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Functional outcomes of two types of subtotal colectomy for slow-transit constipation: ileosigmoidal anastomosis and cecorectal anastomosis
The American Journal of Surgery 195 (2008) 73–77
Clinical surgery–International
Functional outcomes of two types of subtotal colectomy for slow-transit constipation: ileosigmoidal anastomosis and cecorectal anastomosis Ye Feng, M.D.*, Lin Jianjiang, M.D. Department of Colorectal Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China Manuscript received November 20, 2006; revised manuscript February 5, 2007
Abstract Background: Some patients with severe slow-transit constipation may benefit from subtotal colectomy, but there is no consensus on standard operative mode. The aim of the study was to compare the functional outcomes of subtotal colectomy with cecorectal anastomosis (CRA) with those of subtotal colectomy with ileosigmoidal anastomosis (ISA) in patients with severe slow-transit constipation. Methods: Records of 79 patients who received preoperative investigation to confirm slow transit at our institution from 1989 to 2004 and subsequently received colectomy with CRA (n ⫽ 34) or colectomy with ISA (n ⫽ 45) were reviewed. The mean follow-up was 2 years (range 1–15). Results: Postoperative defecation frequency increased and symptoms such as bloating and abdominal pain decreased in both groups. More CRA patients than ISA patients experienced persistent constipation and continued using laxatives or enemas at the 12-month follow-up. More ISA patients (93.3%) than CRA patients (73.5%) were satisfied with the procedure, whereas some patients in both groups complained of excessively high stool frequency and fecal incontinence. Conclusion: Both CRA and ISA procedures increase the number of bowel movements; however, ISA results in higher defecation frequency, less use of laxatives and enemas, and higher patient satisfaction. © 2008 Excerpta Medica Inc. All rights reserved. Keywords: Subtotal colectomy; Cecorectal anastomosis; Ileosigmoidal anastomosis; Slow-transit constipation
Patients with slow-transit constipation (STC) typically have reduced stool frequency but a morphologically normal colon and rectum [1]. Many of these patients have a long history of laxative abuse and have become dependent on these agents. After failed medical treatment, unsuccessful bowel habit training, and excluding the presence of obstructed defecation (eg, symptomatic rectocele or nonrelaxing puborectalis muscle), the treatment of choice becomes surgery [2,3]. In most centers, the standard surgical treatment for STC is total colectomy with ileorectal anastomosis or subtotal colectomy with ileosigmoidal anatomosis (ISA) [4 – 8]. These procedures are effective in increasing the frequency of bowel movements and relieving symptoms in the majority of patients. However, symptoms such as bloating and abdominal pain may persist. Furthermore, some patients experience postoperative side effects such as diarrhea and incontinence [4 – 6]. One possible way to reduce
these side effects is to perform a limited resection of the colon. In 1931, Ogilvie [9] was the first to propose subtotal colectomy with preservation of the ileocecal junction, which preserves continuity by anastomosing the cecum to the rectal stump. This kind of reconstruction preserves the important functions of the cecum, the distal ileum, and the ileocecal valve such as the absorption of water, bile, vitamin B12, and electrolytes. Other studies have been published on subtotal colectomy with cecorectal anastomosis (CRA), which represents an interesting alternative to subtotal colectomy with ISA [5,10,11]. To date, very few studies have been published comparing the 2 procedures. The specific aim of our investigation was to compare the long-term results of subtotal colectomy with CRA with those of subtotal colectomy with ISA in patients with severe STC.
* Corresponding author. Tel. ⫹86-571-87236882; fax: ⫹86-5718723667. E-mail address: [email protected]
Methods We performed a retrospective analysis of 79 consecutive patients with severe STC admitted in the Department of Colorectal Surgery, First Affiliated Hospital, School of
0002-9610/08/$ – see front matter © 2008 Excerpta Medica Inc. All rights reserved. doi:10.1016/j.amjsurg.2007.02.015
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Y. Feng and L. Jianjiang / The American Journal of Surgery 195 (2008) 73–77
Medicine, Zhejiang University, China, from January 1989 to December 2004. All received preoperative investigation, including colonoscopy, colonic transit, and anorectal tests (eg, defecography, manometry, and water-filled balloon expulsion tests), and radiopaque marker studies to document slow gut transit [12,13]. Slow transit was defined as the retention of more than 12 of 20 (⬎60%) radiopaque markers. All patients had failed traditional conservative treatments such as bulk-forming agents, oral laxatives, bowelcleansing solutions, enemas, or suppositories. Each patient was accepted for colectomy performed with either CRA or ISA. All operations were performed by the same surgical team. Each patient provided a signed informed consent before each procedure. Pertinent data regarding sex, age, constipation intervals, colonic transit, pharmacologic treatment, symptoms, severity, operation performed, histologic assessment, and postoperative complications was obtained from the charts of patients who had been seen approximately 1, 6, and 12 months postoperatively. All study patients were assessed by follow-up for an average of 2 years (range 1–15 years) using postal questionnaires, which were supplemented by telephone interviews as needed. Functional variables, including stool frequency per week, symptoms of abdominal pain, bloating, postoperative diarrhea, fecal incontinence, and use of laxatives or enema for bowel-movement assistance, were assessed pre- and postoperatively. Additionally, patients were asked to rate their satisfaction with the surgical outcome. Analyses were performed by using the SPSS statistical software package (version 11.0; SPSS Inc, Chicago, IL). Nonparametric analysis was by performed by using Wilcoxon signed rank testing for paired data and the MannWhitney U test for unpaired data. Chi-square criterion and a Fisher exact test were used to analyze contingency tables. P ⬍ .050 was considered statistically significant. Values were expressed as means ⫾ standard deviation, median (range), or number (percentage). Results A total of 79 patients were treated surgically for colonic inertia; 74 (93.7%) were female. Average age was 43.5 (21– 67) years. Unrelenting constipation was the primary complaint of all 79 patients with a mean duration before surgical intervention of 9.0 (2–25) years. Other presenting symptoms included abdominal pain in 56 patients (70.8%) and bloating in 58 patients (73.4%). All patients had used laxatives to treat their constipation, and 45 admitted to enema use. Colonic transit tests showed that retention of radiopaque markers averaged 15.2 ⫾ 2.5. The general data of CRA and ISA groups are shown in Tables 1 and 2; no significant differences were noted between the 2 groups. Thirty-four patients were accepted for colectomy and CRA and 45 patients for colectomy and ISA. Thirty-six patients (45.6%) received a stapled anastomosis with an end-to-end anastomotic stapler versus 43 (54.4%) who received a handsewn anastomosis. Postoperative hospitalization was 12.8 ⫾ 6.0 days. Operative data of the CRA and ISA groups are shown in Table 1; no significant differences were noted between the 2 groups. Pathology evaluation was con-
Table 1 Patient characteristics and operative data Category
CRA
ISA
Total
Sex (male/female) Age (y) Constipation intervals (y) Colonic transit* Operative time (min) Stapled anastomosis/ hand-sewn anastomosis Ileus Incision infection Anastomotic leakage Postoperative stay (d)
2/32 45.2 (25–67) 8.8 (2–22) 16.2 ⫾ 2.5 120 ⫾ 35
3/42 42.4 (21–65) 9.5 (2–25) 15.0 ⫾ 2.2 135 ⫾ 30
5/74 43.5 (21–67) 9.0 (2–25) 15.2 ⫾ 2.5 128 ⫾ 33
16/18 3 (8.8%) 1 (2.9%) 0 12.5 ⫾ 6.3
20/25 5 (11.1%) 1 (2.2%) 0 13.1 ⫾ 5.8
36/43 8 (10.1%) 2 (2.5%) 0 12.8 ⫾ 6.0
* Number of radiopaque markers in colon and rectum.
