Surgical treatment of constipation and fecal incontinence

Current Overview on Clinical Management of Chronic Constipation

Constipation is one of the major gastrointestinal disorders diagnosed in clinical practice in Western countries. Almost 20% of population suffer from this disorder, which means constipation is a substantial utilization of healthcare. Pathophysiology of constipation is complex and multifactorial, where aspects like disturbance in colonic transit, genetic predisposition, lifestyle habits, psychological distress, and many others need to be taken into consideration. Diagnosis of constipation is troublesome and requires thorough accurate examination. A nonpharmacological approach, education of the patient about the importance of lifestyle changes like diet and sport activity state, are the first line of therapy. In case of ineffective treatment, pharmacological treatments such as laxatives, secretagogues, serotonergic agonists, and many other medications should be induced. If pharmacologic treatment fails, the definitive solution for constipation might be surgical approach. Commonness of this disorder, costs of medical care and decrease in quality life cause constipation is a serious issue for many specialists. The aim of this review is to present current knowledge of chronic constipation and management of this disorder.

Epidemiology and management of chronic constipation in elderly patients

Constipation is a common functional gastrointestinal disorder, with prevalence in the general population of approximately 20%. In the elderly population the incidence of constipation is higher compared to the younger population, with elderly females suffering more often from severe constipation. Treatment options for chronic constipation (CC) include stool softeners, fiber supplements, osmotic and stimulant laxatives, and the secretagogues lubiprostone and linaclotide. Understanding the underlying etiology of CC is necessary to determine the most appropriate therapeutic option. Therefore, it is important to distinguish from pelvic floor dysfunction (PFD), slow and normal transit constipation. Evaluation of a patient with CC includes basic blood work, rectal examination, and appropriate testing to evaluate for PFD and slow transit constipation when indicated. Pelvic floor rehabilitation or biofeedback is the treatment of choice for PFD, and its efficacy has been proven in clinical trials. Surgery is rarely indicated in CC and can only be considered in cases of slow transit constipation when PFD has been properly excluded. Other treatment options such as sacral nerve stimulation seem to be helpful in patients with urinary dysfunction. Botulinum toxin injection for PFD cannot be recommended at this time with the available evidence. CC in the elderly is common, and it has a significant impact on quality of life and the use of health care resources. In the elderly, it is imperative to identify the etiology of CC, and treatment should be based on the patient’s overall clinical status and capabilities.

[Urgent abdominal pain: constipation differential diagnosis]

Constipation is a common health problem in our clinics. At first, we think that a physical examination and additional tests are not necessary. This condition may be considered unimportant initially, but it can give rise to ongoing pain, discomfort, for the many who suffer from it, and sometimes can present with severe clinical symptoms. We present a case of a patient presented with this condition, and after conducting a brief anamnesis and a complete and rapid physical examination, the patient was finally treated as a surgical emergency.

Advances in diagnostic assessment of fecal incontinence and dyssynergic defecation

Disorders of the anorectum and pelvic floor affect approximately 25% of the population. Their evaluation and treatment have been hindered by a lack of understanding of underlying mechanism(s) and a working knowledge of the diagnostic advances in this field. A meticulous evaluation of anorectal structure and its function can provide invaluable insights to the practicing gastroenterologist regarding the pathogenic mechanism(s) of these disorders. Also, significant new knowledge has emerged over the past decade that includes the development of newer diagnostic tools such as high-resolution manometry and magnetic resonance defecography as well as a better delineation of the clinical and pathophysiologic subtypes of constipation and incontinence. This article provides an up-to-date review on the role of diagnostic tests in the evaluation of fecal incontinence and constipation with dyssynergic defecation.

