Chapter 6.2
Managing Slow-Transit Constipation
Johann Pfeifer
History
In 1908, Sir Arbuthnot Lane published the first series of abdominal proce- dures for the treatment of chronic intractable constipation (1). He postu- lated that “autointoxication” (caused by chronic constipation) was responsible for a large number of diseases in the population of London, such as, “dilatation of the stomach, peptic ulceration, mobility of the kidney and degenerative changes of the breasts.” His advocacy of colectomy for constipation is still a controversial issue among specialist surgeons dealing with this problem. Over recent decades, there have been a variety of phys- iological tests designed in part to improve our understanding of the patho- physiology of constipation, where it was realized that there is indeed a small group of patients with this chronic complaint who can benefit from surgery.
The aim of this chapter is to summarize the indications for and results of surgery in adult patients presenting with severe and intractable slow-transit constipation.
Introduction
Constipation is one of the most frequent gastrointestinal symptoms and one of the most common reasons for medical consultation. Broadly, constipa- tion can be related to intestinal motility disorders, pelvic floor disturbances, or a combination of both, although the exact origin of these disorders (and the interplay of factors responsible for their chronicity) is not yet fully understood.
The definition of constipation is sometimes difficult, as physicians and patients have different opinions about what constitutes constipation.
Patients often include such subjective feelings as incomplete evacuation, abdominal or rectal pain, firm stool consistency, and the repeated need for straining. Probably the best definition for constipation was proposed by Whitehead and colleagues (2), where two or more of the following com-
429
plaints must be present when the patient is not taking laxatives and where symptoms must have persisted for at least 12 months; namely:
1. Straining on ≥25% of bowel movements
2. Feeling of incomplete evacuation after ≥25% of bowel movements 3. Scyballous stools on ≥25% of bowel movements
4. Stools less frequent than two per week with or without other symptoms of constipation.
Objective scoring recently has been introduced to standardize the clini- cal presentation and severity of chronic constipation, and although these systems have been validated in specialized clinical practice, they have not yet been widely adopted or utilized as discriminants in the decision for surgery (3,4).
Initial Assessment
History
A detailed history addressing the specifics of bowel activities, as well as the medication profile, must be obtained from constipated patients. Extra- colonic causes for constipation must be excluded systematically before applying terms such as “functional disorder” or “idiopathic constipation.”
Table 6.2-1 shows a veritable legion of extracolonic causes that may play a role in the patient’s presentation with this symptom. The scoring systems (alluded to above) provide a much more detailed and objective assessment, as they include more variables than just stool frequency and stool consis- tency; however, it must be remembered that constipation is a symptom and not a disorder. Several authors report higher rates of constipation in patients after hysterectomy (5).
Physical Examination
The first step is inspection of the anus and the perianal area, as well as a
digital examination. During rectal digitations, the patient should be asked
to squeeze, push down, and to relax. With this simple test, it often is easy
to diagnose pelvic outlet obstruction caused by non-relaxation of the pelvic
floor muscles. The next step is a proctoscopy without any preliminary bowel
preparation. As patients with slow-transit constipation typically complain
of diffuse abdominal pain and bloating, the abdomen should be inspected
and palpated. Examination also will reveal a rectocele by turning the exam-
ining digit through 180 degrees and inspecting the posterior vaginal wall
(6), and bimanual examination in the standing position during a Valsalva
maneuver will be suggestive of an attendant enterocele (7).
Table 6.2-1. Extracolonic causes for constipation.