ducted on all specimens. On gross appearance, the majority of colon specimens were significantly redundant but without bowel wall thickening. No evidence of microscopic abnormalities was found in any of the specimens, except for a reduction in argyrophilic neurons. Melanosis coli were present in almost half of the population because of chronic use of laxatives. Early postoperative complications are shown in Table 1. Ileus was the single most common event, occurring in 8 patients (10.1%). Incision infection was seen in 2 patients (2.5%). No anastomotic leakage occurred. No significant differences were shown between the 2 groups (P ⬎ .05). The mean follow-up was 2 years (1–15). No mortality was found. In both groups, postoperative defecation frequency at follow-up increased compared with preoperative stool frequency (P ⬍ .05). Postoperative symptoms such as bloating and abdominal pain were decreased in both groups (P ⬍ .05). At the 12-month follow-up, ISA patients averaged 15.5 ⫾ 3.8 stools per week versus 10.2 ⫾ 5.4 (P ⬍ .05) of the CRA group. Some patients in both groups continued to complain of bloating and abdominal pain, and small-bowel obstruction occurred infrequently in both groups. At the 12-month follow-up, 9 patients in the CRA group (26.8%) experienced persistent constipation and continued to use laxatives compared with only 3 patients (6.7%) in the ISA group (P ⬍ .05). Four patients in the CRA group (11.8%) had to use enemas to assist defecation compared with only 1 patient (2.2%) in the ISA group (P ⬍ .05). At 1, 6, and 12 months, 12, 3, and 2 patients, respectively (26.7%, 6.7%, and 4.5%), in the ISA group complained of excessively high stool frequency, and 8, 1, and 1 patients (23.5%, 2.9%, and 2.9%) complained of fecal incontinence. However, at the same follow-up intervals, 8, 1, and 1 patients (17.8%, 2.2%, and 2.2%) in the CRA group complained of excessively high stool frequency, and 5, 0, and 0 patients (14.7%, 0%, and 0%) complained of fecal incontinence. Differences between the 2 groups were not statistically significant (P ⬎ .05). Patient satisfaction was associated with postoperative complications, recurrent constipation, persistent abdominal pain, and bloating. Stool frequency played an important role in ultimate patient satisfaction. Forty-two patients (93.3%) in the ISA group and 31 (73.5%) in the CRA group stated that they were satisfied with the procedure (P ⬍ .05). Functional outcomes
Y. Feng and L. Jianjiang / The American Journal of Surgery 195 (2008) 73–77
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Table 2 Functional outcomes of CRA and ISA Category
Preoperative CRA
Number of stools per week* Abdominal pain Bloating Laxative use Enema use Small-bowel obstruction Postoperative diarrhea† Postoperative fecal incontinence Number of patients satisfied
1.5 ⫾ 0.9 26 (76.5%) 26 (76.5%) 34 (100%) 21 (61.8%)
ISA 1.6 ⫾ 0.8 30 (66.7%) 32 (71.1%) 45 (100%) 24 (53.3%)
1 month postoperative
6 months postoperative
12 months postoperative
CRA
CRA
CRA
18.5 ⫾ 6.0 12 (35.3%) 11 (32.4%) 1 (2.9%) 0 ‡ 8 (23.5%) 5 (14.7%) 29 (85.3%)
ISA 23.5 ⫾ 8.8 14 (31.1%) 12 (26.7%) 1 (2.2%) 0 ‡ 12 (26.7%) 8 (17.8%) 41 (91.1%)
14.5 ⫾ 5.5 9 (26.5%) 10 (29.4%) 5 (14.7%) 2 (5.9%) 3 (8.9%) 1 (2.9%)vii 0ix 27 (79.4%)
ISA 16.8 ⫾ 4.2 10 (22.2%) 10 (22.2%) 2 (4.4%)ii iv 0 3 (6.7%) 3 (6.7%)viii 1 (2.2%)x 41 (91.1%)
ISA ①
10.2 ⫾ 5.4 8 (23.5%)③ 8 (23.5%)⑤ 9 (26.8%)⑦ 4 (11.8%)⑨ 3 (8.9%) 1 (2.9%) 0 25 (73.5%)
15.5 ⫾ 3.8②i 8 (17.8%)④ 7 (15.6%)⑥ 3 (6.7%)⑧iii 1 (2.2%)⑩v 3 (6.7%) 2 (4.5%) 1 (2.2%) 42 (93.3%)*
Data presented as number of patients follow by percent in parentheses. * Except for patients with laxative use, diarrhea, and postoperative incontinence. † Diarrhea was considered 5 or more bowel movements per day [13]. ‡ Presented in Table 1 as row “Ileus.” Compared with preoperative phase: ① ② ③ ④ ⑤ ⑥ ⑦ ⑧ ⑨ ⑩, P ⬍ .05. Compared with CRA group: i, ii, iii, iv, v, vi, P ⬍ .05. Compared with 1 month postoperative phase: vii, viii, ix, x, P ⬍ .05.
