ORIGINAL CONTRIBUTIONS
Colectomy for Constipation: Physiologic Investigation is the Key t o Success Steven D. Wexner, M.D., Norma Daniel, R.N., David G. Jagelman, M.D. From the Department of Colorectal Surgery, Cleveland Clinic Florida, Fort Lauderdale, Florida The results of total abdominal colectomy (TAC) with ileorectal anastomosis as a treatment for colonic inertia (CI) were prospectively assessed. One hundred sixtythree patients were evaluated for chronic constipation between July 1988 and November 1990. Patients underwent pancolonic transit times, anorectal manometry, cinedefecography (CD), and electromyography (EMG). CI was defined as diffuse marker delay on transit study without evidence of puborectalis contraction on CD or EMG. Sixteen patients (10 percent; 15 females and 1 male) with a mean age of 45 years (range, 24-75 years) with CI underwent TAC. Preoperative bowel frequency ranged from three per week to one per month; all 16 patients evacuated only with high doses of laxatives, enemas, or both. TAC was performed with no postoperative mortality or major morbidity; three patients were readmitted four times for successful conservative treatment of partial small bowel obstruction. At a mean followup of 15 months (range, 2-35 months), these 16 patients reported a mean frequency of spontaneous bowel evacuations of 3.5 per day (range, one to six per day). Patient satisfaction with the operation was "excellent" or "good" in 15 cases (94 percent). Thorough preoperative physiologic evaluation permits the selection of a small group of patients with CI who may benefit tremendously from TAC. [Key words: Constipation; Colonic inertia; Colectomy; Colonic dysmotility; Slow transit constipation]
inertia (CI) is a p o o r l y u n d e r s t o o d condition w h i c h results in infrequent b o w e l evacuation. Although patients may r e s p o n d to conservative medical management, by the time of surgical consultation, these patients are usually refractory to multiple r e g i m e n s of laxatives, enemas, suppositories, and fiber. In this select s u b g r o u p of patients, surgical intervention has b e e n a t t e m p t e d ) '3 Although surgery has included segmental colectomy, cecorectostomy, and other procedures, most recent authors have r e c o m m e n d e d total a b d o m i n a l c o l e c t o m y (TAC) with ileorectal anastomosis (IRA) as the p r o c e d u r e of choice. 4-m However, the selection criteria for TAC and IRA have b e e n variable o w i n g to the lack of u n d e r s t a n d i n g of the p a t h o p h y s i o l o g y of this condition. Thus, there has not b e e n a rational, reproducible, diagnostic schema, and the functional results have often b e e n suboptimal. The aims of this prospective study were, first, to assess the results of TAC and IRA for CI and, second, to analyze the use of preoperative physiologic testing in this decision-making process.
Wexner SD, Daniel N, Jagelman DG. Colectomy for constipation: physiologic investigation is the key to success. Dis Colon Rectum 19 91 ;3 4:8 51-8 5 6.
MATERIALS A N D he s y m p t o m s of chronic constipation are almost as diverse as the u n d e r l y i n g etiologies. Its causes include insufficient dietary fiber intake, drug ingestion, and neurologic, endocrine, and metabolic derangements. 1 In addition to structural abnormalities of the c o l o n such as tumors and strictures, functional colonic abnormalities may lead to chronic constipation. Specifically, colonic
T
METHODS
All patients with chronic constipation refractory to both conservative and medical m a n a g e m e n t were prospectively evaluated as previously described. 1 Patients were q u e r i e d by a nurse, physician's assistant, or resident regarding their b o w e l habits. The standardized 10-page questionnaire addressed m a n y areas, including ease, frequency, and c o m p l e t e n e s s of evacuation. All patients then u n d e r w e n t examination, w h i c h i n c l u d e d inspection, digital examination, anoscopy, and proctosigm o i d o s c o p y . In addition, patients had either a barium e n e m a or c o l o n o s c o p y within 12 m o n t h s
Read at the meeting of The American Society of Colon and Rectal Surgeons, Boston, Massachusetts, May 12 to 17, 1991. Address reprint requests to Dr. Wexner: Department of Colorectal Surgery, Cleveland Clinic Florida, 3000 W. Cypress Creek Road, Fort Lauderdale, Florida 33309. 851
852
WEXNER E T AL
of presentation. Patients underwent complete physiologic assessment. This included anorectal manometry, cinedefecography (CD), pancolonic transit study, and concentric needle electromyography (EMG). These studies were performed as previously described and are listed in Table 1.11'12 CI was defined as the presence of at least 16 of the 20 transit markers on the 5th day after ingestion. The markers were scattered diffusely throughout the colon. In addition, there could be no evidence of paradoxical puborectalis contraction (PPC; nonrelaxing puborectalis syndrome, anismus, spastic pelvic floor) on either EMG or CD. An absent or equivocal rectoanal inhibitory reflex (RAIR) prompted transanal, full-thickness, excisional strip anorectal myectomy to exclude Hirschsprung's disease. Thus, those patients with CI judged to be surgical candidates had no evidence of either PPC or Hirschsprung's disease. Patients thus classified as CI underwent TAC and IRA as previously described. 1 Bowel function was then assessed by patient interview at the time of follow-up utilizing a standardized questionnaire. All data were collected, compiled, and tabulated by a single nurse (N.D.). RESULTS Between July 1988 and November 1990, 163 chronically constipated patients underwent physiologic investigation. Sixteen patients (10 percent; 15 females and 1 male) were diagnosed as having CI. Mean age was 45 years (range, 24-75 years). Mean duration of chronic constipation was 20 years (range, 2-68 years). Preoperative bowel assistance included laxative dependency in 16 patients (median, daily; range, three times daily to weekly).
