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| 번호 | 제목 | 등록일 | 조회수 |
|---|---|---|---|
| 8 | Long-Term Follow-Up of Patients Undergoing Colectomy for Colonic Inertia [2001년 2월 DCR] | 2011-11-12 | 2975 |
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Alon J. Pikarsky, M.D., Jay J. Singh, M.D., Eric G. Weiss, M.D.,
Juan J. Nogueras, M.D., Steven D. Wexner, M.D. From the Department of Colorectal Surgery, Cleveland Clinic Florida, Fort Lauderdale, Florida
PURPOSE: Total abdominal colectomy with ileorectal anastomosis has been the procedure of choice for patients with the established diagnosis of colonic inertia. Previous studies with a limited follow-up of only one to two years have shown acceptable results and a high rate of patient satisfaction. The aim of this study was to evaluate the long-term results of total abdominal colectomy in these patients in terms of complications, bowel function, and overall patient satisfaction.
METHODS: Access to the colorectal registry at the Cleveland Clinic Florida identified all patients who underwent total abdominal colectomy for colonic inertia between 1988 and 1993, with a minimum of five-year followup. Telephone interviews were designed to assess bowel function, concomitant use of any antidiarrlaeal medications, postoperative complications, persistence or development of preoperative symptoms such as pain or bloating, and overall satisfaction. Patients were asked to rate their outcome
as excellent, good, fair, or poor. RESULTS: Fifty patients underwent total abdominal colectomy for the diagnosis of colonic inertia. Three patients died of unrelated causes and 30 (60 percent) were available for follow-up. The mean follow-up was 106 months, ranging from 61 to 122 months. All 30 patients reported the outcome of surgery
as "excellent." The average frequency of spontaneous bowel movements was 2.5 (range, 1-6) per day. During the period of follow-up, six patients (20 percent) required admission for small-bowel obstruction, three of whom (10 percent) required laparotomy. Four patients complained of mild pelvic pain, only one of whom had the onset of pelvic pain postoperatively that persisted tmtil the time of interview. In the other three patients the pain was present preoperatively but had decreased in intensity since the operation. Two patients (6 percent) still required assistance with bowel movements, one by laxatives and the other by enemas. Only two patients (6 percent) needed antidiarrheal medications to reduce bowel frequency. CONCLUSION: This long-term follow-up revealed a high degree of patient satisfaction and very good bowel habits, with an acceptable long-term rate of bowel obstruction. Based on these results, total abdominal colectomy can be recommended to patients with well-established colonic inertia with expectations of sustained benefit up to ten years after surgery.
DISCUSSION
Patients with diffuse delay on transit study who fail to respond to conservative treatment measures are
considered to have CI and are candidates for colectomy. The cause of CI is still poorly understood, although alteration in the local neurohumoral net-work certainly plays a role. Colectomy for constipation dates back to a report made almost one century ago. These procedures were initially abandoned because of both a high complication rate and a poor success rate. However, they have been revitalized during the past two decades, since physiologic studies have allowed more accurate patient selection. Since 1980 surgeons have performed a TAC with ileorectal anastomosis and subtotal colectomy with ileosigmoid or cecorectal anastomosis for CI. A cecorectal anastomosis, while preserving the ileocecal valve with the theoretical advantage of water preservation, is often complicated by cecal distention. Sigmoid preservation also predisposes patients to postoperative constipation. In a study published by Pemberton et al. 50 percent of patients after cecorectal anastomosis were eventually converted to an ileorectal anastomosis. Several recent publications indicate TAC to be the procedure of choice for CI. Preston et al. 19 reported a retrospective analysis of 21 females undergoing surgery for CI, and by comparison of the various procedures, this group concluded that TAC was the best surgical alternative. Overall, TAC had a success rate of more than 90 percent in several studies. A previous study conducted at our institution showed an overall success rate of 94 percent (Table
1). Despite this excellent success rate, postoperative morbidity remains a discouraging problem. The most frequent complication reported is small-bowel obstruction, with a reported incidence of 7 to 50 percent, The incidence in our previous study at 27 months after surgery was 10 percent. Another issue deserving discussion is the incidence of postoperative pain and bloating. As reported in past studies, these complaints are less likely to subside after colectomy, perhaps because of irritable bowel symptoms, The mean follow-up period in all previous studies reported in Table 3 was approximately one to two years, making it difficult to reach any definitive conclusions. The current study, with a mean follow-up of almost nine years, may address some issues more comprehensively. A potential problem with this current study is the 34 percent of patients who were lost to follow-up. However, information gathered from these patients' charts at the time of their last office visit (mean, 60 months from surgery to last visit) revealed functional results that were equivalent to those of the other patients. Thus, regardless of the length of follow-up, whether a mean of 60 or a mean of 106 months, the functional results and morbidity were similar. During the period of 10 years, there was a slight decrease in bowel frequency from 3.7 per day at 27 months to 2.5 per day at up to 10 years. This decrease may reflect continuing adaptation of the alimentary tract to the colectomy. With time stool consistency had changed and the initial 16 percent of patients complaining of semiliquid stool currently report semisolid stools. Additionally, the incidence of incontinent episodes decreased from 24 to 17 percent, respectively, and the use of antidiarrheal medications from 17 to 6 percent, respectively. At the time of the interview, only two patients suffered from mild constipation needing laxatives or enemas. The rate of small-bowel obstruction was unchanged from our previous study, with all obstructions occurring within two years of the operation. Preoperatively, 60 percent of our patients reported bloating, an incidence that remained unchanged at 27 months. However, with longer follow-up the rate decreased to 23 percent, again possibly because of small-bowel adaptation. Chart review revealed no other cases of bowel obstruction in those patients lost to follow-up. The 100 percent satisfaction rate noted in this 60 percent of patients is encouraging. |
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