according to the 2 types of surgical anastomosis are shown in Table 2. Comments STC is an uncommon condition that occurs most often in women in the third decade of life [1,14,15]. It usually presents with symptoms of constipation and abdominal pain. Individuals diagnosed with this disorder suffer considerably and experience a major impact on lifestyle and quality of life [16]. The diagnosis of STC represents the severe part of the spectrum of slow-transit constipation, a clinical syndrome of constipation attributable to ineffective colonic propulsion. Most patients with constipation can be treated medically to improve symptoms. Patients with objective evidence of delayed colonic transit whose symptoms are refractory to medical management may benefit from surgical therapy. The most commonly performed surgical procedures have been total abdominal colectomy with ileorectal anastomosis and subtotal colectomy with ISA [4 – 8]. Some studies have shown that subtotal colectomy with CRA represents an interesting alternative to total colectomy with ileorectal anastomosis. No standard surgical technique exists for performing subtotal colectomy. ISA and CRA procedures are able to increase the frequency of bowel movements and relieve symptoms such as bloating and abdominal pain in the majority of patients. Nevertheless, some patients continue to endure persistent symptoms. In our study, ISA and CRA procedures for slow-transit constipation were compared with operative time, stapled anastomosis/hand-sewn anastomosis, ileus, anastomotic leakage, incision infection, and postoperative stay. Patient records were reviewed retrospectively from the 1997 to 2004. During 1989 to 1997, ISA was the preferred procedure at our institution. From 1997 to 2002, CRA was preferred because of diarrhea and fecal incontinence observed in patients who had undergone ISA. Because of a high incidence of constipation noted with CRA,
ISA has been the procedure of choice at our institution since 2002. No statistically significant differences were found between CRA and ISA procedures, either in operative techniques themselves, postoperative recovery, or in complications not relative to intestinal function. Some studies have found that the outcomes of stapled anastomosis are similar to those of hand-sewn anastomosis [17,18]. Because of the even distribution of stapled anastomosis and hand-sewn anastomosis in both ISA and CRA groups, we can compare the functional outcomes by ISA versus CRA in singleelement variant analysis. After subtotal colectomy with ISA, nearly all patients were able to pass stools spontaneously, which persisted for a mean of 1 year after surgery without the aid of laxatives or enema. At 1-year follow-up, only 3 patients were still using laxatives once or twice a day. Additionally, 42 (93.3%) patients reported satisfaction with the postoperative result. Although some constipation symptoms persisted after surgery, patients perceived that they were much better than before the operation. One month after surgery, 23.5% of patients reported diarrhea, and 14.4% reported fecal incontinence. The cause of diarrhea is most probably physiologic because stools become watery after subtotal colectomy. Early postoperative diarrhea stays only a short time and does not require long-term therapy. One year after surgery, diarrhea requiring medical support was reported by only 4.5% of patients and fecal incontinence by 2.2%. It has been reported that subtotal colectomy with ISA leads to an appreciable incidence of incontinence and loss in quality of life [19,20]. However, patient satisfaction seems to be related to stool frequency, which is an important parameter in patient-defined constipation. The ability to have at least 1 spontaneous bowel movement per day represented an improvement over their preoperative situation. In the majority of our patients, the CRA procedure for treatment of STC also caused an increase in the number of bowel movements. However, compared with ISA patients, those undergoing CRA had a lower frequency of bowel
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movements, resulting in a higher postoperative rate of constipation and a lower rate of satisfaction with the operation (P ⬍ .05). In our opinion, subtotal abdominal colectomy with CRA for treating constipation has a poorer functional outcome than ISA in the Chinese population we have studied. However, some Western studies have shown good functional outcomes from subtotal abdominal colectomy with CRA for treating constipation [5,10,11,21–23]. Our data do not agree with these studies. The possible reason for this discrepancy may be the differences between Western and Oriental colonic anatomy [24]. Perhaps there are also differences in the physiological functioning of the ascending colon and the sigmoid colon in the Oriental population and that in the Occidental population. This study showed that there are different bowel functional outcomes between surgical procedures that retain the cecum or part of the sigmoid and rectosigmoid junction, respectively. Moreover, given the fact that there are different bowel functional outcomes between the Occidental population and the Oriental population undergoing the same surgical procedure, we recommend that different surgical procedures be performed for different populations with STC. Several studies have found a distal delay in some patients in the left or rectosigmoid colon, which is sometimes referred to as a functional rectosigmoid obstruction [25–27]. In our study, we observed better results with the CRA approach in patients whose colonic transit test showed that nearly all radiopaque markers stayed in the left or rectosigmoid colon. This has led us to consider subtotal colectomy with CRA as the treatment of choice for selected patients with distal colonic delay, thereby possibly avoiding side effects of resection of the terminal ileum, ileocecal junction, and cecum, which is known to affect water and electrolyte resorption. Despite the success rate in our series and others [4,7,8], postoperative mortality and morbidity deserves comment. We found no mortality in our patients. The morbidity was considerable because 26 (32.9%) of our patients continued to have 1 or more symptoms of constipation, intestinal obstruction, or developed severe diarrhea. Small-bowel obstruction occurred 12 times in 9 patients at follow-up. Some patients continued to complain of bloating and abdominal pain at different times postoperatively. No statistically significant differences were shown between ISA and CRA procedures in these aspects. These complications are likely to have been caused by the primary disease and not by the operation itself because postcolectomy patients with diseases other than STC have been reported to be relatively free of abdominal symptoms, and only rarely has the surgery been found to induce intestinal obstruction [28,29]. Diarrhea was reported by 25.3% of our patients at 1-month follow-up, and fecal incontinence by 15.2%. As time passed, the occurrence of these symptoms as rare events lessened. In 2 patients, diarrhea was constant and severe, requiring medical intervention. The differences between the ISA and CRA groups regarding postoperative diarrhea and fecal incontinence were not statistically significant (P ⬎ .05), although the CRA group had better results than the ISA group.