T a b l e 1.
Suggested Preoperative Investigations History List of current medications Physical examination with sigmoidoscopy Serum chemistry, as necessary Thyroid function tests, as necessary Barium enema Pancolonic transit study Anal manometry CD EMG Consider psychiatric consultation Consider small bowel transit
Dis Colon Rectum, October 1991 T a b l e 2.
Activity Limitations Preoperative
Activity
Postoperative
11 11 9 4
Social Vocational Physical Sexual
2 0 0 1
Seven of these patients also utilized enemas (median, daily; range, daily to every 10 days), and one also employed digitation "sometimes." Preoperative bowel action occurred at a mean interval of 8.5 days, ranging from three bowel movements per week to one per month. Additional symptoms included distention in 12 (75 percent), abdominal pain in 12 (75 percent), and bloating in 11 (69 percent) patients. Patients attributed a variety of limitations to their bowel habits. These are noted in Table 2. Manometry confirmed the presence of a RAIR in 14 patients. The two patients in whom an equivocal RAIR was elicited underwent myectomy; in both cases, the presence of myenteric ganglia was confirmed. Transit study revealed diffuse marker delay in all 16 patients. Neither EMG nor CD revealed paradoxical puborectalis contraction in any patient. However, three patients had small (
Colectomy for Constipation: Physiologic Investigation is the Key t o Success Steven D. Wexner, M.D., Norma Daniel, R.N., David G. Jagelman, M.D. From the Department of Colorectal Surgery, Cleveland Clinic Florida, Fort Lauderdale, Florida The results of total abdominal colectomy (TAC) with ileorectal anastomosis as a treatment for colonic inertia (CI) were prospectively assessed. One hundred sixtythree patients were evaluated for chronic constipation between July 1988 and November 1990. Patients underwent pancolonic transit times, anorectal manometry, cinedefecography (CD), and electromyography (EMG). CI was defined as diffuse marker delay on transit study without evidence of puborectalis contraction on CD or EMG. Sixteen patients (10 percent; 15 females and 1 male) with a mean age of 45 years (range, 24-75 years) with CI underwent TAC. Preoperative bowel frequency ranged from three per week to one per month; all 16 patients evacuated only with high doses of laxatives, enemas, or both. TAC was performed with no postoperative mortality or major morbidity; three patients were readmitted four times for successful conservative treatment of partial small bowel obstruction. At a mean followup of 15 months (range, 2-35 months), these 16 patients reported a mean frequency of spontaneous bowel evacuations of 3.5 per day (range, one to six per day). Patient satisfaction with the operation was "excellent" or "good" in 15 cases (94 percent). Thorough preoperative physiologic evaluation permits the selection of a small group of patients with CI who may benefit tremendously from TAC. [Key words: Constipation; Colonic inertia; Colectomy; Colonic dysmotility; Slow transit constipation]
inertia (CI) is a p o o r l y u n d e r s t o o d condition w h i c h results in infrequent b o w e l evacuation. Although patients may r e s p o n d to conservative medical management, by the time of surgical consultation, these patients are usually refractory to multiple r e g i m e n s of laxatives, enemas, suppositories, and fiber. In this select s u b g r o u p of patients, surgical intervention has b e e n a t t e m p t e d ) '3 Although surgery has included segmental colectomy, cecorectostomy, and other procedures, most recent authors have r e c o m m e n d e d total a b d o m i n a l c o l e c t o m y (TAC) with ileorectal anastomosis (IRA) as the p r o c e d u r e of choice. 4-m However, the selection criteria for TAC and IRA have b e e n variable o w i n g to the lack of u n d e r s t a n d i n g of the p a t h o p h y s i o l o g y of this condition. Thus, there has not b e e n a rational, reproducible, diagnostic schema, and the functional results have often b e e n suboptimal. The aims of this prospective study were, first, to assess the results of TAC and IRA for CI and, second, to analyze the use of preoperative physiologic testing in this decision-making process.
