Constipation

WHO, WHAT, WHEN

M62 2006 E S Kiff

Review: Surgery,constipation

Google: 1,730,000 Google scholar: 15,000 PubMed: 2453 Last 500 papers = August 2002 My view

Constipation

One of a set of SYMPTOMS of a disease that we do not understand.

Treatment modifies the symptoms – it does NOT treat the disease.

If you embark on surgery you will have to take on all the symptoms

3 Main Groups

Never learnt Dysmotility Mechanical

Obstruction, drugs, metabolic

Locke et al Gastroenterology 2000; 119

Dysmotility

IBS…………………Chronic constipation….

Emotions control the motions

Parkes Weber 1900 “constipation may be due to psychical factors”

Mechanical – connective tissue

Perineal descent Intussusception of rectum Rectocoele Everting anus Urogynae

Mechanical - muscle

End stage neuropathy

Defaecation is an extrusion process

Others

Spinal injury MS Megacolon, megarectum Drugs – antipsychotics, antidepressants,

analgesics Myxoedema Hypercalcaemia

Treatments - conservative

Dietary manipulation Perineal support Retraining – biofeedback Clinical psychology Oral laxatives – osmotic, irritant, herbal Suppositories, micro enemas Rectal irrigation

Treatment - mechanical

Posterior colporrhaphy Transanal plication Transperineal plication STARR procedure Sacrocolporectopexy

Requirements for surgery for obstructed defaecation

Proctogram shows rectocoele +/- rectal intussusception

Normal transit study Digitalisation useful? Degree of perineal descent?

Treatment - dysmotility

Colectomy and IRA

SNS ACE – open or endoscopic

Long-term results of ACE for constipation in adults. Lees et al. Colorectal Disease 2004; 6 :362-8

32 patients,26F over 10 year period FU 36 months 28 needed 1 or more revisions 19 reversed 47% satisfactory function

Exclude prior to colectomy

Disorders of defaecation

Weak sphincters

Other causes

Inappropriate expectations from patient and family

Platell et al. AusNZJSurg 1997

96 patients -92 female had TAC+IRA 5 year FU 50% strain 51% FI 55% pain 75% bloat 35% reoperation 9% ileostomy

Fitzharris DCR 2003 (Minnesota)

112 patients 109 female – 10 years Postal survey 41% pain 21% FI 46% diarrhoea 93% - would do it again

Colectomy

Shapes study can be misleading Colectomy is JUST a surgical laxative Problems –early or late – constipation or

incontinence Resolution can lead to more surgery and

eventually a stoma YOU will have done this to them

Ileostomy first

Allows 1 year to recover emotionally Certainty that small bowel works Confirms that could live with stoma if all

else fails Only when all agreed – colectomy with

ileo-rectal anastomosis. Expect to see them again…..and

again…

Alarm bells

Attention seekers – need to be ill Attending friend / relative Other aids Nursing background Anger towards other medical staff Medico-legal proceedings Factitious disorder

Summary

Treating symptoms not the disease Multifactorial – so be clear about what

surgery can and cannot do. Treat the whole patient Fools rush in where angels fear to tread