Update on the management of constipation in the elderly: new treatment options

Constipation disproportionately affects older adults, with a prevalences of 50% in community-dwelling elderly and 74% in nursing-home residents. Loss of mobility, medications, underlying diseases, impaired anorectal sensation, and ignoring calls to defecate are as important as dyssynergic defecation or irritable bowel syndrome in causing constipation. Detailed medical history on medications and co-morbid problems, and meticulous digital rectal examination may help identify causes of constipation. Likewise, blood tests and colonoscopy may identify organic causes such as colon cancer. Physiological tests such as colonic transit study with radio-opaque markers or wireless motility capsule, anorectal manometry, and balloon expulsion tests can identify disorders of colonic and anorectal function. However, in the elderly, there is usually more than one mechanism, requiring an individualized but multifactorial treatment approach. The management of constipation continues to evolve. Although osmotic laxatives such as polyethylene glycol remain mainstay, several new agents that target different mechanisms appear promising such as chloride-channel activator (lubiprostone), guanylate cyclase agonist (linaclotide), 5HT₄ agonist (prucalopride), and peripherally acting μ-opioid receptor antagonists (alvimopan and methylnaltrexone) for opioid-induced constipation. Biofeedback therapy is efficacious for treating dyssynergic defecation and fecal impaction with soiling. However, data on efficacy and safety of drugs in elderly are limited and urgently needed.

Evaluation and treatment of anal incontinence, constipation, and defecatory dysfunction

Posterior compartment disorders include anal incontinence, constipation, and defecatory dysfunction. These disorders cause considerable morbidity, and are typically underreported by patients and undertreated by providers. The purpose of this article is outline the approach to diagnosis and treatment of anal incontinence, constipation, and defecatory dysfunction with a brief description of the nature of the problem and approaches to evaluation and diagnosis, as well as medical and surgical management.

Chronic constipation in the elderly

Chronic constipation is a common problem in the elderly, with a variety of causes, including pelvic floor dysfunction, medication effects, and numerous age-specific conditions. A stepwise diagnostic and therapeutic approach to patients with chronic constipation based on historical and physical examination features is recommended. Prudent use of fiber supplements and laxative agents may be helpful for many patients. Based on their capabilities, patients with pelvic floor dysfunction should be considered for pelvic floor rehabilitation (biofeedback), although efficacy in the elderly is uncertain. Clinical awareness and focused testing to identify the physiologic abnormalities underlying constipation, while being mindful of situations unique to the elderly, facilitate management, and improve patient outcomes.

Factors associated with failure of the artificial bowel sphincter: a study of over 50 cases from Cleveland Clinic Florida

PURPOSE

This study investigated the risk factors related to artificial bowel sphincter infection, complications, and failure.

METHOD

Complications may occur at any time after artificial bowel sphincter implantation. Early-stage complication is defined as any complications that occurred before artificial bowel sphincter activation, whereas late-stage complications are defined as any complications that occurred after device activation. Assessment of the outcomes of all artificial bowel sphincter operations included evaluation of factors related to patient demographics, operative procedures, and postoperative events.

RESULT

From January 1998 to May 2007, 51 artificial bowel sphincter implantations were performed in 47 patients (43; 84.3% female) with a mean age of 48.8 +/- 12.5 (range, 19-79) years and a mean incontinence score of 18 +/- 1.4 (range, 0-20). In 24 patients (54.5%), the etiology of incontinence was secondary to imperforate anus; 15 (24.2%) patients had obstetric injury or anorectal trauma. Twenty-three (41.2%) artificial bowel sphincter implantations became infected, 18 (35.3%) of which developed early-stage infection, whereas 5 (5.9%) had late-stage infection. One patient in the latter group had associated erosion, and two patient had fistula formation. Late-stage complications continued to increase with time. Multivariate analysis revealed that the time between artificial bowel sphincter implantation and first bowel movement and a history of perineal sepsis were independent risk factors for early-stage artificial bowel sphincter infection.

CONCLUSION

The time from implantation to first bowel movement and history of perineal infection were risk factors for early-stage artificial bowel sphincter infection and failure. Late-stage failures were more often the result of device malfunction and indicated the need for mechanical refinement.

