JNM J Neurogastroenterol Motil, Vol. 19 No. 1 January, 2013 pISSN: 2093-0879 eISSN: 2093-0887 Original Article http://dx.doi.org/10.5056/jnm.2013.19.1.78 Journal of Neurogastroenterology and Motility Successful Outcome of Refractory Chronic Constipation by Surgical Treatment: A Series of 34 Patients Ashok Kumar,1* HM Lokesh1 and Uday C Ghoshal2 Departments of1Surgical Gastroenterology and2Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, UP, India Background/Aims Chronic constipation is commonly managed medically, and surgical options have been advocated in patients with refractory symptoms. We aimed to study the role of surgical procedures in patients with constipation, refractory to medical therapy. Methods Data on 34 surgically managed patients with refractory chronic constipation during a 6-year period (March 2003 to May 2009) were retrospectively analyzed. Results All the 34 patients (24 males and 10 females, median age of 45 years [range, 18-77 years]) had symptoms for a long period (median 96 months [range, 12-360 months]) without response to medical treatment including biofeedback. Preopertive inves- tigations included barium enema, colonoscopy, colonic transit study, defecography and anorectal manometry as indicated. Eight patients (23.5%) had slow transit constipation, 4 (11.8%) had Hirschsprung’s disease and 22 (64.7%) had rectal prolapse. Total colectomy and ileo-rectal anastomosis, anterior resection, Delorme’s procedure, resection rectopexy and Duhamel’s operation were the surgical procedures performed. Though 7 (20.6%) patients had post operative complications, there was no mortality. One patient whose symptoms recurred following anterior resection was successfully treated by total colectomy and ileo-rectal anastomosis. Median spontaneous bowel movements increased following surgical treatment compared to that while on medical treatment (1 per week [range, 0 to 3 per week] vs. 14 per week [range, 7-28 per week], P < 0.00001). Patients remained well during 3-60 months follow-up (n = 27). Conclusions Spontaneous bowel movements significantly increased following surgical operation for refractory chronic constipation, nature of which is dependent on underlying etiology and the expertise available. Careful preoperative work-up and selection of pa- tients are critical for obtaining good functional results. (J Neurogastroenterol Motil 2013;19:78-84) Key Words Constipation; Outcome assessment; Surgery Received: August 22, 2012 Revised: November 8, 2012 Accepted: November 15, 2012 CC This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons. org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. *Correspondence: Ashok Kumar, MS, FACS, FRCS Department of Surgical Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Rae Bareli Road, Lucknow 226014, UP, India Tel: +91-522-2668700 (ext. 4423, 4401) or +91-522-2998550, Fax: +91-522-2668017 (or 2668078), E-mail: doc.ashokgupta@gmail. com Financial support: None. Conflicts of interest: None. Author contributions: Ashok Kumar: conception and design of the article. HM Lokesh: drafting of the article. Uday C Ghoshal: analysis and inter- pretation of the data. ⓒ2013 The Korean Society of Neurogastroenterology and Motility 78 J Neurogastroenterol Motil, Vol. 19 No. 1 January, 2013 www.jnmjournal.org Surgical Management of Chronic Constipation sensation of incomplete evacuation in more than 25% of defeca- tions, (4) manual maneuvers (e.g., digital evacuation and support Introduction of the pelvic floor) to facilitate more than 25% of defecations and Chronic constipation (CC) is a common complaint at all ages (5) 2 or less bowel movements per week. Details regarding his- and is commonly associated with symptoms interfering with pa- tory, spontaneous bowel movements (SBM) per week, clinical tient’s quality of life. Constipation can result from several factors, examination, and treatment received at other center before re- like person’s life style such as low fiber diet, inadequate fluid in- ferral and associated medical conditions were documented. They take, consumption of intake of some drugs, slow colonic motility, were then investigated based on standard protocol using barium fecal evacuation disorders and combination of above.1 Organic enema, colonoscopy, colonic transit time (CTT) study, defecog- and anatomical causes affect the management strategy. Correc- raphy and anorectal manometry. The investigations were tailored tion of life style factors and supplementation with laxatives relieve as per the clinical diagnosis; therefore, all patients did not under- constipation in majority of patients. Surgery will be required in go every test. Systemic causes for constipation were ruled out by minority of patients who fail medical management. Colectomy for testing serum thyroxin, thyroid stimulating hormones and post- constipation was first described by Sir Arbuthnot Lane a century prandial blood sugar levels in all patients. HD patients were re- ago,2 