Endocrine and metabolic: Diabetes mellitus Glycagonoma Hypercalcemia Hyperparathyroidism Hypokalemia Hypopituitarism Hypothyroidism Milk—alkali—syndrome Pheochromocytoma Porphyria
Pregnancy Uremia
Neurologic Cerebral Parkinson’s disease Stroke
Tumors
Spinal Cauda equina tumor
Ischemia Iatrogenic Meningocele Multiple sclerosis Paraplegia
Shy—Drager syndrome Tabes dorsalis Trauma
Peripheral Autonomic neuropathy
Chagas disease
Multiple endocrine neoplasia, Type 2B Von Recklinghausen’s disease
Drugs Anesthetics
Analgesic
Antacids (calcium and aluminium compounds) Anticholinergics
Anticonvulsants Antidepressants Anti-Parkinsonians Barium sulfate
Calcium channel blockers Diuretics
Ganglion blockers Hematinics (iron) Hypotensives Laxative abuse
Monoamono oxidase (MAO) inhibitors Metals (arsenic, lead, mercury, phosphorus) Opiates
Paralytic agents Psychotherapeutics Myopathy Amyloidosis
Dermatomyositis Myotonic dystrophy Sclerodermia
Clinical Evaluation
A barium enema and/or a colonoscopy should be part of the general eval- uation for constipated patients to rule out structural (mechanically obstruc- tive) disorders such as strictures, polyps, or cancer. We also perform screening abdominal sonography to exclude other intra-abdominal diseases that might present clinically as constipation. Blood chemistry—especially serum calcium and potassium levels, as well as thyroxine levels—also should be performed. Defecography (see Chapter 3.1) has a specialized place in proctological practice to assess rectal evacuation for the specific diagnoses of rectocele, enterocele, rectoanal intussusception, and occult rectal prolapse.
Initial Therapy
Conservative Treatment
The initial treatment of chronic constipation is always conservative and involves three main elements: general health issues, high-fiber diet, and medications (laxatives and enemas). General health issues are physical training (e.g., jogging, hiking, and gymnastics) and enough fluid intake (at least 1.5 to 2 liters per day). Furthermore, patients should be informed that physiological bowel activity is high in the morning after getting up and they should be encouraged to invoke the “gastrocolic reflex” by providing enough time after breakfast for evacuation (“toilet training”). Sometimes suppositories that increase rectal contractility can augment this reflex.
One of the best therapy options for increasing colon transit time is a high- fiber diet, which, in some patients, may increase cramping and bloating. In patients with an irritable bowel syndrome, a low-fiber diet is preferred.
Medication for constipation consists of laxatives and cathartics, stool soft-
eners, and agents affecting neurotransmission. Long-term use of oral stim-
ulant laxatives (bisacodyl, phenolphthalein, cascara, senna) is best avoided
due to the risk of electrolyte disturbances and damage to the colon. Prob-
ably the best laxative for chronic constipation is Macrogol [polyethylene
glycol (PEG) with a molecular mass exceeding 3000]. It is inert and practi-
cally nonabsorbable. Further advantages include its lack of intestinal enzy-
matic degradation or bacterial metabolism and its water-binding capacity,
and even long-term therapy does not appear to result in any significant side
effects—a feature that is especially advantageous in cardiac and renal
patients (8).
Advanced Assessment
Only if all of these basic tests fail to reveal a specific diagnosis and if the above-mentioned conservative therapy fails to produce improvement is a more exact and time-consuming physiological work up required.
Colonic Motility Study (See Chapter 2.7)
A radiopaque marker study is the least expensive examination available and is the easiest to perform; it is also the most informative and most com- monly used colonic motility test. The markers are ingested and the time to arrival in the rectum is evaluated by serial abdominal X-rays. In normal subjects, 80% of the markers are passed by the fifth post-ingestion day and all are expelled by Day 7. Intraluminal measurements of colonic myoelec- trical and motor functions are still experimental.
Anorectal Manometry
With anorectal manometry, resting and squeeze pressures, as well as the length of the high-pressure zone (HPZ), and especially the rectoanal inhibitory reflex (RAIR), can be assessed. The absence of the latter is char- acteristic of some young adolescent patients presenting late with short- segment Hirschsprung’s disease (HD) in the absence of previous rectal surgery. Furthermore, anal sensitivity, urge to evacuate, and rectal capacity can be estimated.
Defecography
Defecography, a dynamic study, is especially useful for diagnosing outlet obstructions; however, defecography reveals abnormalities in as many as 50% of asymptomatic individuals. Considering significant findings worthy of extensive conservative (biofeedback) or surgical treatment, defeco- graphic findings are considered reliable and reproducible in 87.9% of patients (9).