Conclusions Our study is a retrospective study with a small series, and, to confirm any conclusions regarding colectomy with CRA versus ISA, we need the results of randomized clinical trials and large sample data. We plan to continue to perform the 2 procedures for STC and collect data. At present, controversies remain regarding STC itself [30 –33], the significance of the procedure [34,35], and selection of a modus operandi for treatment [21,23,36]. We believe that the more data we provide, the more we can reduce the controversies. In conclusion, both CRA and ISA procedures increase the number of bowel movements, but ISA is the superior method because it generates increased patient satisfaction. The CRA procedure can be performed for selected patients with distal colonic inertia. Secondary morbidity can be considerable in a small number of patients. Further studies are needed to explore mechanisms of the pathogenesis of constipation and to improve individualized treatment for constipation symptoms. Acknowledgments The authors thank Dr. Xu Jiahe (Department of Colorectal Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, China) for linguistic revision of this manuscript. References [1] Preston D, Lennard-Jones JE. Severe chronic constipation of young women: idiopathic slow transit constipation. Gut 1986;27:41– 8. [2] Rao SSC, Tuteja AK, Vellema T, et al. Dyssynergic defecation: demographics, symptoms, stool patterns and quality of life. J Clin Gastroenterol 2004;38:680 –5. [3] Pare P, Ferrzazzi S, Thompson WG, et al. An epidemiological survey of constipation in Canada: definitions, rates, demographics and predictors of health care seeking. Am J Gastroenterol 2001;96:3130 –7. [4] Lubowski DZ, Chen FC, Kennedy ML, King DW. Results of colectomy for severe slow transit constipation. Dis Colon Rectum 1996; 39:23–9. [5] Knowles CH, Scott M, Lunniss PJ. Outcome of coloectomy for slow transit constipation. Ann Surg 1999;230:627–38. [6] Blachut K, Bednarz W, Paradowski L. Surgical treatment of constipation. Rocz Akad Med Bialymst 2004;49:47–52. [7] Nylund G, Oresland T, Fasth S, Nordgren S. Long-term outcome after colectomy in severe idiopathic constipation. Colorectal Dis 2001;3: 253– 8. [8] Bharucha AE. Treatment of severe and intractable constipation. Curr Treat Options Gastroenterol 2004;7:291– 8. [9] Ogilvie WH. The preservation of the ileocecal sphincter in resection of the right half of the colon. Br J Surg 1931;14:8. [10] Sarli L, Iusco D, Donadei E, et al. The rationale for cecorectal anastomosis for slow transit constipation. Acta Biomed Ateneo Parmense 2003;74(suppl 2):74 –9. [11] Sarli L, Costi R, Iusco D, Roncoroni L. Long-term results of subtotal colectomy with antiperistaltic cecoproctostomy. Surg Today 2003;33: 823–7. [12] Abrahamsson H, Antov S, Bosaeus I. Gastrointestinal and colonic segmental transit time evaluated by a single abdominal x-ray in healthy subjects and constipated patients. Scand J Gastroenterol 1988; 152:72– 80. [13] Bernini A, Madoff RD, Lowry AC, et al. Should patients with combined colonic inertia and nonrelaxing pelvic floor undergo subtotal colectomy? Dis Colon Rectum 1998;41:1363– 6. [14] Knowles CH, Scott SM, Rayner C, et al. Idiopathic slow-transit constipation: an almost exclusively female disorder. Dis Colon Rectum 2003;46:1716 –7. [15] MacDonald A, Baxter JN, Finlay IG. Idiopathic slow-transit constipation. Br J Surg 1993;80:1107–11.
Y. Feng and L. Jianjiang / The American Journal of Surgery 195 (2008) 73–77 [16] Halder SL, Locke GR III, Talley NJ, et al. Impact of functional gastrointestinal disorders on health-related quality of life: a population-based case– control study. Aliment Pharmacol Ther 2004;19: 233– 42. [17] Lustosa SA, Matos D, Atallah AN, Castro AA. Stapled versus handsewn methods for colorectal anastomosis surgery: a systematic review of randomized controlled trials. Sao Paulo Med J 2002;120: 132– 6. [18] MacRae HM, McLeod RS. Handsewn vs. stapled anastomoses in colon and rectal surgery: a meta-analysis. Dis Colon Rectum 1998; 41:180 –9. [19] JF Lim JF, YH Ho YH. Total colectomy with ileorectal anastomosis leads to appreciable loss in quality of life irrespective of primary diagnosis. Tech Coloproctol 2001;5:79 – 83. [20] Thaler K, Dinnewitzer A, Oberwalder M, et al. Quality of life after colectomy for colonic inertia. Tech Coloprotocol 2005;9:133–7. [21] Lacy AM, Garcia-Valdecasas JC, Delgado S, et al. Laparoscopicassisted colectomy versus open colectomy for treatment of nonmetastatic colon cancer: a randomised trial. Lancet 2002;359:2224 –9. [22] Msika S, Iannelli A, Deroide G, et al. Can laparoscopy reduce hospital stay in the treatment of Crohn’s disease? Dis Colon Rectum 2001;44:1661– 6. [23] Sarli L, Costi R, Sarli D, Roncoroni L. Pilot study of subtotal colectomy with antiperistaltic cecoproctostomy for the treatment of chronic slow-transit constipation. Dis Colon Rectum 2001;44: 1514 –20. [24] Saunders BP, Masaki T, Sawada T, et al. A peroperative comparison of Western and Oriental colonic anatomy and mesenteric attachments. Int J Colorectal Dis 1995;10:216 –21. [25] Cook BJ, Lim E, Cook D, et al. Radionuclear transit to assess sites of delay in large bowel transit in children with chronic idiopathic constipation. J Pediatr Surg 2005;40:478 – 83.
