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1、Constipation:The Evolving Role for Surgery,Ursula Szmulowicz,MDDepartment of Colorectal SurgeryDigestive Disease InstituteCleveland Clinic FoundationShanghai,ChinaMarch 12,2011,Outline,Normal defecationDefinition of constipationIncidenceHistory and evaluationSurgical optionsColectomyBypassAntegrade
2、colonic enemaStomaSacral nerve stimulation,Normal Defecation,Colonic and rectal motility Reservoir function of the rectumRectal Sensation Expulsion,Talley et al,Am J Gastroenterol,1996;Zhou et al,Chinese Med J,2007.,Incidence,Prevalence of 2-28%in Western populationsEstimated 30 million affected25.9
3、2%prevalence in Chinese adolescentsWomen men1/2 women and 1/3 men age 65Management of constipation costs$29 billion annually in the US$800 million spent on laxatives each year,American Gastroenterological Association,Gastroenterol,2000.,Constipation:Rome III Criteria,Duration 3 months Symptom onset
4、at least 6 months prior to diagnosis2 or more of the following symptoms 25%of the time Excessive straining Lumpy or hard stoolsSensation of incomplete evacuation Sensation of anorectal obstruction/blockageManual maneuvers to assist in defecation 3 unassisted defecations per week Rare loose BMs witho
5、ut laxatives,Etiology of Constipation,LifestyleMedicationsMedical illnessNeurologicEndocrine/MetabolicPsychiatricPrimary disease of the colon/anorectumCancerHirschsprungs diseaseProctitisFissure,Nyam et al,Dis Colon Rectrum,1997.,Chronic Idiopathic Constipation,Slow transit constipation(11%)Ineffect
6、ive colonic propulsionPelvic outlet obstruction(13%)Paradoxical puborectalis contractionRectoceleCombined(5%)IBS-C(71%),Bharucha,Best Pract Res Clin Gastroenterol,2007.,Pathophysiology of Slow-Transit Constipation,Structurally normal colon and rectumBlunted gastrocolic response to mealsReduced colon
7、ic response to morning wakingImpaired phasic colonic motor activityDecreased HAPCsvelocity,frequency,amplitudeIncreased periodic rectal motor activity Paucity of interstitial cells of CajalDecreased level of motilinConcurrent upper GI motility disorder(77%),Detailed History,Onset/duration of constip
8、ationSymptomsfrequency,consistency,size,strainingLifestyleDiet,exerciseChangesComorbidities,past surgeriesMedicationsObstetric historyPsychiatric history(sexual abuse)Family history,Factors Suggestive of STC,Female Onset in childhood or adolescence20-30sExcessive laxative useGynecologic complaintsIr
9、regular mensesOvarian cystsGalactorrhea 2 BMs per week,Physical Examination,Abdominal examTenderness,distentionMass,palpable stool,herniaPelvic examPelvic organ prolapse with strainDigital examinationRectocelePerineal descentVoluntary relaxation of the sphincter,Diagnostic Studies,Laboratory evaluat
10、ionColonoscopy/barium enemaColonic transit studyScintigraphyMarker studiesManometry/balloon expulsionDefocography vs.dynamic MRISmall bowel transit,Hinton et al,Gut,1969.,Radiopaque Marker,Hinton et al(1969)Single capsule containing 24 markersX-ray on day 5X-ray on day 1,3,and 5(segmental)Single cap
11、sule on three successive daysX-ray on day 4Slow transit=Retention of 20%of markers by day 5,Normal,Colonic Inertia,Outlet obstruction,Sitz Marker Transit Study,Treatment:Medical,Lifestyle modificationFiber supplementationAdequate hydrationRegular exerciseMedication minimizationCorrection of metaboli
12、c abnormalitiesPsychiatric evaluationPharmaceuticalLaxatives,enemasPelvic floor physical therapy/Biofeedback,When to Perform Surgery?,After a complete history and physicalAfter the completion of appropriate testing After failed diet and fluid optimizationAfter failed aggressive medical management an
13、d bowel habit trainingAfter failed physical rehabilitationWhen constipation severely affects QOLMollen et al4.8%fulfill criteria to be offered surgery,Treatment:Surgical,Subtotal colectomy with anastomosisIleorectalIleosigmoidCecorectal Antiperistaltic cecorectal(Sarli)Ileoanal Segmental colectomyCo
14、lonic bypassIleorectal anastomosisAntiperistaltic cecoproctostomyAntegrade colonic enemaStomaSacral nerve stimulation,GoalIncrease the frequency of BMs and relieve associated symptoms.,Feng and Jianjiang,Am J Surg,2008;Di Fabio,Dis Colon Rectum,2010.,Subtotal Colectomy,Arbuthnot Lane1908Ileorectal a
15、nastomosis20%mortality,64%success Ogilvie1931Cecorectal anastomosisMortality0-15%MorbiditySmall bowel obstruction(9-71%)Diarrhea+/-fecal incontinence(10-40%)Persistence of constipation(10-30%)Persistence of abdominal pain and bloatingPoorer QOL reported following IRA for STC than for Crohns and canc
16、er patientsDespite a similar satisfaction with the procedure,Pinto and Sands,Gastrointest Endoscopy Clin N Am,2009.,Results of Subtotal Colectomy with IRA,Pinto and Sands,Gastrointest Endoscopy Clin N Am,2009.,Subtotal Colectomy with CRA,AdvantagePreservation of the ileocecal valve/terminal ileumAbs