Electromyography (EMG) and Pudendal Nerve Terminal Motor Latency (PNTML)
The most common technique comprises placement of fine wire electrodes
into the external anal sphincter (EAS) and puborectalis muscle. In non-
constipated individuals, decreased EMG activity is seen during straining
and, conversely, increased firing of motor potentials is noted during squeez-
ing. Paradoxical puborectalis contraction during straining can be seen in
patients with functional pelvic outlet symptoms. A more elegant, less
painful, and equally reliable method involving plug electrodes has recently been described (10). Complete sphincter studies also should include mea- surement of the PNTML as described by Swash and Henry (11); however, the interpretation of a prolonged PNTML as a prognostic marker in such patients still remains controversial (12).
Other Tests
For the evaluation of constipated patients, many other tests have been pro- posed, such as the balloon expulsion test (13,14), balloon proctography, ultrasonography, magnetic resonance imaging (MRI), perineometry, scinti- graphic assessment of transit time and/or of rectal evacuation, mechanical and electrical stimulation of sensation, as well as evoked potentials by rectal or cerebral stimulation (15). It is worth mentioning that no single test alone is pathognomonic, and therefore the diagnosis of functional disorders must be based upon interpretation of several tests. Especially when surgery is considered, physiologic investigation is mandatory to achieve the desirable postoperative outcome (16).
Small bowel transit studies have recently demonstrated that there might be two different kinds of idiopathic slow-transit constipation (17). One involves just the colon and the other involves the entire gastrointestinal tract [gastrointestinal dysmotility (GID)]. Long-term surgical results after colectomy are much worse in patients with GID when compared with patients with solely colonic slow-transit constipation (17). Patients with a panenteric dysmotility may have either anatomical (morphological) (18,19) or functional disturbances. The latter include changes in gastric emptying and biliary function (20). Additional upper gastrointestinal (GI) evaluation should therefore be done when colon transit studies show colonic inertia to exclude this subgroup of patients with GID, as this may have a direct bearing on surgery. Figure 6.2.1 shows a recommended algorithm approach to this disorder.
Interpretation of Results
If no structural cause for constipation is identified, a transit study should be performed. If transit is normal, the pelvic floor should be evaluated.
After diagnostic evaluation, constipation can be categorized for surgery as follows:
1. (a) Colonic inertia (CI) or slow-transit constipation with/without megabowel
(b) Colonic inertia (CI) or slow-transit constipation as part of a com-
prehensive gut dysmotility syndrome (GID)
2. (a) Pelvic floor dysfunction (PFD) with anatomical abnormalities (HD, perineal descent, rectocele, sigmoidocele, intussusception, rectal prolapse, etc.)
(b) Pelvic floor dysfunction (PFD) without anatomical abnormalities (paradoxical puborectalis contraction, levator spasm, anismus, rectal pain)
3. Combined slow-transit constipation and PFD
4. Normal transit constipation [probably due to irritable bowel disease (IBS)]
Advanced Therapy
Conservative Treatment
If routine conservative therapy fails, a supervised diary of bowel habits during a regime including a high-fiber diet, fluid intake, and special
Chronic Constipation
Colon Transit study
Scattered Markers in colon (CI) Negative Marker predominantly in (no constipation] pelvic region (PFD)
Upper GI-Evaluation Anal manometry (e.g. small bowel transit, gastric emptying study) Cinedefecography
EMG of the pelvic floor PNTML
Endoanal ultrasonography normal pathological
Rectocele Anismus
Operative Sigmoidocele (nonrelaxing puborectalis muscle] Conservative Rectal prolapse Intussusception
Figure 6.2.1. Algorithm for evaluation and treatment of chronic constipation. CI, colonic inertia; PFD, pelvic floor dysfunction; PNTML, pudendal nerve terminal motor latency.
medication can provide guidance for altering and adjusting the appropri- ate conservative treatment.
