Skip to main content
PMC home page
Annals of Surgery logoLink to Annals of Surgery
. 1991 Oct;214(4):403–413. doi: 10.1097/00000658-199110000-00005

Evaluation and surgical treatment of severe chronic constipation.

J H Pemberton 1, D M Rath 1, D M Ilstrup 1
PMCID: PMC1358538  PMID: 1953096

Abstract

Patients with chronic constipation may have one of several physiologic disorders, not all of which are amenable to operative therapy. The aim of this study was to test colonic and pelvic floor function preoperatively, to identify patients suitable for surgery based on these studies, and to determine operative outcome over time. Between 1987 and January 1991, 277 patients referred for severe symptoms of chronic intractable constipation underwent colon transit studies, measurement of anal canal pressures and reflexes, and measurements of anorectal angle movements and efficiency of evacuation. Balloon expulsion studies, electromyography of the pelvic floor, and defecating proctograms also were done. Based on these studies, patients were categorized as having: slow transit constipation (STC), 29 patients; pelvic floor dysfunction (PFD), 37 patients; STC + PFD, combined slow transit and pelvic floor dysfunction, 14 patients; and irritable bowel syndrome (IBS), 197 patients. Slow transit constipation patients underwent abdominal colectomy and reanastomosis. Pelvic floor dysfunction patients underwent pelvic floor retraining only. Patients with STC + PFD underwent pelvic floor retraining followed by abdominal colectomy. Irritable bowel syndrome patients were treated symptomatically. Among the 38 patients operated on (STC and STC + PFD), there was no operative mortality. Prolonged ileus developed in 13%, and small bowel obstruction occurred in 11% of patients. On follow-up, a mean of 20 months after ileorectostomy, no patient was constipated, none required a laxative, and none was incontinent. The mean number of stools per day was four. The authors concluded that a prospective evaluation of colonic and pelvic floor function reliably delineated constipated patients with slow transit, suitable for operative management, from those with pure pelvic floor dysfunction or irritable bowel syndrome, who were not. Abdominal colectomy and ileorectostomy in the slow transit patients was safe and effective, resulting in prompt and prolonged relief of constipation.