and since then various combinations of surgical procedures ferred for surgical management once the diagnosis was made. have been used. Studies regarding surgical management of re- Remaining patients were referred for surgery after failed medical fractory constipation have been conducted on Western popula- management using laxatives, enemas and biofeedback therapy. tion. No study has addressed the need of surgery and its outcome Pressure Biofeedback therapy was performed using a water per- in Indian population, where the dietary and bowel habits are dif- fusion manometry system and 2 port low compliance polyvinyl ferent, and the indication for surgery may also be different. This catheter (one port in rectum and another in anal canal) (RedTech, study was conducted to assess the postoperative and long-term Calabasas, CA, USA). Each session lasted 20 to 30 minutes, in outcome of surgical management in CC patients, who were re- which patient received visual and auditory feedback showing fractory to medical management. whether he/she could reduce anal sphincter pressure below the target level and rectal pressure above the target pressure. Patient received 2 sessions each day for a period of 14 days. Biofeedback Materials and Methods was given only to consenting patients with fecal evacuation dis- Retrospective analysis of prospectively maintained data of 34 order (except HD) with or without STC. surgically managed patients with refractory chronic constipation CTT study was done using locally manufactured radio-opa- was performed at Department of Surgical Gastroenterology in que markers in gelatin capsules (SG mark); subjects were asked Sanjay Gandhi Postgraduate Institute of Medical Sciences to ingest 4 capsules at a time (5 markers in each capsule) at 0, 12 (SGPGIMS), Lucknow, a tertiary referral center in northern and 24 hours. Subsequently, abdominal X-rays were taken at 36 India from March 2003 to May 2009. Patients were divided into and 60 hours. STC was diagnosed when more than 30 markers in 3 groups according to the indication for surgery, such as slow 36 hours X-ray or more than 14 markers in 60 hours X-ray were transit constipation (STC) (n = 8, 23.5%), congenital anomaly retained in colon.4 like Hirschsprung’s disease (HD) (n = 4, 11.8%) and con- stipation with rectal prolapse (n = 22, 64.7%). Definitions SBM was defined as passage of stools without the use of lax- Evaluation and Medical Management atives or enemas or digital evacuation. Surgery was considered All patient initially presented to the Department of Gastroen- when one or more of the following criteria were present. terology at our center, where each of them was evaluated clinically (1) Requiring excessive cathartics (failure of osmotic lax- with detailed history and physical examination. CC in these pa- atives to work requiring stimulant laxatives or enema on tients was defined by Rome II diagnostic criteria3; 2 or more of regular basis) the following criteria were present for at least 12 weeks in the pre- (2) Not responding to cathartics, (less than 3 bowel move- ceding 12 months, (1) straining in more than 25% of defecations, ments per week and with unusual prolonged straining in (2) lumpy or hard stools in more than 25% of defecations, (3) spite of high dose of laxatives) Vol. 19, No. 1 January, 2013 (78-84) 79 Ashok Kumar, et al (3) Fecal impaction and rectal prolapse on rectal examination (4) Gastrointestinal transit test showing slow colonic transit Surgical Management and Follow-up on CTT Consent for surgery was obtained from all patients after in- (5) Rectocele confirmed on defecography forming the nature of disease, its outcome, treatment options, (6) Absence of ganglion cells in submucosal and myenteric possible outcomes of surgical management, complication and plexus on rectal biopsy suggesting HD long-term functional outcomes. Resectional surgical procedures Gastrointestinal organic diseases were excluded by colono- were performed according to the indications for surgery. Close scopy or barium enema as indicated. Response to treatment was monitoring of patients was done in post-operative period for any defined by number of SBM per day and it was considered sat- complication. Patients were then followed up in outpatient clinic; isfactory with minimum of one SBM per day. details regarding SBM per day, need of laxatives and satisfaction with surgical outcome were documented. Statistical Methods Table 1. Patients Characteristics (N = 34) Data was entered in SPSS 15.0 statistical package software Sex (n [%]) (SPSS Inc., Chicago, IL, USA). All data are expressed as me- Male 24 (70.5) Female 10 (29.4) Age (yr) Table 2.Duration of Symptoms and Medical Therapy (Months) Median 45 Duration of Duration of Range 18-77 Group symptoms medical therapy Duration of symptoms (yr) (mean [range]) (mean [range]) Median 8 Range 1-30 STC (n = 8) 114 (24-300) 100 (24-240) Group wise distribution (n [%]) HD (n = 4) 117 (12-360) 58 (6-120) Slow transit constipation 8 (23.5) Constipation with 121 (24-360) 104 (6-360) Hirschsprung’s disease 4 (11.8) prolapse (n = 22) Constipation with prolapse 22 (64.7) STC, slow transit constipation; HD, Hirschsprung’s disease. Figure 1. (A) Defecography - showing anterior rectocele (white long arrow) with intra-anal intussusception (white arrow heads) and incomplete rectal evacuation during defecation, (B) Defecography - showing rectocele (white short arrow) on straining, (C) Colonic transit study - 60 hourrs abdominal X-ray showing retained markers (black arrows) dispersed through- out the colon. 