normal
  individuals
• Mental components low
• Vitality
• Social functioning

Zutshi M, Hull TL, et al. Int J Colorect Dis 2006
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Colectomy for constipation

• Surgery for constipation not perfect and symptoms
  may persist after surgery
• Because 77 report long term improvement, surgery
  is beneficial for appropriate patients

Zutshi M, Hull TL, et al. Int J Colorect Dis 2006
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Colectomy for constipation

• 450 patients evaluated for chronic constipation
• 1995 2004
• 33 patients with slow transit constipation
• Daily evacuation diary
• SF-36
• Colonic transit time
• Barium enema, colpo-cysto-defecography
• Anal manometry

Ripetti V, Caputo D, et al. Surgery 2006
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Colectomy for constipation

• 15 patients
• Colonic slow transit
• Dolichocolon
• Total laparoscopic colectomy 2
• Total open colectomy 6
• Lap left colectomy 7

Ripetti V, Caputo D, et al. Surgery 2006
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Colectomy for constipation

• Mean follow up 38 months
• 14 / 15 patients improved
• Daily evacuations
• SF-36 scores in physical, emotional, mental

Ripetti V, Caputo D, et al. Surgery 2006
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Slow transit constipation with Small Bowel
Dysmotility

• 17 patients subtotal colectomy
• Median age 46 years (23 70 yrs)
• Mean duration constipation 31 yrs
• 14 patients available for f/u
• Antroduodenal manometry to evaluate small bowel
  motility

Glia A, et al. DCR 2004
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Slow transit constipation with Small Bowel
Dysmotility

• Outcome of surgery goor or excellent
• Normal ADM 7/7
• Abnormal ADM 5/9
• Trend toward better long-term results in patients
  with normal ADM preoperatively

Glia A, et al. DCR 2004
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Ileal pouch anastomosis

• 15 patients
• 7 year period (1993-1999)
• Colonic inertia and rectal inertia
• Mean age 41 years (25-47 yrs)
• All had temporary loop ileostomy

Kalbassi MR, et al. DCR 2003
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Ileal pouch anastomosis

• 15 patients
• Two patients required pouch excision due to
  chronic pelvic pain within 18 months
• Mean stool frequency 5/day
• Significant improvement in QOL scores

Kalbassi MR, et al. DCR 2003
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Summary

• A select subgroup of patients with constipation
  may benefit from surgical approach
• Careful patient selection
• Physiologic evaluation
• Psychiatric evaluation
• Total abdominal colectomy with ileorectal
  anastomosis
• Role of partial colectomy not clear
• Pan enteric inertia difficult subgroup