Full text

PDF
403

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Barkel D. C., Pemberton J. H., Pezim M. E., Phillips S. F., Kelly K. A., Brown M. L. Scintigraphic assessment of the anorectal angle in health and after ileal pouch-anal anastomosis. Ann Surg. 1988 Jul;208(1):42–49. doi: 10.1097/00000658-198807000-00006. [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Barnes P. R., Hawley P. R., Preston D. M., Lennard-Jones J. E. Experience of posterior division of the puborectalis muscle in the management of chronic constipation. Br J Surg. 1985 Jun;72(6):475–477. doi: 10.1002/bjs.1800720623. [DOI] [PubMed] [Google Scholar]
  3. Beck D. E., Jagelman D. G., Fazio V. W. The surgery of idiopathic constipation. Gastroenterol Clin North Am. 1987 Mar;16(1):143–156. [PubMed] [Google Scholar]
  4. Belliveau P., Goldberg S. M., Rothenberger D. A., Nivatvongs S. Idiopathic acquired megacolon: the value of subtotal colectomy. Dis Colon Rectum. 1982 Mar;25(2):118–121. doi: 10.1007/BF02553250. [DOI] [PubMed] [Google Scholar]
  5. Bleijenberg G., Kuijpers H. C. Treatment of the spastic pelvic floor syndrome with biofeedback. Dis Colon Rectum. 1987 Feb;30(2):108–111. doi: 10.1007/BF02554946. [DOI] [PubMed] [Google Scholar]
  6. Drossman D. A., Sandler R. S., McKee D. C., Lovitz A. J. Bowel patterns among subjects not seeking health care. Use of a questionnaire to identify a population with bowel dysfunction. Gastroenterology. 1982 Sep;83(3):529–534. [PubMed] [Google Scholar]
  7. Hinton J. M., Lennard-Jones J. E., Young A. C. A ne method for studying gut transit times using radioopaque markers. Gut. 1969 Oct;10(10):842–847. doi: 10.1136/gut.10.10.842. [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Hughes E. S., McDermott F. T., Johnson W. R., Polglase A. L. Surgery for constipation. Aust N Z J Surg. 1981 Apr;51(2):144–148. doi: 10.1111/j.1445-2197.1981.tb05926.x. [DOI] [PubMed] [Google Scholar]
  9. Jones P. N., Lubowski D. Z., Swash M., Henry M. M. Is paradoxical contraction of puborectalis muscle of functional importance? Dis Colon Rectum. 1987 Sep;30(9):667–670. doi: 10.1007/BF02561685. [DOI] [PubMed] [Google Scholar]
  10. Kamm M. A., Hawley P. R., Lennard-Jones J. E. Lateral division of the puborectalis muscle in the management of severe constipation. Br J Surg. 1988 Jul;75(7):661–663. doi: 10.1002/bjs.1800750713. [DOI] [PubMed] [Google Scholar]
  11. Kamm M. A., Hawley P. R., Lennard-Jones J. E. Outcome of colectomy for severe idiopathic constipation. Gut. 1988 Jul;29(7):969–973. doi: 10.1136/gut.29.7.969. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Kamm M. A. The surgical treatment of severe idiopathic constipation. Int J Colorectal Dis. 1987 Nov;2(4):229–235. doi: 10.1007/BF01649511. [DOI] [PubMed] [Google Scholar]
  13. Keighley M. R., Shouler P. Outlet syndrome: is there a surgical option? J R Soc Med. 1984 Jul;77(7):559–563. doi: 10.1177/014107688407700707. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Keighley M. R. Surgery for constipation. Br J Surg. 1988 Jul;75(7):625–626. doi: 10.1002/bjs.1800750702. [DOI] [PubMed] [Google Scholar]
  15. Klatt G. R. Role of subtotal colectomy in the treatment of incapacitating constipation. Am J Surg. 1983 May;145(5):623–625. doi: 10.1016/0002-9610(83)90107-1. [DOI] [PubMed] [Google Scholar]
  16. Krishnamurthy S., Schuffler M. D., Rohrmann C. A., Pope C. E., 2nd Severe idiopathic constipation is associated with a distinctive abnormality of the colonic myenteric plexus. Gastroenterology. 1985 Jan;88(1 Pt 1):26–34. doi: 10.1016/s0016-5085(85)80128-1. [DOI] [PubMed] [Google Scholar]
  17. Lanfranchi G. A., Bazzocchi G., Brignola C., Campieri M., Labò G. Different patterns of intestinal transit time and anorectal motility in painful and painless chronic constipation. Gut. 1984 Dec;25(12):1352–1357. doi: 10.1136/gut.25.12.1352. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Leon S. H., Krishnamurthy S., Schuffler M. D. Subtotal colectomy for severe idiopathic constipation. A follow-up study of 13 patients. Dig Dis Sci. 1987 Nov;32(11):1249–1254. doi: 10.1007/BF01296374. [DOI] [PubMed] [Google Scholar]