80 Journal of Neurogastroenterology and Motility Surgical Management of Chronic Constipation dian and range. Statistical comparison of pre-operative and All HD patients were found to have dilated colon and prox- post-operative SBM was done with Wilcoxon signed-rank test and imal rectum on barium enema examination. Four patients with P-value of less than 0.05 was considered statistically significant. STC showed normal small bowel transit on barium meal follow through examination. Defecography examination revealed in- ternal intussusception in 1 (Fig. 1A), anterior rectocele in 3 pa- Results tients (Fig. 1B), posterior rectocele in 1, posterior wall ulcer in 1 During the study period from March 2003 to May 2009, 34 and rectocele with abnormal pelvic floor descent in 2 patients patients with refractory CC were surgically treated at our center. (Table 3). There were 24 males (70.6%) and 10 females (29.4%) in the age On CTT study all eight patients with STC revealed delayed range of 18-77 years (median, 45 years). Patient’s characteristics passage of markers. Retention of more than 14 markers dispersed are shown in Table 1. All patients had complaints of constipation in colon on 60 hours X-ray was seen in 5 patients (Fig. 1C) and and feeling of incomplete bowel evacuation for a significantly retention of more than 14 markers in sigmoid colon and rectum long period of time. Median duration of symptoms was 96 was seen in remaining 3 patients. Two patients of HD who un- months (range, 12-360 months) and the median duration of med- derwent CTT revealed delayed excretion with retention of mark- ical management was 60 months (range, 6-360 months). The ers in sigmoid colon and rectum. Anorectal manometry showed group wise distribution of duration of symptoms and medical absent recto-anal inhibitory reflex, abnormal balloon expulsion treatment was almost similar except in HD patients; they were re- (> 200 g) and normal sphincter pressures in all HD patients. ferred sooner for surgical intervention once the diagnosis was Sphincter length was 3.5 ± 1.5 cm in HD patients. made (Table 2). HD patients were treated for significantly long Unsuccessful surgical interventions were already performed period at outside hospital before referral to our center. in 8 patients elsewhere (2 in HD group and 6 in prolapse with Table 3. Investigations Performed Barium enema (n = 7) Colonoscopy (n = 12) CTT (n = 12) ARM (n = 21) Defecogram (n = 8) Normal Abnormal Normal Abnormal Normal Abnormal Normal Abnormal Normal Abnormal STC 3 5 8 4 3 6 HD 4 2 2 4 Constipation with prolapse 5 2 6 4 2 CTT, colonic transit study; ARM, anorectal manometry; STC, slow transit constipation; HD, Hirschsprung’s disease. Figure 2. Flow chart showing surgical procedures, complications and early outcome among patients with refractory chronic constipation. SBM, spontaneous bowel movements. Vol. 19, No. 1 January, 2013 (78-84) 81 Ashok Kumar, et al Table 4. Post Operative Major Complications Complication n (%) Anastomotic leak 2 (5.9) Intra-abdominal bleed 1 (2.9) Adhesive obstruction 3 (8.8) Ureteric injury 1 (2.9) Total 7 (20.6) constipation group) before referral to our center. Two patients with HD had sigmoidectomy; among rectal prolapse group, su- ture rectopexy and Thiersch wiring were performed on 2 patients, mesh rectopexy in 2, Fothergill’s surgery for uterine prolapse in 1 Figure 3. Spontaneous bowel movements before and after surgical treatment (Wilcoxon signed-rank test). and Thiersch wiring in 1 patient. After detailed evaluation as described above, patients were taken up for surgical management (Fig. 2). Three patients with with outcome of surgery. One patient with STC had recurrence STC underwent total colectomy and ileo-rectal anastomosis of constipation after anterior resection. On subsequent evaluation (IRA), 4 patients underwent low anterior resection (LAR) and 1 by CTT study, the patient was diagnosed with colonic inertia and underwent anterior resection in view of redundant sigmoid colon completion total colectomy and IRA was done later. This patient on barium enema study. Three out of 4 patients with HD under- had average of 2 SBMs per day and remained asymptomatic for 2 went modified Duhamel’s procedure while 1 had Swenson’s years of follow-up. procedure. In patients with constipation and rectal prolapse, ante- rior resection was done in 5 patients, resection