Neurophysiological testing in anorectal disorders

Neurophysiological tests of anorectal function can provide useful information regarding the integrity of neuronal innervation, as well as neuromuscular function. This information can give insights regarding the pathophysiological mechanisms that lead to several disorders of anorectal function, particularly fecal incontinence, pelvic floor disorders and dyssynergic defecation. Currently, several tests are available for the neurophysiological evaluation of anorectal function. These tests are mostly performed on patients referred to tertiary care centers, either following negative evaluations or when there is lack of response to conventional therapy. Judicious use of these tests can reveal significant and new understanding of the underlying mechanism(s) that could pave the way for better management of these disorders. In addition, these techniques are complementary to other modalities of investigation, such as pelvic floor imaging. The most commonly performed neurophysiological tests, along with their indications and clinical utility are discussed. Several novel techniques are evolving that may reveal new information on brain-gut interactions.

Colonic irrigation for defecation disorders after dynamic graciloplasty

BACKGROUND AND AIMS

Dynamic graciloplasty (DGP) improves anal continence and quality of life for most patients. However, in some patients, DGP fails and fecal incontinence is unsolved or only partially improved. Constipation is also a significant problem after DGP, occurring in 13-90%. Colonic irrigation can be considered as an additional or salvage treatment for defecation disorders after unsuccessful or partially successful DGP. In this study, the effectiveness of colonic irrigation for the treatment of persistent fecal incontinence and/or constipation after DGP is investigated.

MATERIALS AND METHODS

Patients with defecation disorders after DGP visiting the outpatient clinic of the University Hospital Maastricht were selected for colonic irrigation as additional therapy or salvage therapy in the period between January 1999 and June 2003. The Biotrol(R) Irrimatic pump or the irrigation bag was used for colonic irrigation. Relevant physical and medical history was collected. The patients were asked to fill out a detailed questionnaire about colonic irrigation.

RESULTS

Forty-six patients were included in the study with a mean age of 59.3 +/- 12.4 years (80% female). On average, the patients started the irrigation 21.39 +/- 38.77 months after the DGP. Eight patients started irrigation before the DGP. Fifty-two percent of the patients used the irrigation as additional therapy for fecal incontinence, 24% for constipation, and 24% for both. Irrigation was usually performed in the morning. The mean frequency of irrigation was 0.90 +/- 0.40 times per day. The mean amount of water used for the irrigation was 2.27 +/- 1.75 l with a mean duration of 39 +/- 23 min. Four patients performed antegrade irrigation through a colostomy or appendicostomy, with good results. Overall, 81% of the patients were satisfied with the irrigation. Thirty-seven percent of the patients with fecal incontinence reached (pseudo-)continence, and in 30% of the patients, the constipation completely resolved. Side effects of the irrigation were reported in 61% of the patients: leakage of water after irrigation, abdominal cramps, and distended abdomen. Seven (16%) patients stopped the rectal irrigation.

CONCLUSION

Colonic irrigation is an effective alternative for the treatment of persistent fecal incontinence after DGP and/or recurrent or onset constipation additional to unsuccessful or (partially) successful DGP.

Is the Quality of Life Better in Patients with Colostomy than Patients with Fecal Incontience?

BACKGROUND

A colostomy offers definitive treatment for individuals with fecal incontinence (FI). Patients and physicians remain apprehensive regarding this option because the quality of life (QOL) with a colostomy is presumably worse than living with FI. The aim of this study, therefore, was to compare the QOL of colostomy patients to patients with FI.

METHODS

A cross-sectional postal survey of patients with FI or an end colostomy was undertaken. QOL measures used included the Short Form 36 General Quality of Life Assessment (SF-36) and the Fecal Incontinence Quality of Life score (FIQOL).

RESULTS

The colostomy group included 39 patients and the FI group included 71 patients. The average FI score for FI group was 12 +/- 4.9 (0 = complete continence, 20 = severe incontinence). In the colostomy group the average colostomy function score was 12.9 +/- 3.8 (7 = good function, 35 = poor function). Analysis of the SF-36 revealed higher social function score in the colostomy group compared to the FI group. Analysis of the FIQOL revealed higher scores in the coping, embarrassment, lifestyle scales, and depression scales in the colostomy group compared to the FI group.

CONCLUSION

A colostomy is a viable option for patients who suffer from FI and offers a definitive cure with improved QOL.

