BACKGROUND: Patients with chronic constipation can be difficult to manage either medically or surgically. We used Roma classification as criteria for including patients in our study. There are many diseases which could lead to chronic constipation. If they are treated by a surgeon, there can be obtained a permanent therapeutic effect. The group of patients with idiopathic chronic constipation couldn't obtain satisfying effect by surgical treatment, which was presided by inaccurate and embarrassed selection. Our aim is to present the results of experience of Clinic of General and Operative Surgery, Varna, Bulgaria.MATERIAL: For a period of 10 years, we have been operated 52 patients with diagnosis as morbus Pair (15 patients), megacolon (31 patients), and idiopathic chronic constipation (6 patients). The main indication for undergoing surgical treatment was the retention of more then 20% of the applied barium enema after the 5th day from irrigography. There were applied the followed operative methods: colectomy, subtotal colectomy, hemicolectomy, resection of the colon sygmoideum, anterior resection of the rectum and mobilization of the lineal flexure. We did analysis of the results. The evaluation of curativeness to applied methods was done. We followed the quality of life of our patients from 11 months to 6.2 years (median 3.2 years).CONCLUSION: The presence of organic disease is associated with very good therapeutic effect from the surgical treatment of chronic constipation. The problem with idiopathic chronic constipation remains unsolved when colectomy with ileo-recto anastomosis was undergone. The right selection of patients is a crucial factor for the success of the surgical treatment