rectopexy in 6, Discussion LAR in 7 and Delorme’s procedure in 4 patients. Seven patients (20.6%) had major post operative complica- Constipation is a common problem all over the world. The tions (Table 4). However, there was no mortality. One patient first important step in management of constipation is to exclude had ureter injury in deep pelvis during modified Duhamel’s pro- organic and anatomic causes with detailed evaluation. Medical cedure; requiring re-exploration and ureter re-implantation, and management along with biofeedback program is effective in ma- recovered well after the surgery. One patient had intra-abdominal jority of patients with constipation.5 Surgery is required in small bleed which manifested as drain bleed and underwent re-explora- proportion of patients for correction of anatomical problems like tion. Three patients had adhesive small bowel obstructions, 2 of stenotic diverticulitis or outlets problems or specific disorders like them were managed conservatively and one patient required HD or functional disorders like slow transit constipation. re-exploration. Another 2 patients required re-exploration for Planning prospective studies related to surgery in refractory anastomotic leak. Six patients had minor complications like constipation is difficult due to the small number of patients. Pa- wound infection (3 patients), post operative fever (1 patient) and tients with CC require thorough medical history, physical and paralytic ileus (2 patients). Out of 8 patients, who were operated laboratory examination, colonoscopy, barium enema and defe- elsewhere before referral to our center, 4 patients had complica- cography to rule out the secondary causes of constipation. Barium tions, of which 3 had major complications; 2 had adhesive ob- defecography and anorectal manometry studies are required to struction and 1 had ureteric injury. evaluate evacuation disorders. Colonic transit studies are neces- Follow-up information was available in 27 (79.4%) patients, sary to rule out slow transit constipation. When surgical treat- and length of follow-up duration varied from 3 to 60 months ment is performed according to results of all the above mentioned (mean, 17.8 months). Median SBM significantly improved from investigations, successful outcomes might be achieved.6 1 per week (range, 0-3 per week) to 14 per week (range, 7-28 per Different types of surgical procedures have been described in week) following surgical treatment (P < 0.00001) (Fig. 2 and 3). literature, such as total colectomy and IRA (72%) the most com- Two (5.9%) patients required laxatives to facilitate the passage of mon type, sigmoid colectomy (10%), subtotal colectomy with ce- stools intermittently. Overall 25 (92.6%) patients were satisfied co-rectal anastomosis (6%) and left hemicolectomy (6%).7 In our 82 Journal of Neurogastroenterology and Motility Surgical Management of Chronic Constipation study, total colectomy with IRA and LAR were performed in 4 pa- constipation in 98%, satisfactory bowel movements in 85%, and tients with STC. Laparoscopic total colectomy and IRA have been improvement in performance measures including social activity reported with post operative ileus (11.4%), intestinal obstruction (75%) and sexual life (81%) have been reported.14 Same study al- (4.5%) and satisfaction rate of 88.6% in post operative period.8 so reported the improvement in physical and mental health after Most common early complications following surgery are post surgery comparable to normal population. Surgery resulted in operative ileus, infection and anastomotic leak.7 Reported in- durable symptomatic relief and also improvement in long-term cidence of post operative ileus varies from 0 to 13%; infection rate quality of life comparable to general population. Cochrane review varies from 0 to 11.5% and anastomotic leak from 0 to 2.3%.8-12 was done with 12 randomised controlled trials, including 380 pa- In our study, the incidence of post operative obstruction (8.8%) tients with rectal prolase, to determine the effects of surgery for and anastomotic leak (5.9%) was similar to reported series. the treatment of rectal prolapse in adults. Only two trials with a Overall complication rate was 20%. total of 48 patients addressed the effect of resection on recurrence Knowles et al13 systematically reviewed the literature on co- of rectal prolapse and constipation. The combined results of the lectomy for slow transit constipation in respect to results and out- study suggested that resection improved constipation and none of comes in 1999, which included 32 case series ranging from 12 pa- the patients had recurrence.15 tients to 106 patients. The commonest postoperative morbidity Limitations of our study include selection bias and lack of a was small bowel obstruction occurring in 2 to 71% patients control group. Other limitation of the study is the small number (median, 18%) which resulted in reoperation in 0 to 50% (median, of patients. Despite these limitations, our study addresses the is- 14%). Similar findings have been observed in our study also with sue which is infrequently addressed in Asian patients. 