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[26] Lundin E, Karlbom U, Westlin JE, et al. Scintigraphic assessment of slow transit constipation with special reference to right- or left-sided colonic delay. Colorectal Dis 2004;6:499 –505. [27] Husni-Hag-Ali R, Gomez Rodriguez BJ, Mendoza Olivares FJ, et al. Measuring colonic transit time in chronic idiophatic constipation. Rev Esp Enferm Dig 2003;95:181–90. [28] bin Mohd Zam NA, Tan KY, Ng C, et al. Mortality, morbidity and functional outcome after total or subtotal abdominal colectomy in the Asian population. ANZ J Surg 2005;75:840 –3. [29] Alves A, Panis Y, Bouhnik Y, et al. Subtotal colectomy for severe acute colitis: a 20-year experience of a tertiary care center with an aggressive and early surgical policy. J Am Coll Surg 2003;197: 379 – 85. [30] Glia A, Akerlund JE, Lindberg G. Outcome of colectomy for slowtransit constipation in relation to presence of small-bowel dysmotility. Dis Colon Rectum 2004;47:96 –102. [31] Bassotti G, Villanacci V. Slow transit constipation: a functional disorder becomes an enteric neuropathy. World J Gastroenterol 2006; 12:4609 –13. [32] Rao SS, Ozturk R, Laine L. Clinical utility of diagnostic tests for constipation in adults: a systematic review. Am J Gastroenterol 2005; 100:1605–15. [33] Bassotti G, de Roberto G, Castellani D, et al. Normal aspects of colorectal motility and abnormalities in slow transit constipation. World J Gastroenterol 2005;11:2691– 6. [34] Zutshi M, Hull TL, Trzcinski R, et al. Surgery for slow transit constipation: are we helping patients? Int J Colorectal Dis 2007; 22:265–9. [35] Ripetti V, Caputo D, Greco S, et al. Is total colectomy the right choice in intractable slow-transit constipation? Surgery 2006;140:435– 40. [36] Sample C, Gupta R, Bamehriz F, Anvari M. Laparoscopic subtotal colectomy for colonic inertia. J Gastrointest Surg 2005;9:803– 8.
Clinical surgery–International
Functional outcomes of two types of subtotal colectomy for slow-transit constipation: ileosigmoidal anastomosis and cecorectal anastomosis Ye Feng, M.D.*, Lin Jianjiang, M.D. Department of Colorectal Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China Manuscript received November 20, 2006; revised manuscript February 5, 2007
Abstract Background: Some patients with severe slow-transit constipation may benefit from subtotal colectomy, but there is no consensus on standard operative mode. The aim of the study was to compare the functional outcomes of subtotal colectomy with cecorectal anastomosis (CRA) with those of subtotal colectomy with ileosigmoidal anastomosis (ISA) in patients with severe slow-transit constipation. Methods: Records of 79 patients who received preoperative investigation to confirm slow transit at our institution from 1989 to 2004 and subsequently received colectomy with CRA (n ⫽ 34) or colectomy with ISA (n ⫽ 45) were reviewed. The mean follow-up was 2 years (range 1–15). Results: Postoperative defecation frequency increased and symptoms such as bloating and abdominal pain decreased in both groups. More CRA patients than ISA patients experienced persistent constipation and continued using laxatives or enemas at the 12-month follow-up. More ISA patients (93.3%) than CRA patients (73.5%) were satisfied with the procedure, whereas some patients in both groups complained of excessively high stool frequency and fecal incontinence. Conclusion: Both CRA and ISA procedures increase the number of bowel movements; however, ISA results in higher defecation frequency, less use of laxatives and enemas, and higher patient satisfaction. © 2008 Excerpta Medica Inc. All rights reserved. Keywords: Subtotal colectomy; Cecorectal anastomosis; Ileosigmoidal anastomosis; Slow-transit constipation
Patients with slow-transit constipation (STC) typically have reduced stool frequency but a morphologically normal colon and rectum [1]. Many of these patients have a long history of laxative abuse and have become dependent on these agents. After failed medical treatment, unsuccessful bowel habit training, and excluding the presence of obstructed defecation (eg, symptomatic rectocele or nonrelaxing puborectalis muscle), the treatment of choice becomes surgery [2,3]. In most centers, the standard surgical treatment for STC is total colectomy with ileorectal anastomosis or subtotal colectomy with ileosigmoidal anatomosis (ISA) [4 – 8]. These procedures are effective in increasing the frequency of bowel movements and relieving symptoms in the majority of patients. However, symptoms such as bloating and abdominal pain may persist. Furthermore, some patients experience postoperative side effects such as diarrhea and incontinence [4 – 6]. One possible way to reduce
these side effects is to perform a limited resection of the colon. In 1931, Ogilvie [9] was the first to propose subtotal colectomy with preservation of the ileocecal junction, which preserves continuity by anastomosing the cecum to the rectal stump. This kind of reconstruction preserves the important functions of the cecum, the distal ileum, and the ileocecal valve such as the absorption of water, bile, vitamin B12, and electrolytes. Other studies have been published on subtotal colectomy with cecorectal anastomosis (CRA), which represents an interesting alternative to subtotal colectomy with ISA [5,10,11]. To date, very few studies have been published comparing the 2 procedures. The specific aim of our investigation was to compare the long-term results of subtotal colectomy with CRA with those of subtotal colectomy with ISA in patients with severe STC.
