Constipation

							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