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| 번호 | 제목 | 등록일 | 조회수 |
|---|---|---|---|
| 15 | Colectomy for Slow-Transit Constipation: Preoperative Functional Evaluation Is Important but Not a Guarantee for a Successful Outcome [2001년 4월 DCR] | 2011-11-12 | 3333 |
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Roland M. Mollen, M.D., Han C. Kuijpers, M.D., Ph.D.,Ad T. Claassen, M.D.S:
From the Department of Surgery, Gelderse Vallei hospital, Bennekom, the Netherlands, Department of Surgery, Bernhoven Hospital, Veghel, the Netherlands, and Department of Surgery, University Hospital Nijmegen, Nijmegen, the Netherlands PURPOSE: This study" was designed to assess the results of preoperative functional evaluation of patients with severe slow-transit constipation in relation to functional outcome.
METHODS: Four hundred thirty-nine patients with chronic intractable constipation were evaluated by marker studies. Twenty-one patients underwent colectomy and ileorectal anastomosis for slow-transit constipation. Mean colorectal transit time was 156 hours (normal, <45 hours). Small bowel transit time was normal in ten patients and delayed in five patients. Six were nonresponders. Morbidity was 33 percent, Small-bowel obstruction occurred in six patients; relaparotomy was done in four patients. Follow-up varied from 14 to 153 (mean, 62) months. RESULTS: After three months, defecation frequency was increased in all. Mean stool frequency improved from one bowel movement per 5.9 days to 2.8 times per day. Sixteen patients felt improved
after surgery. Seventeen continued to experience abdominal pain, and 13 still used laxatives and enemas. Satisfaction rate was 76 percent (16 patients). After one year, defecation frequency was back at the preoperative level in five patients. An ileostomy was created in two more patients because of incontinence and persistent diarrhea. Eleven patients (52 percent) still felt improved. A relation between small-bowel function and functional results could not be demonstrated. CONCLUSIONS: Preoperative evaluation is important but not a guarantee for successful outcome. Colectomy remains an ultimate option for patients with disabling slow-transit constipation, but patients should be informed that, despite an increased defecation frequency, abdominal symptoms might persist. Any promiscuous use of colectomy to treat constipation should be discouraged.
DISCUSSION
Although slow-transit constipation is usually managed conservatively by medical treatment, some patients are treated by cotectomy with ileorectal anastomosis in an attempt to relieve intractable symptoms. Several authors have reported excellent results. Defecation frequency improves from less than once per week to several times daily. All of these authors agree that the best assurance of successful outcome after colectomy is thorough preoperative evaluation.
Others, however, report conflicting data. In their studies, severe constipation persists in 10 to 15 percent of patients; more than one-third continue to take laxatives or enemas; about half of them have persistent abdominal pain; and one-third continue to strain despite adequate preoperative evaluation. Additional
surgery is required in up to one-third of patients, all resulting in a patient's satisfaction rate of about 50 percent. In this study, we report a standardized method of preoperative evaluation of patients with severe slow transit constipation using colonic transit studies, anal manometry, defecography/pelvic floor EMG, and determination of small-bowel transit time. Despite this thorough selection, the satisfaction rate was only 52 percent after one year, and 33 percent required further surgery.
It has been suggested that the persistent abdominal symptoms after colectomy or ileostomy are a result of a more diffuse neurologic involvement of the small intestine affecting its motility. This may explain the
up-to-44-percent reported incidence of intestinal obstruction and the periods of near-absent ileostomy output without radiologic evidence of mechanical obstruction, well known to all surgeons treating these patients. In this study, the intestinal obstruction rate was 35 percent and findings at operation were suspicious for small-intestinal pseudo-obstruction. The 33 percent incidence of a delay in small-bowel transit time strongly supports this hypothesis. Slow transit constipation not only is a colonic disorder but also affects the small bowel. The disorder has a progressive course because success rate decreased with time. After one year, 52 percent felt improved after colectomy. Therefore, we still consider colectomy the
ultimate option for patients with disabling slow-transit constipation not relieved by medical treatment. However, patients should be informed that, although defecation frequency will increase, abdominal symptoms may persist and may be accompanied by fecal incontinence. Preoperative functional evaluation is important but not a guarantee for a successful functional outcome.
Along with others, we strongly caution against any promiscuous use of colectomy to treat functional constipation. |
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