Biofeedback as therapy for patients with PFD is an accepted treatment tool. Recently, long-term improvement of symptoms also was reported in patients with severe intractable constipation. In a mixed group of 100 patients (65% slow transit; 59% paradoxical pelvic floor contraction), 55%
felt that biofeedback had helped and 57% felt that their constipation was improved (21).
One cannot overlook the psychological component in many of these constipated patients. If an operation for a functional disorder is planned, there should be a preoperative psychiatric work up, including the Min- nesota Multiphasic Personality Inventory (MMPI). Another interesting, semi-conservative approach recently published by the St. Mark’s group is the use of sacral nerve stimulation. Eight women with proven slow-transit constipation were implanted with a temporary percutaneous stimulating S3 electrode for three weeks. Although colon transit time did not return to normal in any patient, two patients reported cessation or marked diminu- tion of symptoms, including normalization of bowel frequency. In particu- lar, rectal sensory threshold to distension was decreased (22).
Surgery should always be the last option in a highly selected group of patients suffering from pure CI. Surgery should never be performed on patients with GID. It must be stressed that the surgeon should not let him/herself be forced by the patient or relatives into performing an opera- tion for pain and bloating, as surgery will not alleviate these disorders.
Recommendations and Indications
Surgical Treatment for Colonic Inertia with/without Megabowel Antegrade Colonic Enema (ACE) (Malone Procedure)
In 1990, Malone described a washout technique for the colon in children using the appendix stump as a stoma sutured to the skin (23). There are only a few reports in the literature on the use of this technique in adult patients with intractable constipation. Hill reported 6 patients who received antegrade enemas with saline or phosphate enemas every 48 to 72 hours.
The symptoms could be resolved in 4 patients and improved in 2 patients.
The main problem was skin-level stenosis of the stoma in 50% requiring repeated dilatation. Hill concluded that this procedure might be especially suitable for patients with pelvic floor weakness who would be at risk of developing fecal incontinence if subtotal colectomy (STC) with ileorectal anastomosis (IRA) were performed (24).
Baeten and colleagues reported 12 patients (8 females) with intractable
constipation in whom either the appendix or the distal ileum was used as
the colon conduit. Although constipation scores could be markedly reduced
(21.5 reduced to 5.5), 4 patients eventually required STC and IRA. The
advantage of this approach is that this minimally invasive procedure does not compromise further surgery if needed (25). Other colonic conduits described are located in the transverse and sigmoid colon with mixed results (26). Gerharz, who applied this method to 16 patients with different patho- logic conditions, concluded that, in adults, the Malone procedure is associ- ated with a high failure rate due to stoma complications, wound infections, pain, and psychological problems (27).
Subtotal Colectomy
In megabowel, the dilated bowel caliber often precludes stapling of the distal rectal stump. Because of the size discrepancy between the dilated rectum and the small caliber small bowel, a hand-sutured anastomosis usually will be required. Subtotal colectomy with IRA is the standard oper- ation for patients with colonic inertia with or without megabowel. The reported success rates are listed in Table 6.2-2 (17,28–45). In recent studies, an equivalent success rate was seen for a laparoscopic- (hand-) assisted approach as for conventional treatment, whereby the former approach resulted in shorter postoperative ileus and hospital stay, earlier return to work, and better cosmesis (41).
Assessment of the literature concerning the role of STC and IRA in chronic constipation reveals some salient points. A combination of func- tional colonic inertia and outlet obstruction seems to be associated with a poorer outcome in patients who have undergone surgery (46). Furthermore, a good postoperative outcome can be expected for patients with normal rectal sensation; however, Nyam et al., reporting the experience of the Mayo clinic, failed to identify any differences in the outcome in patients with (22 patients) or without (52 patients) concomitant PFD (40). In the study by Pluta and colleagues (36), 24 patients underwent STC and IRA for chronic constipation with an overall success rate of 71%, and all of the patients who complained of either pain or bloating before the operation noted continued postoperative persistence of these symptoms. Moreover, half of the patients had a documented psychiatric disorder and in only 2 of 12 patients in this subgroup were surgeries successful. Thus, the success rate was over 90% in patients without psychiatric disorders, but only 17% with such a history.