3 (8.7%) patients having small bowel obstruction among which 1 In conclusion, careful preoperative work-up and selection of patient (2.9%) required re-exploration. Mortality rates varied patients is critical for obtaining good functional results. Surgery from 0 to 6%. None of our patient died in post operative period. should be considered only in patients who have severe refractory Overall documented patient satisfaction rates varied from 39 to constipation after medical treatment. Surgery depends on etiol- 100% (median, 86%). Postoperative bowel habit was only nu- ogy of constipation. SBM significantly increases following surgi- merically quantified in 20 series, with median bowel habits of cal operation, nature of which is dependent on underlying etiol- 2.9/day. Recurrence of constipation symptoms was documented ogy of the constipation and the expertise available. Although the in 0 to 33%, with median of 9%. number of study population was small, our study showed mean- In our study, we achieved an excellent satisfaction rate of ingful results that surgical management is effective and sat- 92% with median spontaneous bowel movements of 14 stools per isfactory with acceptable morbidity in patients with refractory week (range, 7-28 stools per week). Overall reported satisfaction constipation. rate in literature was 88% (57-100%). Only few studies included objective questionnaires to record improvement and quality of References life. Mean stool frequency in the published reports was 19.5 stools per week (range, 7-56 stools per week).7 1. Borum ML. Constipation: evaluation and management. Prim Care Post operative fecal incontinence as late complication has 2001;28:577-590. vi. 2. Lane WA. Remarks on the result of the operative treatment of chron- been reported with incidence of 18% in literature ranging from ic constipation. Br Med J 1908;1:126-130. 1.3 to 53.0%.7 None of our patients experienced incontinence in 3. Wald A. Pathophysiology, diagnosis and current management of post operative period. Post operative recurrent constipation was chronic constipation. Nat Clin Pract Gastroenterol Hepatol 2006;3: reported in 12.5% patients (2-51%). Requirement of laxatives to 90-100. 4. Ghoshal UC, Gupta D, Kumar A, Misra A. The Colonic transit relieve constipation has been reported from 0 to 37.5%.7 Only 3 study by radio-opaque markers to investigate constipation: validation (8.7%) of our patient had recurrence of constipation, with 2 of a new protocol for a population with rapid gut transit. Nat Med J (5.9%) requiring laxatives to relieve the symptoms and 1 (2.9%) India 2007;20:225-229. completion total colectomy. 5. Heymen S, Scarlett Y, Jones K, Ringel Y, Drossman D, Whitehead WE. Randomized, controlled trial shows biofeedback to be superior Long-term functional and quality of life have been evaluated to alternative treatments for patients with pelvic floor dyssynergia- in 104 patients with STC who underwent total colectomy and type constipation. Dis Colon Rectum 2007;50:428-441. IRA, with median follow-up period of 11 years. Improvement in 6. FitzHarris GP, Garcia-Aguilar J, Parker SC, et al. Quality of life af- Vol. 19, No. 1 January, 2013 (78-84) 83 Ashok Kumar, et al ter subtotal colectomy for slow transit constipation. Dis Colon Rectum patients undergoing colectomy for chronic idiopathic constipation. 2003;46:433-440. Aust N Z J Surg 1996;66:525-529. 7. Arebi N, Kalli T, Howson W, Clark S, Norton C. Systematic review 12. Pemberton JH, Rath DM, Ilstrup DM. Evaluation and surgical of abdominal surgery for chronic idiopathic constipation. Colorectal treatment of severe chronic constipation. Ann Surg 1991;214:403- Dis 2011;13:1335-1343. 411. 8. Hsiao KC, Jao SW, Wu CC, Lee TY, Lai HJ, Kang JC. Hand-as- 13. Knowles CH, Scott M, Lunniss PJ. Outcome of colectomy for slow sisted laparoscopic total colectomy for slow transit constipation. Int J transit constipation. Ann Surg 1999;230:627-638. Colorectal Dis 2008;23:419-424. 14. Hassan I, Pemberton JH, Young-Fadok TM, et al. Ileo-rectal anas- 9. Feng Y, Jianjiang L. Functional outcomes of two types of subtotal tomosis for slow transit constipation: long-term functional and quality colectomy for slow-transit constipation: ileo-sigmoidal anastomosis of life results. J Gastrointest Surg 2006;10:1330-1336, discussion and ceco-rectal anastomosis. Am J Surg 2008;195:73-77. 1336-1337. 10. Lahr SJ, Lahr CJ, Srinivasan A, Clerico ET, Limehouse VM, 15. Tou S, Brown SR, Malik AI, Nelson RL. Surgery for complete rec- Serbezov IK. Operative management of severe constipation. Am tal prolapse in adults. Cochrane Database Syst Rev 2008;(4): Surg 1999;65:1117-1121, discussion 1122-1123. CD001758. 11. Platell C, Scache D, Mumme G, Stitz R. A long-term follow-up of 84 Journal of Neurogastroenterology and Motility