  19. Mahieu P., Pringot J., Bodart P. Defecography: II. Contribution to the diagnosis of defecation disorders. Gastrointest Radiol. 1984;9(3):253–261. doi: 10.1007/BF01887846. [DOI] [PubMed] [Google Scholar]
  20. Martelli H., Devroede G., Arhan P., Duguay C. Mechanisms of idiopathic constipation: outlet obstruction. Gastroenterology. 1978 Oct;75(4):623–631. [PubMed] [Google Scholar]
  21. Metcalf A. M., Phillips S. F., Zinsmeister A. R., MacCarty R. L., Beart R. W., Wolff B. G. Simplified assessment of segmental colonic transit. Gastroenterology. 1987 Jan;92(1):40–47. doi: 10.1016/0016-5085(87)90837-7. [DOI] [PubMed] [Google Scholar]
  22. O'Connell P. R., Kelly K. A., Brown M. L. Scintigraphic assessment of neorectal motor function. J Nucl Med. 1986 Apr;27(4):460–464. [PubMed] [Google Scholar]
  23. Preston D. M., Hawley P. R., Lennard-Jones J. E., Todd I. P. Results of colectomy for severe idiopathic constipation in women (Arbuthnot Lane's disease). Br J Surg. 1984 Jul;71(7):547–552. doi: 10.1002/bjs.1800710726. [DOI] [PubMed] [Google Scholar]
  24. Preston D. M., Lennard-Jones J. E. Anismus in chronic constipation. Dig Dis Sci. 1985 May;30(5):413–418. doi: 10.1007/BF01318172. [DOI] [PubMed] [Google Scholar]
  25. Preston D. M., Lennard-Jones J. E. Severe chronic constipation of young women: 'idiopathic slow transit constipation'. Gut. 1986 Jan;27(1):41–48. doi: 10.1136/gut.27.1.41. [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Preston D. M., Lennard-Jones J. E., Thomas B. M. The balloon proctogram. Br J Surg. 1984 Jan;71(1):29–32. doi: 10.1002/bjs.1800710109. [DOI] [PubMed] [Google Scholar]
  27. Read N. W., Timms J. M., Barfield L. J., Donnelly T. C., Bannister J. J. Impairment of defecation in young women with severe constipation. Gastroenterology. 1986 Jan;90(1):53–60. doi: 10.1016/0016-5085(86)90074-0. [DOI] [PubMed] [Google Scholar]
  28. Read N. W., Timms J. M. Defecation and the pathophysiology of constipation. Clin Gastroenterol. 1986 Oct;15(4):937–965. [PubMed] [Google Scholar]
  29. Rutter K. R. Electromyographic changes in certain pelvic floor abnormalities. Proc R Soc Med. 1974 Jan;67(1):53–56. [PMC free article] [PubMed] [Google Scholar]
  30. Stanghellini V., Camilleri M., Malagelada J. R. Chronic idiopathic intestinal pseudo-obstruction: clinical and intestinal manometric findings. Gut. 1987 Jan;28(1):5–12. doi: 10.1136/gut.28.1.5. [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Taylor B. M., Beart R. W., Jr, Phillips S. F. Longitudinal and radial variations of pressure in the human anal sphincter. Gastroenterology. 1984 Apr;86(4):693–697. [PubMed] [Google Scholar]
  32. Turnbull G. K., Lennard-Jones J. E., Bartram C. I. Failure of rectal expulsion as a cause of constipation: why fibre and laxatives sometimes fail. Lancet. 1986 Apr 5;1(8484):767–769. doi: 10.1016/s0140-6736(86)91783-6. [DOI] [PubMed] [Google Scholar]
  33. Vasilevsky C. A., Nemer F. D., Balcos E. G., Christenson C. E., Goldberg S. M. Is subtotal colectomy a viable option in the management of chronic constipation? Dis Colon Rectum. 1988 Sep;31(9):679–681. doi: 10.1007/BF02552582. [DOI] [PubMed] [Google Scholar]
  34. Walsh P. V., Peebles-Brown D. A., Watkinson G. Colectomy for slow transit constipation. Ann R Coll Surg Engl. 1987 Mar;69(2):71–75. [PMC free article] [PubMed] [Google Scholar]
  35. Weber J., Ducrotte P., Touchais J. Y., Roussignol C., Denis P. Biofeedback training for constipation in adults and children. Dis Colon Rectum. 1987 Nov;30(11):844–846. doi: 10.1007/BF02555421. [DOI] [PubMed] [Google Scholar]
  36. Yoshioka K., Keighley M. R. Clinical results of colectomy for severe constipation. Br J Surg. 1989 Jun;76(6):600–604. doi: 10.1002/bjs.1800760625. [DOI] [PubMed] [Google Scholar]
  37. Yoshioka K., Keighley M. R. Randomized trial comparing anorectal myectomy and controlled anal dilatation for outlet obstruction. Br J Surg. 1987 Dec;74(12):1125–1129. doi: 10.1002/bjs.1800741217. [DOI] [PubMed] [Google Scholar]

Articles from Annals of Surgery are provided here courtesy of Lippincott, Williams, and Wilkins

RESOURCES