* Corresponding author. Tel. ⫹86-571-87236882; fax: ⫹86-5718723667. E-mail address: [email protected]
Methods We performed a retrospective analysis of 79 consecutive patients with severe STC admitted in the Department of Colorectal Surgery, First Affiliated Hospital, School of
0002-9610/08/$ – see front matter © 2008 Excerpta Medica Inc. All rights reserved. doi:10.1016/j.amjsurg.2007.02.015
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Medicine, Zhejiang University, China, from January 1989 to December 2004. All received preoperative investigation, including colonoscopy, colonic transit, and anorectal tests (eg, defecography, manometry, and water-filled balloon expulsion tests), and radiopaque marker studies to document slow gut transit [12,13]. Slow transit was defined as the retention of more than 12 of 20 (⬎60%) radiopaque markers. All patients had failed traditional conservative treatments such as bulk-forming agents, oral laxatives, bowelcleansing solutions, enemas, or suppositories. Each patient was accepted for colectomy performed with either CRA or ISA. All operations were performed by the same surgical team. Each patient provided a signed informed consent before each procedure. Pertinent data regarding sex, age, constipation intervals, colonic transit, pharmacologic treatment, symptoms, severity, operation performed, histologic assessment, and postoperative complications was obtained from the charts of patients who had been seen approximately 1, 6, and 12 months postoperatively. All study patients were assessed by follow-up for an average of 2 years (range 1–15 years) using postal questionnaires, which were supplemented by telephone interviews as needed. Functional variables, including stool frequency per week, symptoms of abdominal pain, bloating, postoperative diarrhea, fecal incontinence, and use of laxatives or enema for bowel-movement assistance, were assessed pre- and postoperatively. Additionally, patients were asked to rate their satisfaction with the surgical outcome. Analyses were performed by using the SPSS statistical software package (version 11.0; SPSS Inc, Chicago, IL). Nonparametric analysis was by performed by using Wilcoxon signed rank testing for paired data and the MannWhitney U test for unpaired data. Chi-square criterion and a Fisher exact test were used to analyze contingency tables. P ⬍ .050 was considered statistically significant. Values were expressed as means ⫾ standard deviation, median (range), or number (percentage). Results A total of 79 patients were treated surgically for colonic inertia; 74 (93.7%) were female. Average age was 43.5 (21– 67) years. Unrelenting constipation was the primary complaint of all 79 patients with a mean duration before surgical intervention of 9.0 (2–25) years. Other presenting symptoms included abdominal pain in 56 patients (70.8%) and bloating in 58 patients (73.4%). All patients had used laxatives to treat their constipation, and 45 admitted to enema use. Colonic transit tests showed that retention of radiopaque markers averaged 15.2 ⫾ 2.5. The general data of CRA and ISA groups are shown in Tables 1 and 2; no significant differences were noted between the 2 groups. Thirty-four patients were accepted for colectomy and CRA and 45 patients for colectomy and ISA. Thirty-six patients (45.6%) received a stapled anastomosis with an end-to-end anastomotic stapler versus 43 (54.4%) who received a handsewn anastomosis. Postoperative hospitalization was 12.8 ⫾ 6.0 days. Operative data of the CRA and ISA groups are shown in Table 1; no significant differences were noted between the 2 groups. Pathology evaluation was con-
Table 1 Patient characteristics and operative data Category
CRA
ISA
Total
Sex (male/female) Age (y) Constipation intervals (y) Colonic transit* Operative time (min) Stapled anastomosis/ hand-sewn anastomosis Ileus Incision infection Anastomotic leakage Postoperative stay (d)
2/32 45.2 (25–67) 8.8 (2–22) 16.2 ⫾ 2.5 120 ⫾ 35
3/42 42.4 (21–65) 9.5 (2–25) 15.0 ⫾ 2.2 135 ⫾ 30
5/74 43.5 (21–67) 9.0 (2–25) 15.2 ⫾ 2.5 128 ⫾ 33
16/18 3 (8.8%) 1 (2.9%) 0 12.5 ⫾ 6.3
20/25 5 (11.1%) 1 (2.2%) 0 13.1 ⫾ 5.8
36/43 8 (10.1%) 2 (2.5%) 0 12.8 ⫾ 6.0
* Number of radiopaque markers in colon and rectum.
ducted on all specimens. On gross appearance, the majority of colon specimens were significantly redundant but without bowel wall thickening. No evidence of microscopic abnormalities was found in any of the specimens, except for a reduction in argyrophilic neurons. Melanosis coli were present in almost half of the population because of chronic use of laxatives. Early postoperative complications are shown in Table 1. Ileus was the single most common event, occurring in 8 patients (10.1%). Incision infection was seen in 2 patients (2.5%). No anastomotic leakage occurred. No significant differences were shown between the 2 groups (P ⬎ .05). The mean follow-up was 2 years (1–15). No mortality was found. In both groups, postoperative defecation frequency at follow-up increased compared with preoperative stool frequency (P ⬍ .05). Postoperative symptoms such as bloating and abdominal pain were decreased in both groups (P ⬍ .05). At the 12-month follow-up, ISA patients averaged 15.5 ⫾ 3.8 stools per week versus 10.2 ⫾ 5.4 (P ⬍ .05) of the CRA group. Some patients in both groups continued to complain of bloating and abdominal pain, and small-bowel obstruction occurred infrequently in both groups. At the 12-month follow-up, 9 patients in the CRA group (26.8%) experienced persistent constipation and continued to use laxatives compared with only 3 patients (6.7%) in the ISA group (P ⬍ .05). Four patients in the CRA group (11.8%) had to use enemas to assist defecation compared with only 1 patient (2.2%) in the ISA group (P ⬍ .05). At 1, 6, and 12 months, 12, 3, and 2 patients, respectively (26.7%, 6.7%, and 4.5%), in the ISA group complained of excessively high stool frequency, and 8, 1, and 1 patients (23.5%, 2.9%, and 2.9%) complained of fecal incontinence. However, at the same follow-up intervals, 8, 1, and 1 patients (17.8%, 2.2%, and 2.2%) in the CRA group complained of excessively high stool frequency, and 5, 0, and 0 patients (14.7%, 0%, and 0%) complained of fecal incontinence. Differences between the 2 groups were not statistically significant (P ⬎ .05). Patient satisfaction was associated with postoperative complications, recurrent constipation, persistent abdominal pain, and bloating. Stool frequency played an important role in ultimate patient satisfaction. Forty-two patients (93.3%) in the ISA group and 31 (73.5%) in the CRA group stated that they were satisfied with the procedure (P ⬍ .05). Functional outcomes