Ignatov, Valentin

Ivanov, Krasimir

Kolev, Nikola

Tonev, Anton

English

Varna Medical University Press: Journals

SUR GI CAL TREAT MENT OF PA TIENTS WITH CHRONIC CON STI PA TION - EX PE RI ENCE OF CLINIC OF COLOPROCTOLOGY - VARNATonev A., K. Ivanov, V. Ignatov, N. KolevDepartment of General and Operative Surgery, University Hospital "St. Marina"Reviewed by: assoc. prof. R. Madjov ABSTRACTBACKGROUND: Pa tients with chronic con sti pa tion can be dif fi cult to man age ei ther med i cally or sur gi cally. We used Roma clas si fi ca tion as cri te ria for in clud ing pa tients in our study. There are many dis eases whichcould lead to chronic con sti pa tion. If they are treated by a sur geon, there can be ob tained a per ma nent ther a -peu tic ef fect. The group of pa tients with id io pathic chronic con sti pa tion could n't ob tain sat is fy ing ef fect bysur gi cal treat ment, which was pre sided by in ac cu rate and em bar rassed se lec tion. Our aim is to pres ent the re -sults of ex pe ri ence of Clinic of Gen eral and Op er a tive Sur gery, Varna, Bul garia. MATERIAL: For a pe riodof 10 years, we have been op er ated 52 pa tients with di ag no sis as morbus Pair (15 pa tients), megacolon (31 pa -tients), and id io pathic chronic con sti pa tion (6 pa tients). The main in di ca tion for un der go ing sur gi cal treat -ment was the re ten tion of more then 20% of the ap plied bar ium en ema af ter the 5th day from irrigography.There were ap plied the fol lowed op er a tive meth ods: colectomy, sub to tal colectomy, hemicolectomy, re sec tionof the co lon sygmoideum, an te rior re sec tion of the rec tum and mo bi li za tion of the lin eal flex ure. We did anal y -sis of the re sults. The eval u a tion of cura tive ness to ap plied meth ods was done. We fol lowed the qual ity of life of our pa tients from 11 months to 6.2 years (me dian 3.2 years). CONCLUSION: The pres ence of or ganic dis easeis as so ci ated with very good ther a peu tic ef fect from the sur gi cal treat ment of chronic con sti pa tion. The prob -lem with id io pathic chronic con sti pa tion re mains un solved when colectomy with ileo-recto anas to mo sis wasun der gone. The right se lec tion of pa tients is a cru cial fac tor for the suc cess of the sur gi cal treat ment.Pa tients with chronic con sti pa tion can be dif fi cult to man -age ei ther med i cally or sur gi cally. Such dis ease is usu allyvoiced to in ter nists, gastroenterologists, and co lon and rec -tal sur geons alike. Pa tient def i ni tions of con sti pa tion are sovari able that the term it self is mean ing less and fo cusedques tion ing re gard ing the pa tient's ac tual bowel hab its isman da tory. To fa cil i tate re search into and treat ment of con -sti pa tion and other func tional bowel dis or ders, a mul ti na -tional panel of ex perts was con vened in Rome, It aly. TheRome cri te ria for the di ag no sis of con sti pa tion re quire twoor more of the fol low ing for at least 3 months:• Straining more than 25% of the time• Hard stools more than 25% of the time• Incomplete evacuation more than 25% of the time• Two or fewer bowel movements per weekOne in two women and one in three men over the age of 65ei ther had com plaints of con sti pa tion or took lax a tives. Themag ni tude of the prob lem re quires the co lon and rec tal sur -geon to un der stand the cau sa tion of con sti pa tion, be fac ilewith the tests used in the eval u a tion of the con sti pated pa -tient, and be able to rec om mend both med i cal and sur gi calther a pies when ap pro pri ate (1,2). EvaluationDe tailed his tory is the mile stone of the proper eval u a tion.We ex am ine those com po nents -stool size, fre quency, con -sis tency, ease and ef fi cacy of evac u a tion. Sym ptoms, dietand ex er cise de tails, med i cal his tory, sur gi cal his tory, andmed i ca tion are also eval u ated. Query into psy chi at ric ill -ness and sex ual and phys i cal abuse must be per formed, be -cause they are as so ci ated with def e ca tion dif fi cul ties. Rec tal ex am i na tion should in volve a clin i cal eval u a tion ofrest ing tone and the abil ity to vol un tarily con tract and re laxthe anal sphincter. Eval u a tion for pel vic floor dys func tionsuch as per i neal de scent with strain ing, the pres ence of arectocele or cystocele, and the vol ume and con sis tency ofstool in the rec tal vault should be noted. The eval u a tion ofthe pa tient with symp toms of con sti pa tion that do not re -spond to a trial of diet and med i cal ther apy be gins with theelim i na tion of a struc tural bowel ob struc tion viacolonoscopy or bar ium en ema. Once ob struc tion has beenelim i nated as the cause of con sti