Wexner SD, Daniel N, Jagelman DG. Colectomy for constipation: physiologic investigation is the key to success. Dis Colon Rectum 19 91 ;3 4:8 51-8 5 6.
MATERIALS A N D he s y m p t o m s of chronic constipation are almost as diverse as the u n d e r l y i n g etiologies. Its causes include insufficient dietary fiber intake, drug ingestion, and neurologic, endocrine, and metabolic derangements. 1 In addition to structural abnormalities of the c o l o n such as tumors and strictures, functional colonic abnormalities may lead to chronic constipation. Specifically, colonic
T
METHODS
All patients with chronic constipation refractory to both conservative and medical m a n a g e m e n t were prospectively evaluated as previously described. 1 Patients were q u e r i e d by a nurse, physician's assistant, or resident regarding their b o w e l habits. The standardized 10-page questionnaire addressed m a n y areas, including ease, frequency, and c o m p l e t e n e s s of evacuation. All patients then u n d e r w e n t examination, w h i c h i n c l u d e d inspection, digital examination, anoscopy, and proctosigm o i d o s c o p y . In addition, patients had either a barium e n e m a or c o l o n o s c o p y within 12 m o n t h s
Read at the meeting of The American Society of Colon and Rectal Surgeons, Boston, Massachusetts, May 12 to 17, 1991. Address reprint requests to Dr. Wexner: Department of Colorectal Surgery, Cleveland Clinic Florida, 3000 W. Cypress Creek Road, Fort Lauderdale, Florida 33309. 851
852
WEXNER E T AL
of presentation. Patients underwent complete physiologic assessment. This included anorectal manometry, cinedefecography (CD), pancolonic transit study, and concentric needle electromyography (EMG). These studies were performed as previously described and are listed in Table 1.11'12 CI was defined as the presence of at least 16 of the 20 transit markers on the 5th day after ingestion. The markers were scattered diffusely throughout the colon. In addition, there could be no evidence of paradoxical puborectalis contraction (PPC; nonrelaxing puborectalis syndrome, anismus, spastic pelvic floor) on either EMG or CD. An absent or equivocal rectoanal inhibitory reflex (RAIR) prompted transanal, full-thickness, excisional strip anorectal myectomy to exclude Hirschsprung's disease. Thus, those patients with CI judged to be surgical candidates had no evidence of either PPC or Hirschsprung's disease. Patients thus classified as CI underwent TAC and IRA as previously described. 1 Bowel function was then assessed by patient interview at the time of follow-up utilizing a standardized questionnaire. All data were collected, compiled, and tabulated by a single nurse (N.D.). RESULTS Between July 1988 and November 1990, 163 chronically constipated patients underwent physiologic investigation. Sixteen patients (10 percent; 15 females and 1 male) were diagnosed as having CI. Mean age was 45 years (range, 24-75 years). Mean duration of chronic constipation was 20 years (range, 2-68 years). Preoperative bowel assistance included laxative dependency in 16 patients (median, daily; range, three times daily to weekly).
T a b l e 1.
Suggested Preoperative Investigations History List of current medications Physical examination with sigmoidoscopy Serum chemistry, as necessary Thyroid function tests, as necessary Barium enema Pancolonic transit study Anal manometry CD EMG Consider psychiatric consultation Consider small bowel transit
Dis Colon Rectum, October 1991 T a b l e 2.
Activity Limitations Preoperative
Activity
Postoperative
11 11 9 4
Social Vocational Physical Sexual
2 0 0 1
Seven of these patients also utilized enemas (median, daily; range, daily to every 10 days), and one also employed digitation "sometimes." Preoperative bowel action occurred at a mean interval of 8.5 days, ranging from three bowel movements per week to one per month. Additional symptoms included distention in 12 (75 percent), abdominal pain in 12 (75 percent), and bloating in 11 (69 percent) patients. Patients attributed a variety of limitations to their bowel habits. These are noted in Table 2. Manometry confirmed the presence of a RAIR in 14 patients. The two patients in whom an equivocal RAIR was elicited underwent myectomy; in both cases, the presence of myenteric ganglia was confirmed. Transit study revealed diffuse marker delay in all 16 patients. Neither EMG nor CD revealed paradoxical puborectalis contraction in any patient. However, three patients had small (