Systematic review of surgical options for idiopathic megarectum and megacolon

OBJECTIVE

A subgroup of patients with intractable constipation has persistent dilatation of the bowel, which in the absence of an organic cause is termed idiopathic megabowel (IMB). The aim of this systematic review was to evaluate the published outcome data of surgical procedures for IMB in adults.

METHODS

Electronic searches of the MEDLINE (PubMed) database, Cochrane Library, EMBase, and Science Citation Index were performed. Only peer-reviewed articles of surgery for IMB published in the English language were evaluated. Studies of all surgical procedures were included, providing they were performed on 3 or more patients, and overall success rates were documented. Studies were critically appraised in terms of design and methodology, inclusion criteria, success, mortality and morbidity rates, and functional outcomes.

RESULTS

A total of 27 suitable studies were identified, all evidence was low quality obtained from case series, and there were no comparative studies. The studies involved small numbers of patients (median 12, range 3-50), without long-term follow-up (median 3 years, range 0.5-7). Inclusion of subjects, methods of data acquisition, and reporting of outcomes were extremely variable. Subtotal colectomy was successful in 71.1% (0%-100%) but was associated with significant morbidity related to bowel obstruction (14.5%, range 0%-29%). Segmental resection was successful in 48.4% (12.5%-100%), and recurrent symptoms were common (23.8%). Rectal procedures achieved a successful outcome in 71% to 87% of patients. Proctectomy, the Duhamel, and pull-through procedures were associated with significant mortality (3%-25%) and morbidity (6%-29%). Vertical reduction rectoplasty (VRR) offered promising short-term success (83%). Pelvic-floor procedures were associated with poor outcomes. A stoma provided a safe alternative but was only effective in 65% of cases.

CONCLUSIONS

Outcome data of surgery for IMB must be interpreted with extreme caution due to limitations of included studies. Recommendations based on firm evidence cannot be given, although colectomy appears to be the optimum procedure in patients with a nondilated rectum, restorative proctocolectomy the most suitable in those with dilatation of the colon and rectum, and VRR in those patients with dilatation confined to the rectum. Appropriately designed studies are required to make valid comparisons of the different procedures available.

Investigation of the pathophysiology of fecal seepage

BACKGROUND AND AIM

Unintentional seepage of stool without awareness is common but its pathophysiology is poorly understood. Our aim was to examine the underlying mechanism(s) for fecal seepage.

METHODS

We evaluated prospectively 25 patients with fecal seepage, by performing anorectal manometry, balloon expulsion, saline infusion, pudendal nerve latency tests, and symptom assessments and compared their data with 26 fecal incontinence patients and 43 healthy controls.

RESULTS

Predisposing factors for fecal seepage were back injury (7), obstetric injury (6), hemorrhoidectomy (3), pelvic radiotherapy (1), and unknown (8). In the seepage group, the resting and squeeze sphincter pressures were lower (p < 0.02) than healthy controls, but higher (p < 0.002) than incontinent group. During straining, the intrarectal pressure and defecation index were lower (p < 0.05) in the seepage group compared to controls; 72% showed dyssynergia and balloon expulsion time was prolonged (p < 0.01). Threshold for first rectal sensation was impaired (p < 0.002) in the seepage group compared to controls and incontinent group. The seepage group retained more (p < 0.001) saline than the incontinent group but pudendal nerve latency time was impaired (p < 0.05) in both patient groups compared to controls.

CONCLUSIONS

Anal sphincter function and rectal reservoir capacity were relatively well preserved but most patients with seepage demonstrated dyssynergia with impaired rectal sensation and impaired balloon expulsion. Thus, incomplete evacuation of stool may play a significant role in the pathogenesis of seepage.

Sexual function following sphincteroplasty for women with third- and fourth-degree perineal tears

OBJECTIVE

Our goal was to evaluate sexual function following anal sphincteroplasty in women with third and fourth degree perineal tears secondary to birth trauma

METHODS

Our study was performed using a retrospective cohort design in a group of women (n = 32) who had experienced either third-degree or fourth-degree perineal tears during labor and then elected to undergo sphincteroplasty for fecal incontinence. We surveyed our patients with a questionnaire that was developed by the Obstetrics and Gynecology Epidemiology Center at Harvard Medica School and was previously used to survey women with obstetric injuries. Self-reported presphincteroplasty and post sphincteroplasty degree of physical sensation, sexual satisfaction, and likelihood of achieving orgasm were measured Also measured were libido, partner satisfaction, and presence of emotional or physical inability to engage in sexual behavior.