pa tion symp toms, co lonictran sit time should then be as sessed.The managemnt of pa tients with in trac ta ble con sti pa tion whofail to re spond to nonsurgical in ter ven tion con tin ues to rep re sent 151Scripta Scientifica Medica, 2010; vol. 42 (3), pp 151-153 Copyright © Med i cal Uni ver sity, VarnaAd dress for cor re spon dence:Kr.Ivanov, Varna, 1 Hr. Smirnenski str, Uni ver sity Hos pi tal "St. Ma rina"e-mail: teraton@abv.bg, kivanov@gisurgery.bga chal lenge for gen eral and colorectal sur geons pa tients withmega co lon are man aged con ser va tively in the first in stance. In -deed, it is claimed that the ma jor ity of pa tients can be suc cess -fully man aged nonsurgically (3). How ever, med i cal treat mentmay fail to al le vi ate symp toms in 50% to 70% of pa tients (4,5),may be poorly tol er ated (6), and must be con tin ued life long topre vent re cur rence of symp toms. (7). Fur ther more, it fails toachieve a res to ra tion of the co lon cal i ber to nor mal, evenfollowig sev eral years of med i cal ther apy (8). More re cently, the role of be hav ioral re train ing, in cor po rat ing bio feed back, hasbeen ex plored (9), al though only 6 pa tients were eval u ated inthe short term, and clin i cal and phys i o logic pa ram e ters were notrig or ously com pared be fore and af ter in ter ven tion. Con se -quently, many pa tients are forced to seek a sur gi cal so lu tion totheir symp toms when con ser va tive ther apy is in ef fec tive orpoorly tol er ated. In ad di tion, cer tain pa tients re quire sur gi cal in -ter ven tion due to the de vel op ment of com pli ca tions of mega co -lon, such as re cur rent sig moid volvulus (10).Sub to tal colectomy was the most widely ap plied op er a tionfor mega co lon that lead to chronic con sti pa tion. The ra tio -nale for this pro ce dure is based on the find ing that many pa -tients have de layed co lonic tran sit and that co lonic re sec -tion al lows the as so ci ated pel vic floor dys func tion to beover come by pro mot ing a more liq uid stool, which is eas ier to pass. We think that sub to tal colectomy is a sim ple pro ce -dure with low mor bid ity in pa tients with mega co lon.There is a mor tal ity of up to 14% and high mor bid ity of ap -prox i mately 25%; pa tients un der go ing this pro ce dure mustbe warned of the high risk of re cur rent bowel ob struc tion.Sub to tal colectomy ap pears to be suc cess ful in ap prox i mately70% of our pa tients with IMB, al though such re sults werehighly vari able, rang ing from 0% to 100%. Re cur rence ofcon sti pa tion is a sig nif i cant prob lem fol low ing sub to talcolectomy, re sult ing in ap prox i mately 5% of pa tients re quir -ing ad di tional sur gi cal in ter ven tion. Dis ten sion of the re tainedce cum in CRA and the sig moid co lon in ISA  may pre dis poseto the de vel op ment of symp toms of ab dom i nal dis ten sion, im -paired evac u a tion, and re cur rent con sti pa tion, and ne ces si tatefur ther, more ag gres sive re sec tion. Con se quently, colectomyand IRA has been rec om mended as the pro ce dure of choice to pre vent re cur rence of con sti pa tion. How ever, re ten tion of thece cum pre serves its ab sorp tive ca pac ity and may re duce thelike li hood of fre quent, loose stools and ep i sodes of in con ti -nence. Fur ther more, re ten tion of the rec tum it self in IRA mayre sult in re cur rence of symp toms due to di la ta tion. As moststud ies did not strat ify re sults ac cord ing to the type of anas to -mo sis per formed, firm sta tis ti cal con clu sions re gard ing the op -ti mum choice can not be made, al though it is likely that IRA isas so ci ated with lower rates of re cur rence of con sti pa tion.MATERIALFor a pe riod of 10 years, we have been eval u ated 132 pa -tients which have di ag no sis "con sti pa tion" accorditng toRoma clas si fi ca tion. We op er ated 52 pa tients with di ag no -sis as morbus Pair (15 pa tients), megacolon (31 pa tients),and id io pathic chronic con sti pa tion (6 pa tients). The mainin di ca tion for un der go ing sur gi cal treat ment was the re ten -tion of more then 20% of the ap plied bar ium en ema af terthe 5th day from irrigography.Morbus Pair is a syn drome of high lienic flex ure that leads to chronic con sti pa tion. We had 15 pa tients with that di ag -nose. All of them un der went a explorative laparotomy withdi vi sion of the flex ure. The symp toms of con sti pa tion faded away in the post op er a tive pe riod and all the pa tients sub -scribe for re liev ing of con sti pa tion symp toms dur ing thefol low-up of 52 months (range 6-122). MegacolonThe mean clin i cal fol low-up was 64 months (range 5-132).One pa tient de vel oped, one year af ter sur gery, in tes ti nal oc -clu sion due to ad he sions that re quired sur gery; af ter twoyears and a half, the pa tient still com plains of ab dom i nalpain (with reg u lar bowel move ments). A month af ter sur -gery, the mean fre quency of bowel move ments was 3.7 perday (range 1-7). Nine pa tients re ported nor mal bowelmove ments with semi liquid stool con sis tency, 8 pa tientsre ported di ar rhoea with more than 4 bowel move ments perday. 