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Table 2 Functional outcomes of CRA and ISA Category
Preoperative CRA
Number of stools per week* Abdominal pain Bloating Laxative use Enema use Small-bowel obstruction Postoperative diarrhea† Postoperative fecal incontinence Number of patients satisfied
1.5 ⫾ 0.9 26 (76.5%) 26 (76.5%) 34 (100%) 21 (61.8%)
ISA 1.6 ⫾ 0.8 30 (66.7%) 32 (71.1%) 45 (100%) 24 (53.3%)
1 month postoperative
6 months postoperative
12 months postoperative
CRA
CRA
CRA
18.5 ⫾ 6.0 12 (35.3%) 11 (32.4%) 1 (2.9%) 0 ‡ 8 (23.5%) 5 (14.7%) 29 (85.3%)
ISA 23.5 ⫾ 8.8 14 (31.1%) 12 (26.7%) 1 (2.2%) 0 ‡ 12 (26.7%) 8 (17.8%) 41 (91.1%)
14.5 ⫾ 5.5 9 (26.5%) 10 (29.4%) 5 (14.7%) 2 (5.9%) 3 (8.9%) 1 (2.9%)vii 0ix 27 (79.4%)
ISA 16.8 ⫾ 4.2 10 (22.2%) 10 (22.2%) 2 (4.4%)ii iv 0 3 (6.7%) 3 (6.7%)viii 1 (2.2%)x 41 (91.1%)
ISA ①
10.2 ⫾ 5.4 8 (23.5%)③ 8 (23.5%)⑤ 9 (26.8%)⑦ 4 (11.8%)⑨ 3 (8.9%) 1 (2.9%) 0 25 (73.5%)
15.5 ⫾ 3.8②i 8 (17.8%)④ 7 (15.6%)⑥ 3 (6.7%)⑧iii 1 (2.2%)⑩v 3 (6.7%) 2 (4.5%) 1 (2.2%) 42 (93.3%)*
Data presented as number of patients follow by percent in parentheses. * Except for patients with laxative use, diarrhea, and postoperative incontinence. † Diarrhea was considered 5 or more bowel movements per day [13]. ‡ Presented in Table 1 as row “Ileus.” Compared with preoperative phase: ① ② ③ ④ ⑤ ⑥ ⑦ ⑧ ⑨ ⑩, P ⬍ .05. Compared with CRA group: i, ii, iii, iv, v, vi, P ⬍ .05. Compared with 1 month postoperative phase: vii, viii, ix, x, P ⬍ .05.
according to the 2 types of surgical anastomosis are shown in Table 2. Comments STC is an uncommon condition that occurs most often in women in the third decade of life [1,14,15]. It usually presents with symptoms of constipation and abdominal pain. Individuals diagnosed with this disorder suffer considerably and experience a major impact on lifestyle and quality of life [16]. The diagnosis of STC represents the severe part of the spectrum of slow-transit constipation, a clinical syndrome of constipation attributable to ineffective colonic propulsion. Most patients with constipation can be treated medically to improve symptoms. Patients with objective evidence of delayed colonic transit whose symptoms are refractory to medical management may benefit from surgical therapy. The most commonly performed surgical procedures have been total abdominal colectomy with ileorectal anastomosis and subtotal colectomy with ISA [4 – 8]. Some studies have shown that subtotal colectomy with CRA represents an interesting alternative to total colectomy with ileorectal anastomosis. No standard surgical technique exists for performing subtotal colectomy. ISA and CRA procedures are able to increase the frequency of bowel movements and relieve symptoms such as bloating and abdominal pain in the majority of patients. Nevertheless, some patients continue to endure persistent symptoms. In our study, ISA and CRA procedures for slow-transit constipation were compared with operative time, stapled anastomosis/hand-sewn anastomosis, ileus, anastomotic leakage, incision infection, and postoperative stay. Patient records were reviewed retrospectively from the 1997 to 2004. During 1989 to 1997, ISA was the preferred procedure at our institution. From 1997 to 2002, CRA was preferred because of diarrhea and fecal incontinence observed in patients who had undergone ISA. Because of a high incidence of constipation noted with CRA,
ISA has been the procedure of choice at our institution since 2002. No statistically significant differences were found between CRA and ISA procedures, either in operative techniques themselves, postoperative recovery, or in complications not relative to intestinal function. Some studies have found that the outcomes of stapled anastomosis are similar to those of hand-sewn anastomosis [17,18]. Because of the even distribution of stapled anastomosis and hand-sewn anastomosis in both ISA and CRA groups, we can compare the functional outcomes by ISA versus CRA in singleelement variant analysis. After subtotal colectomy with ISA, nearly all patients were able to pass stools spontaneously, which persisted for a mean of 1 year after surgery without the aid of laxatives or enema. At 1-year follow-up, only 3 patients were still using laxatives once or twice a day. Additionally, 42 (93.3%) patients reported satisfaction with the postoperative result. Although some constipation symptoms persisted after surgery, patients perceived that they were much better than before the operation. One month after surgery, 23.5% of patients reported diarrhea, and 14.4% reported fecal incontinence. The cause of diarrhea is most probably physiologic because stools become watery after subtotal colectomy. Early postoperative diarrhea stays only a short time and does not require long-term therapy. One year after surgery, diarrhea requiring medical support was reported by only 4.5% of patients and fecal incontinence by 2.2%. It has been reported that subtotal colectomy with ISA leads to an appreciable incidence of incontinence and loss in quality of life [19,20]. However, patient satisfaction seems to be related to stool frequency, which is an important parameter in patient-defined constipation. The ability to have at least 1 spontaneous bowel movement per day represented an improvement over their preoperative situation. In the majority of our patients, the CRA procedure for treatment of STC also caused an increase in the number of bowel movements. However, compared with ISA patients, those undergoing CRA had a lower frequency of bowel