A recent report by FitzHarris addresses the problem of quality of life
following STC for CI (45). Seventy-five patients out of 112 answered the
quality of life questionnaire in this study. Even if the vast majority (93%)
stated that they would undergo surgery again, 41% still complained of
abdominal pain, 21% of incontinence, and 46% of occasional diarrhea after
operation. A further interesting study by Redmond et al. (17) discussed 37
patients with CI. All patients underwent evaluation of the upper and lower
GI tract. In this study, 21 patients (18 female, 3 male) were found to have
abnormalities limited to the lower GI tract (CI). The 16 patients (all female)
Table6.2-2.Subtotal colectomy (STC) with ileorectal anastomosis (IRA) with/without megacolon (MC). AuthorYearnFemaleMeanFollow upNoSuccessMegacolonSuccess %age(years)megacolon%% Preston (28)19848100265.7863—— Barnes (29)1986643385.0——667 Akervall (30)198812100393.41266—— Kamm (31)198833100342.03350—— Yoshioka (32)198940*98353.03258+858+ Pena (33)199210591438.07889—— Takahashi (34)199438°——3.03797—— Redmond (17)19953492437.53490~,13#—— Piccirillo (35)19955478492.25494—— Pluta (36)199624————71—— Ghosh (37)19962190468.0—29 &—— Christiansen (38)199612————83—— De Graaf (39)1996248347——33—— Nyam (40)19977492534.67497—— Schiedeck (41)19993100602.0366.6—— Fan (42)20002479371.92487.5—— Pikarsky (43)20013070498.83083—— Athanasakis % (44)20014100470.74100—— FitzHarris (45)200311297n.an.a11293—— *34 IRA,5 coecorectal,1 ileosigmoidal anastomosis(ISA);+overall success;°IRA or ISA;~for colonic inertia;# for gastrointestinal dysmotility;& not a single complication in the long run;%laparoscopic assisted colectomy. n.a=not available.
with abnormalities in the lower and upper GI tract were thought to have gastrointestinal dysmotility with colonic predominance (GID).
Thirty-four patients underwent STC with IRA and three patients had a subtotal colectomy with an end ileostomy. At a mean follow-up of seven and a half years, there had been 3 deaths due to unrelated causes. Bowel frequency per week in the CI group increased from 1.7 per week preoper- atively to 36 per week after 6 months. After one year, the frequency declined to 23 per week and remained constant for up to 10 years. Colonic inertia patients thus had a successful long-term outcome of 90%. In com- parison, among patients with a mixed gastrointestinal dysmotility pattern, although after one year only 12% were constipated, within 5 years the prevalence had risen to 80%. Thus, the ultimate success in the GID group was only a rather unacceptable 13%.
Segmental Resections
Segmental resection of the colon has been associated with poor results.
Partial resection of the colon usually is followed by recurrent constipation, which may in part be due to dilatation of the remaining colon. Idiopathic megasigmoid would seem to be the best indication for sigmoid resection (47,48). The procedure is especially promising when there is a long sigmoid colon with a likelihood of volvulus formation.
Isolated left-sided colectomy has usually produced poor results.
However, DeGraaf et al. provided a recent update on segmental vs. sub- total colectomy (39). Based on segmental colon transit times, patients were foreseen either for segmental resection or STC.Twenty-four patients under- went STC and 18 underwent left-sided segmental resection. In this series, segmental resection was successful in 12 of 18 patients, but STC was only successful in 8 of 24. This report, however, fails to mention upper GI eval- uation. Firstly, patients in the subtotal colectomy group may have had a comprehensive GID disorder rather than isolated CI. Moreover, both the 67% success rate after segmental resection and the 33% success rate after STC are far below expectations.
Lundin and Pahlman (49) presented another interesting work involving 28 patients. Their selection criteria for the type of surgery included a pro- longed segmental transit time based on oral
111In-labelled diethylenetri- amine pentaacetic acid (DTPA) scintigraphic transit study. After a median of 50 months, 23 patients (81.1%) were pleased with the result. The con- clusion of the authors was that impaired rectal sensation might predict poor outcome. Now, we find that segmental resection still has a limited role in the treatment of constipation and should not be offered to patients with inertia (Table 6.2-3).