RESULTS

Our results reaffirmed the findings of the Obstetrics and Gynecology Epidemiology Center's study that sexual function is compromised in women with third and fourth-degree perineal tears. For our patients with this degree of perineal tearing who underwent sphincteroplasty after primary repair, our survey showed consistent improvement in several parameters of sexual function. After sphincteroplasty, physical sensation was higher/much higher in 40 percent, sexual satisfaction was better/much better in 33.3 percent, and 28.6 percent of the patients were more/much more likely to reach orgasm. Libido was improved in 37.5 percent of the study population, and 20 percent reported increased partner satisfaction. Before surgery, 23.5 percent of patients were physically and 31.2 percent emotionally unable to participate in sexual activity because of fear of incontinence or intimacy; after surgery only 6.3 percent were physically unable and 0 percent were emotionally unable to engage in sexual activity. The response rate for our study was 18/32 (56 percent).

CONCLUSIONS

Anal sphincteroplasty for the treatment of incontinence in women with third- and fourth-degree perineal tears improves physical and emotional sexual well-being and function.

Review article: Recent trends in diagnosis and treatment of faecal incontinence

The inability to control bowel discharge is not only common but extremely distressing. It has a negative impact on a patient's lifestyle, leads to a loss of self-esteem, social isolation and a diminished quality of life. Faecal incontinence is often due to multiple pathogenic mechanisms and rarely due to a single factor. Normal continence to stool is maintained by the structural and functional integrity of the anorectal unit. Consequently, disruption of the normal anatomy or physiology of the anorectal unit leads to faecal incontinence. Currently, several diagnostic tests are available that can provide an insight regarding the pathophysiology of faecal incontinence and thereby guide management. The treatment of faecal incontinence includes medical, surgical or behavioural approaches. Today, by using logical approach to management, it is possible to improve symptoms and bowel function in many of these patients.

Effects of biofeedback training by EMG on patients with chronic functional constipation

AIM: To study characteristics of anorectal pressure, EMG activity and effect of biofeedback training system on patient with chronic functional constipation (CFC).

METHODS: Anorectal manometry was carried out in 144 cases of CFC by a monitor system (liquid-phase type) and Biolab dynamics parameter before and after the biofeedback training. 20 healthy individuals were taken as control.

RESULTS: Compared with controls, CFC patients showed slightly lower anal quiesent pressure (P>0.05), lower anorectal sphincteric squeezing pressure (15.7±1.4 vs 12.7± 1.4) (P < 0.01), higher rectal defection volume thresholds and higher rectal maximum talerable volume thresholds (12±6.2 vs 14.9±6.6; 29.3±6.8 vs 36.0±7.3) (P < 0.01; P < 0.01); EMG assessments showed that 100% patients with CFC had the contradictory movement between the pelvic floor muscle (PFM) and abdominal anterior oblique muscle (AAOM). The movement extent of the PFM rose from 5.3±2.8 to 10.2±2.8 under quiet state (P < 0.01), and AAOM reduced from 34.4±5.2 to 30.8±4.9 (P < 0.01); All the abnormalities significantly improved with Orion PC/ 12 m EMG biofeedback training therapy. After biofeedback training therapy, symptoms of CFC patients were improved with efficient rate of 84.03%; With increase of the treatment time and shortenning of the interval and assistant training, the curative efficacy rose and the recurrence rate reduced (78.8% vs 91.7%; 69.2% vs 92.8%) (P < 0.05; P < 0.05).

CONCLUSION: CFC patients have abnormal anorectal pressure, sensation threshold and unusual anus electric activities. Biofeedback training therapy can improve the above-mentioned indexes and is effective in 84.03% of the patients. The relatively intensive long-time training can improve the curative rate in a short period, and family assistant training can reduce the recurrance rate of the disease.

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