Successful outcome of refractory chronic constipation by surgical treatment: a series of 34 patients

Abstract

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 investigations 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 patients are critical for obtaining good functional results.

Keywords: Constipation; Outcome assessment; Surgery.

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 throughout the colon.

Figure 2

Flow chart showing surgical procedures, complications and early outcome among patients with refractory chronic constipation. SBM, spontaneous bowel movements.

Figure 3

Spontaneous bowel movements before and after surgical treatment (Wilcoxon signed-rank test).