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movements, resulting in a higher postoperative rate of constipation and a lower rate of satisfaction with the operation (P ⬍ .05). In our opinion, subtotal abdominal colectomy with CRA for treating constipation has a poorer functional outcome than ISA in the Chinese population we have studied. However, some Western studies have shown good functional outcomes from subtotal abdominal colectomy with CRA for treating constipation [5,10,11,21–23]. Our data do not agree with these studies. The possible reason for this discrepancy may be the differences between Western and Oriental colonic anatomy [24]. Perhaps there are also differences in the physiological functioning of the ascending colon and the sigmoid colon in the Oriental population and that in the Occidental population. This study showed that there are different bowel functional outcomes between surgical procedures that retain the cecum or part of the sigmoid and rectosigmoid junction, respectively. Moreover, given the fact that there are different bowel functional outcomes between the Occidental population and the Oriental population undergoing the same surgical procedure, we recommend that different surgical procedures be performed for different populations with STC. Several studies have found a distal delay in some patients in the left or rectosigmoid colon, which is sometimes referred to as a functional rectosigmoid obstruction [25–27]. In our study, we observed better results with the CRA approach in patients whose colonic transit test showed that nearly all radiopaque markers stayed in the left or rectosigmoid colon. This has led us to consider subtotal colectomy with CRA as the treatment of choice for selected patients with distal colonic delay, thereby possibly avoiding side effects of resection of the terminal ileum, ileocecal junction, and cecum, which is known to affect water and electrolyte resorption. Despite the success rate in our series and others [4,7,8], postoperative mortality and morbidity deserves comment. We found no mortality in our patients. The morbidity was considerable because 26 (32.9%) of our patients continued to have 1 or more symptoms of constipation, intestinal obstruction, or developed severe diarrhea. Small-bowel obstruction occurred 12 times in 9 patients at follow-up. Some patients continued to complain of bloating and abdominal pain at different times postoperatively. No statistically significant differences were shown between ISA and CRA procedures in these aspects. These complications are likely to have been caused by the primary disease and not by the operation itself because postcolectomy patients with diseases other than STC have been reported to be relatively free of abdominal symptoms, and only rarely has the surgery been found to induce intestinal obstruction [28,29]. Diarrhea was reported by 25.3% of our patients at 1-month follow-up, and fecal incontinence by 15.2%. As time passed, the occurrence of these symptoms as rare events lessened. In 2 patients, diarrhea was constant and severe, requiring medical intervention. The differences between the ISA and CRA groups regarding postoperative diarrhea and fecal incontinence were not statistically significant (P ⬎ .05), although the CRA group had better results than the ISA group.
Conclusions Our study is a retrospective study with a small series, and, to confirm any conclusions regarding colectomy with CRA versus ISA, we need the results of randomized clinical trials and large sample data. We plan to continue to perform the 2 procedures for STC and collect data. At present, controversies remain regarding STC itself [30 –33], the significance of the procedure [34,35], and selection of a modus operandi for treatment [21,23,36]. We believe that the more data we provide, the more we can reduce the controversies. In conclusion, both CRA and ISA procedures increase the number of bowel movements, but ISA is the superior method because it generates increased patient satisfaction. The CRA procedure can be performed for selected patients with distal colonic inertia. Secondary morbidity can be considerable in a small number of patients. Further studies are needed to explore mechanisms of the pathogenesis of constipation and to improve individualized treatment for constipation symptoms. Acknowledgments The authors thank Dr. Xu Jiahe (Department of Colorectal Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, China) for linguistic revision of this manuscript. References [1] Preston D, Lennard-Jones JE. Severe chronic constipation of young women: idiopathic slow transit constipation. Gut 1986;27:41– 8. [2] Rao SSC, Tuteja AK, Vellema T, et al. Dyssynergic defecation: demographics, symptoms, stool patterns and quality of life. J Clin Gastroenterol 2004;38:680 –5. [3] Pare P, Ferrzazzi S, Thompson WG, et al. An epidemiological survey of constipation in Canada: definitions, rates, demographics and predictors of health care seeking. Am J Gastroenterol 2001;96:3130 –7. [4] Lubowski DZ, Chen FC, Kennedy ML, King DW. Results of colectomy for severe slow transit constipation. Dis Colon Rectum 1996; 39:23–9. [5] Knowles CH, Scott M, Lunniss PJ. Outcome of coloectomy for slow transit constipation. Ann Surg 1999;230:627–38. [6] Blachut K, Bednarz W, Paradowski L. Surgical treatment of constipation. Rocz Akad Med Bialymst 2004;49:47–52. [7] Nylund G, Oresland T, Fasth S, Nordgren S. Long-term outcome after colectomy in severe idiopathic constipation. Colorectal Dis 2001;3: 253– 8. [8] Bharucha AE. Treatment of severe and intractable constipation. Curr Treat Options Gastroenterol 2004;7:291– 8. [9] Ogilvie WH. The preservation of the ileocecal sphincter in resection of the right half of the colon. Br J Surg 1931;14:8. [10] Sarli L, Iusco D, Donadei E, et al. The rationale for cecorectal anastomosis for slow transit constipation. Acta Biomed Ateneo Parmense 2003;74(suppl 2):74 –9. [11] Sarli L, Costi R, Iusco D, Roncoroni L. Long-term results of subtotal colectomy with antiperistaltic cecoproctostomy. Surg Today 2003;33: 823–7. [12] Abrahamsson H, Antov S, Bosaeus I. Gastrointestinal and colonic segmental transit time evaluated by a single abdominal x-ray in healthy subjects and constipated patients. Scand J Gastroenterol 1988; 152:72– 80. [13] Bernini A, Madoff RD, Lowry AC, et al. Should patients with combined colonic inertia and nonrelaxing pelvic floor undergo subtotal colectomy? Dis Colon Rectum 1998;41:1363– 6. [14] Knowles CH, Scott SM, Rayner C, et al. Idiopathic slow-transit constipation: an almost exclusively female disorder. Dis Colon Rectum 2003;46:1716 –7. [15] MacDonald A, Baxter JN, Finlay IG. Idiopathic slow-transit constipation. Br J Surg 1993;80:1107–11.
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