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All Boards >> Irritable Bowel Syndrome Research Library

HeatherAdministrator

Reged: 12/09/02
Posts: 7677
Loc: Seattle, WA
Surgical Treatment of Chronic Functional Constipation?
      03/04/05 11:24 AM

From Ask the Experts about General Gastroenterology
From Medscape Gastroenterology

Surgical Treatment of Chronic Functional Constipation?

Question
What is the appropriate work-up for chronic functional constipation, and how successful is partial colectomy in patients whose very-slow-transit constipation is "resistant" to routine treatment?

Response from Yehuda Ringel, MD

Assistant Professor of Medicine, University of North Carolina at Chapel Hill; Staff Physician, Department of Medicine, University of North Carolina Hospital, Chapel Hill

Surgical treatment of chronic functional constipation should be considered only in the most severe cases of slow-colonic-transit constipation for those patients who do not respond to aggressive medical therapy. Prior to surgery, patients should be carefully evaluated for existence of other gastrointestinal conditions and symptoms, particularly abdominal pain and irritable bowel syndrome. It is crucial to inform the patient that the surgical procedure is aimed to ease the constipation but is not likely to alleviate other gastrointestinal symptoms. A detailed work-up should include: (1) exclusion of known causes of constipation, such as medications (eg, opiates and anticholinergics); low-fiber diet; mechanical obstruction (eg, colon cancer or stricture); metabolic disorders (eg, hypothyroidism, hypercalcemia); psychological disorders (severe depression); and others; (2) confirming the diagnosis of severe functional colonic inertia (slow transit)-type constipation by studying colonic transit time (eg, radiopaque marker studies); and (3) exclusion of other possible treatable conditions, such as disturbed defecation, as assessed by anorectal manometry (eg, for Hirschsprung's disease and other pelvic floor dysfunctions) and defecation studies (eg, for rectocele and rectal prolapse); and chronic intestinal pseudo-obstruction, as assessed by radiologic or manometric studies.

The recommended surgical procedure is subtotal colectomy with ileorectal anastomosis. Partial colectomy has not been found to be helpful and should therefore not be considered. A comprehensive review of 13 reported studies of 362 patients who underwent colectomy and who were followed for 1.2-8.9 years reported a success rate of 88%.[1] A recent prospective long-term (mean follow-up of 56 months) study of 52 patients who were carefully evaluated and underwent surgery for slow-transit constipation showed that over 90% of patients were satisfied with the results of surgery, and reported a good or improved quality of life.[2] Postoperative complications may include small-bowel obstruction, prolonged ileus, abdominal pain, and diarrhea.

More recently, antegrade continent enema has been suggested as an alternative approach in patients who are unable or unwilling to undergo colectomy. Conduits can be created from the appendix, cecum, or ileum. A recent retrospective study of 32 patients who underwent this procedure, with a median of 36 months' (range, 13-140 months) follow-up, reported satisfactory long-term results in approximately half of the patients -- although revision procedures were often required.[3] However, the procedure is reversible and does not preclude subsequent surgical intervention.



--------------------------------------------------------------------------------

References
Pikarsky AJ, Singh JJ, Weiss EG, Nogueras JJ, Wexner SD. Long-term follow-up of patients undergoing colectomy for colonic inertia. Dis Colon Rectum. 2001;44:179-183. Abstract
Nyam DC, Pemberton JH, Ilstrup DM, Rath DM. Long-term results of surgery for chronic constipation. Dis Colon Rectum. 1997;40:273-279. Abstract
Lee NP, Hodson P, Hill J, Pearson RC, MacLennan I. Long-term results of the antegrade continent enema procedure for constipation in adults. Colorectal Dis. 2004;6:362-368. Abstract




Disclosure: Yehuda Ringel, MD, has disclosed that he has received grants for clinical research from GlaxoSmithKline, AstraZeneca, and Novartis. He has received grants for educational activities from Solvay. Dr. Ringel has also reported that he is on the speaker's bureau for Novartis and has served as an advisor or consultant for GlaxoSmithKline.




Medscape Gastroenterology. 2005; 7 (1): ©2005 Medscape

http://www.medscape.com/viewarticle/497702?src=mp

--------------------
Heather is the Administrator of the IBS Message Boards. She’s the author of Eating for IBS and The First Year: IBS, and the CEO of Heather's Tummy Care. Join her IBS Newsletter. Meet Heather on Facebook!

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