17、orption of water,electrolytes,vit B,bileDecreased incidence of excessive daily BMsDisadvantageCecal distentionRecurrence of constipationAbdominal pain50%conversion rate to IRA(Pemberton et al),Iannelli et al,Surg Endoscop,2005.,Subtotal Colectomy with Antiperistaltic CRA,14 patientsIncreased bowel f
18、requency1.2 0.6/week to 4.8 7.5/dayContinence78.5%Perfect14.2%1 soiling episode/weekPostoperative complications21.4%One reoperation,Feng and Jianjiang,Am J Surg,2008.,Subtotal Colectomy with ISA or CRA,45 ISA/34 CRAMean follow up of 2 yearsPersistent constipation,laxative use6.7%vs.26.8%(p0.05)Fecal
19、 incontinence2.9%vs.0%(p0.05)Overall satisfaction93.3%vs.73.5%,OBrien et al,Dis Colon Rectum,2009;Beck et al,S Med J,1989.,Predictors of Failure?,Small bowel intestinal dysmotilityAntroduodenal manometryLactulose breath hydrogen testUndiagnosed obstructive defecation syndromePsychiatric illnessPrevi
20、ous sexual abusePersistent abdominal pain88%(abused)vs.0%(nonabused),Pinto and Sands,Gastrointest Endoscopy Clin N Am,2009;Lundin et al,Br J Surg,2002.,Segmental Colectomy,Reduction in diarrhea and fecal incontinence?Reduction in SBO?Scintigraphy to determine segmental transitNot widely availableCon
21、firms marker study results of total transitGood patient complianceNot currently recommendedHigh incidence of recurrent/persistent constipation(16-18%)New-onset diarrhea(14-18%),Lundin E et al,Br J Surg,2002.,Result of Segmental Resection,28 patients with a median of 50 months of follow up26 left hem
22、icolectomy6 with suture rectopexyOutcome5 required additional surgery due to persistent constipationImpaired rectal sensationSlower rate of evacuation on preop defocographySignificant improvement in function but not in abdominal pain or bloatingPersistent diarrhea3.6%60.7%-Excellent or good result82
23、.1%-Recommend to a friend or relative,Pinedo et al,Dis Colon Rectum,2008.,Colonic Bypass,First introduced by Pinedo et al.Laparoscopic ileosigmoid anastomosis in two patientsAdvantagesMinimal dissectionLower incidence of SBO?DisadvantageColonic bacterial overgrowth?Increased incidence of colon cance
24、r?,Wang et al.,Int J Colorectal Dis,2010.,Results of Subtotal Colonic Bypass,Subtotal colonic bypass with antiperistaltic cecoproctostomy18 patients(72%female)with 17 mo f/uNo mortality or small bowel obstruction6 month follow up80%improved QOL,17%unsatisfactory72%Normal BMs(average 1.8 per day)17%D
25、iarrhea requiring medications6%Constipation requiring laxatives6%No change in constipation,Sinha et al,Pediatr Surg Int,2008;Pinto and Sands,Gastrointest Endoscopy Clin N Am,2009.,Antegrade Colonic Enema,Malone1990 Children with neurogenic disorders and fecal incontinenceCreates a nonrefluxing condu
26、it for intermittent catheterizationCecum or appendixAllows for colonic irrigation,resulting in rapid and controlled evacuation of the large bowel contentsStomal stenosis,Antegrade Colonic Enema,For patients who do not want a colectomyFor patients at risk of fecal incontinenceDoes not preclude furthe
27、r surgery,Lees et al,Colorectal Disease,2004.,Results of ACE:Adult,32 patients with 37 conduits performed54%appendix5%laparoscopicComplications(88%)Minor revision38%Major revision38%Success47%in use at a median of 36 months50%in use at 5 yearsReversal for stenosis,leakage,or persistent constipation5
28、9%at a median of 13 months8%reversed after 24 monthsEnd stoma(9),colectomy(3),Ileostomy,Rarely performed as an initial intervention for constipationUsually follows failure of subtotal colectomy Poor candidates for more major abdominal surgery,Scarpa M,Colorectal Disease,2005.,Results of Ileostomy,24
29、 patients with a mean follow up of 47 months92%slow transit constipationEnd stoma38%Trephine20.8%Stoma complications53.4%(overall)Retraction25%Peristomal sepsis12.5%Parastomal hernia8.3%Stoma pain8.3%Persistent constipation4%Stoma revision29.1%at a mean of 49 monthsStoma reversal16.6%(4)at 3.3 month
30、sRecurrent constipation(2)Authors favored the trephine loop stoma,Kamm et al,Gut,2010.,Sacral Nerve Stimulation?,Not currently approved for constipation in the USModulation of extrinsic neural control to colonContinuous low amplitude stimulation of sacral nerve rootsIncreased rectal sensitivity to d
31、istention?Increase in pancolonic HAPCs?Low morbidity,well tolerated,reversible,Kamm et al,Gut,2010;Carriero et al,Int J Colorectal Dis,2010.,Results of SNS,Conclusions,Constipation is a common complaint.Constipation usually arises from lifestyle issues.Further evaluation is needed in select cases.Co
32、nstipation symptoms must be distinguished as pelvic or colonic in origin.Most patients are treatable medically.Surgery for constipation is rarely indicated for intractable symptoms in a select patient population.Subtotal colectomy with ileorectal anastomosis remains the gold standard.Surgery for constipation is a field in evolution.Further study of the newer options is needed.,