In a limited number of patients, there has been a good success rate for
proctocolectomy with formation of an ileoanal pouch (Table 6.2-4).
Complications
While standard complications such as bleeding, wound infection, and anas- tomotic leakage may occur after any bowel operation, the most common complication in patients who have undergone bowel resection for consti- pation is small bowel obstruction. Pfeifer et al. reported in a summary of 25 publications an overall small bowel obstruction rate of 18%, 12% of whom required surgical therapy (46). Recent advances in adhesion prevention have included the development of Seprafilm® (Genzyme
Table 6.2-4. Ileoanal pouch operation for constipation.
Author Year N Follow up Success Complications
(years) (%) (%)
Nicholls (61) 1988 2 0.6 100 100
Yoshioka (32) 1989 6 — 70 50
Hosie (62) 1990 13 1.8 85 38
Keighley (63) 1993 6 — 83 17
10 — 70 50
Stewart (64) 1994 18 6 78 17
14 6 71 36
Brown (65) 1997 2 — 100 —
O’Suilleabhain (66) 2001 3 3.6 100 n.a.
n.a.= not available.
Table 6.2-3. Segmental colectomy with/without megacolon (MC).
Author Year n Female Mean Follow up Success
% age (years) %
Jennings (50) 1967 8 — — — 13
Lane (51) 1977 2 — — 8 50
6* — — — 16
Smith (52) 1977 1 0 16 2 100
McCready (47) 1979 13 — — — 85
4* — — 9.2 75
Hughes (53) 1981 5 0 — — 100
Belliveau (54) 1982 7 — — 5.4 85
1* — — 5.4 100
Preston (28) 1984 5 100 35 5 20
Jurvinen (55) 1985 1 0 36 — 100
Barnes (29) 1986 4 43 38 5 50
Gasslander (56) 1987 2 100 36 2 50
Coremans (48) 1990 2 100 34 3.2 100
Kamm (57) 1991 2 100 20 2.5 100
Keighley (58) 1992 2 — — — 50
Stabile (59) 1992 7 30 19 1 71
De Graaf (39) 1996 18 83 47 66
You (60) 1999 40 — — 2 92
Lundin (49) 2002 28 93 52 4,2 82
* Megacolon.
Corporation, Cambridge, MA), a composite bioresorbable membrane of sodiumhyalurinate and carboxymethylcellulose. In a prospective random- ized surgeon-blinded series of 183 patients undergoing ileal pouch anal anastomosis, a 50% reduction in the incidence of adhesions was noted as compared to the control group (67). There was a similar significant decrease in the severity and extent of adhesions. Patients undergoing STL for con- stipation can receive Seprafilm at the time of fascial closure. In this way, complications due to adhesions could perhaps be diminished significantly in the future. The postoperative rate of recurrent constipation or fecal incontinence, as well as the use of laxatives or anti-diarrheal medication, is still unpredictable, but the complication rate after STC and IRA for various indications is generally acceptable (68).
Stoma
The potential result of surgery for constipation is the ultimate construction of a stoma. A stoma may be preferentially offered as an initial procedure to patients with psychiatric disorders, as well as to those with inertia com- bined with refractory pelvic outlet obstruction, or with significant pain and/or bloating. Patients who remain constipated after colectomy may well prefer a functioning stoma to a nonfunctioning anus.
Conclusion
Patients with intractable chronic constipation should be evaluated with physiological tests after structural disorders and extracolonic causes have been excluded. Conservative treatment options should be tried until they are exhausted. If surgery is indicated, STC with IRA is the treatment method of choice, although 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 a poorer prognosis. Patients must be counseled that preoperative pain and/or bloat- ing will likely persist, even if surgery normalizes bowel frequency. Patients with associated problems may be served better by having a stoma without resection as both a therapeutic maneuver and a diagnostic trial. Colectomy is not a treatment option for pain and/or abdominal bloating.
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