9 pa tients used antidiarrhoeal agents. Six months af tersur gery, 22 pa tients re ported nor mal bowel move mentswith solid stool con sis tency, 3 re ported di ar rhoea and theneed for antidiarrhoeal agents, and one re ported con sti pa -tion eas ily con trolled with lax a tives. The fre quency ofbowel move ments in this pe riod was an av er age of 2.7 perday (range 0-5). Eigh teen pa tients had a fol low-up of atleast one year, and af ter one year the mean fre quency ofbowel move ments was 1.5 (range 0-6): 15 pa tients re ported nor mal bowel move ments, 2 re ported con sti pa tion con -trolled with lax a tives and 1 re ported di ar rhoea with in con ti -nence. At the last fol low up visit be fore the anal y sis of thedata of this study, 2 pa tients re ported con sti pa tion con -trolled with lax a tives and one still re ported in con ti nenceand di ar rhoea. The two pa tients that used lax a tives were the ones with out let ob struc tion syn drome, and one of these re -ported rec tal pain and tenesmus. Fif teen pa tients con sid ered their qual ity of life as hav ing im proved com pared with thatbe fore sur gery (2 fairly good, 7 good, 7 very good); two pa -tients con sid ered their qual ity of life as be ing un sat is fac -tory, with no im prove ment from be fore sur gery; two pa -tients man i fested se ri ous psy chi at ric dis tur bances and werenot able to give re li able an swers.For a pe riod of 10 year, 6 pa tients with iso lated chronic id -io pathic slow tran sit con sti pa tion were op er ated upon us ing sub to tal colectomy with cecorectal anas to mo sis. All com -plained of se vere, long last ing and dis abling con sti pa tionthat strongly im paired their qual ity of life. None of themwas ca pa ble of hav ing a bowel move ment with out thechronic use and/or as so ci a tion of lax a tives, prokinetics andfi bers. Pre op er a tive in ves ti ga tions in cluded full his tory andclin i cal ex per tise with in spec tion and dig i tal ex am i na tion,colonoscopy, bar ium en ema, anorectal manometry,cinedefaecography, and co lonic tran sit time (CTT) study toex clude an or ganic cause and con firm the di ag no sis of co -lonic in er tia. Pa tients with the ir ri ta ble bowel syn drome,rec tal out let ob struc tion, or ganic or sec ond ary con sti pa tion, 152Sur gi cal treat ment of pa tients with chronic con sti pa tion...megacolon, megarectum, volvulus, pro lapse, co lonicpseudo-ob struc tion, tu mors, and pol yps were ex cluded. Allpa tients had an an a tom i cally nor mal co lon on colonoscopyor bar ium en ema. All pa tients were con sid ered for a sur gi -cal treat ment of con sti pa tion us ing STC-CRA pro ce dure.All pa tients were fe males with a mean age of 57.5 (range24-72) years. Four pa tients (66.6%) had psy chi at ric dis or derssuch as anx i ety or de pres sion, ne ces si tat ing psychotropicdrugs. No for mal con tra in di ca tion for sur gery was found atpsy chi at ric eval u a tion. One pa tient un der went psy cho ther apyfor one year be fore be ing con sid ered for sur gery. Two pa tients had a non-insulindependent di a be tes mellitus. Uri nary symp -toms were pres ent in five pa tients (83.%), with uri nary in con -ti nence be ing the most fre quent com plaint. All the 6 pa tientsre port that the mean du ra tion of symp toms was more than 10yr. A pre cip i tat ing fac tor was iden ti fied in 4 pa tients (66%).The mean fre quency of bowel move ments with the aid of lax -a tives, en e mas or digi ta tions was 1.2 ±0.6 per week (range4-30 d). All pa tients' com plained of ab dom i nal pain and bloat -ing. Digi ta tions were used by 71.4% of pa tients. Four pa tientshad a to tal of 12 ab dom i nal op er a tions. The most com mon op -er a tion was hys ter ec tomy (40%); 2 pa tients had a leftcolectomy for "chronic con sti pa tion"; and two pa tients had apre vi ous small bowel ob struc tion ne ces si tat ing sur gery. Onepa tient had rectocele re pair, and one had haemorrhoidectomy(Milligan and Mor gan's pro ce dure). Four pa tients (50%)needed pain kill ers. Three pa tients (50%) reg u larly used a high fi bers rich di etary reg i men. All pa tients re ported their symp -toms as hav ing a ma jor in ter fer ence with their work or life ac -tiv i ties. Tran sit study re vealed dif fuse marker de lay in all pa -tients. Anorectal manometry confi rmed the pres ence of aRAIR in all pa tients. Nei ther anorectal manometry nor CD re -vealed Hirshprung dis ease. One pa tient had a small an te riorrectocele (4 cm) that emp tied com pletely dur ing evac u a tion. A di ag no sis of iso lated CI was done confi rmed in all pa tients.Post op er a tive com pli ca tions Post op er a tive com pli ca tion ratewas 21.4%. One pa tient had a hemothorax fol low ing ve nouscen tral line in ser tion, re quir ing drain age; one pa tient had anintrabdominal col lec tion that was suc cess fully treated withCT-guided percutaneous drain age. Fol low-upAll pa tients were alive in 2006 and in vited to the clinic af terthey com pleted the 4-weeks daily symp tom di ary eval u at ingstool fre quency and con sis tency. Pa tients were as sessed at amean of 10.5 (range 5-16) yr af ter sur gery. As com paredwith pre op er a tive bowel habit, the bowel fre quency was sig -nif i cantly (P < 0.05) in creased to a mean of 4.8± 7.5 per d(range 1-30). The stool con sis tency was soft in 11 pa tient(78.5%) and liq uid in three (21.4%). Over all 11 pa tients(78.5%) re ported per fect con ti nence, two pa tients (14.2%)had less than one ep i sode of soil ing (in con ti nence) per week.One pa tient with pre ex ist ing psy chi at ric dis or der de vel opeddis abling di ar rhoea (30 bowel move ments), ac com pa niedwith bloat ing and in con ti nence, and re fused any fur ther treat -ment. Seven pa tients (50%) had less than one ep i sode perweek of mild ab dom i nal pain with bloat ing. Two pa tients(14.2%) used lax a tives less than three times per month. Onepa tient (7.1%) with a ste no sis of the anal ca nal af ter sur geryfor hem or rhoids used en e mas twice per week. None re quired digitation. Three pa tients (21.4%) re ported new symp tomsin clud ing dif fi cult evac u a tion in two and rec tal pain in one.Anti-di ar rhea agents were uti lized by three pa tients (21.4%)less than three times per month. None re quired the ad di tionof fi bers or other di etary changes. Self-re ported sat is fac tion:Eleven pa tients (78.5%) would have cho sen sur gery again ifnec es sary, whereas 3 pa tients (21.4%) were not sat is fiedwith the re sults of sur gery, con sid er ing their sit u a tion as un -changed (2 pa tients) or worse (1 pa tient).The pres ence of or ganic dis ease is as so ci ated with verygood ther a peu tic ef fect from the sur gi cal treat ment ofchronic con sti pa tion. The prob lem with id io pathic chroniccon sti pa tion re mains un solved when colectomy withileorecto anas to mo sis was un der gone. The right se lec tionof pa tients is a cru cial fac tor for the suc cess of the sur gi caltreat ment.REFFERENCES1. Chitkara DK, Talley NJ, Locke GR 3rd,Weaver AL, Katusic SK, De Schepper H,Rucker MJ. Med i cal Pre sen ta tion of Con sti pa tionFrom Child hood to Early Adult hood: A Pop u la -tion-Based Co hort Study. Clin Gastroenterol Hepatol.2007 Jul 12; [Epub ahead of print]2. Johanson JF, Sonnenberg A, Koch TR. Clin i -cal ep i de mi ol ogy of chronic con sti pa tion. J ClinGastroenterol. 1989 Oct;11(5):525-36. Re view3. Gattuso JM, Kamm MA. Clin i cal fea tures of id io pathic megarectum and id io pathic megacolon. Gut. 1997;41:93.4. Lane RH, Todd IP. Id io pathic megacolon: a re -view of 42 cases. Br J Surg. 1977;64:307-310.5. O'Suilleabhain CB, An der son JH, McKee RF, et al.  Strat egy for the sur gi cal man age ment of pa -tients with id io pathic megarectum and megacolon. BrJ Surg. 2001;88:1392-1396.6. Kamm MA, Sta bile G. Man age ment of id io pathicmegarectum and megacolon. Br J Surg. 1991;78:899-900.7. Barnes PR, Lennard-Jones JE, Haw ley PR, et al.  Hirschsprung's dis ease and id io pathic megacolonin adults and ad o les cents. Gut. 1986;27:534-541.8. Goligher J. Dis cus sion on megacolon andmegarectum with the em pha sis on con di tions otherthan Hirschsprung's dis ease. Proc R Soc Med.1961;54:1053-1055.9. Mimura T, Nicholls T, Storrie JB, et al.Treat ment of con sti pa tion in adults as so ci ated with id -io pathic megarectum by be hav ioural re train ing in -clud ing bio feed back. Colorectal Dis. 2002;4:477- 482.10. Chung YF, Eu KW, Nyam DC, et al. Min i miz -ing re cur rence af ter sig moid volvulus. Br J Surg.1999;86:231-233.153Tonev A., K. Ivanov, V. Ignatov...

Surgical treatment of patients with chronic constipation - experience of Clinic of Coloproctology - Varna

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Surgical treatment of patients with chronic constipation - experience of Clinic of Coloproctology - Varna

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