The Role of Laparoscopic Total Colectomy in Treatment of Slow- Transit Constipation: A Prospective Study

The Role of Laparoscopic Total Colectomy in Treatment of Slow- Transit Constipation: A Prospective Study

Mohamed Shaaban Khalifa, MD; Mohamed Ibrahim Hasan, MD; Ahmed Hussein Abdel hafez, MD.

Department of Surgery, Ain Shams University, Cairo, Egypt.

Background: Patients with intractable chronic constipation should be evaluated with physiologic tests after structural disorders, and extracolonic causes have been excluded. Conservative treatment options should be tried excessively. If surgery is indicated, subtotal or total colectomy with ileorectal anastomosis is the treatment method of choice.

Patients and methods: In this prospective study, 7 patients were reviewed including patient demography, clinical manifestations, preoperative investigations, operative procedure, intraoperative and postoperative complications, and postoperative follow up. All patients enrolled in the study underwent laparoscopic total colectomy (LTC), with ileorectal anastomosis (IRA). Average age of the patients was (35±15.8 years), average operative time was (80±30 min), average blood loss was (75±30 ml), average hospital stay was (6±2.5 days).

Results: 7 patients in our study were diagnosed to have slow-transit constipation via history, clinical examination, colonoscopy and barium enema to rule out structural disorders, colonic motility study, anorectal manometry, colonic transit time, and defecography. All patients underwent LTC with IRA after failure of conservative treatment. 3 patients(42.8%) had postoperative diarrhea which resolved spontaneously after 2 weeks, 1 patient (14.2%) had wound infection, 1patient(14.2%) had minor anastomotic leak which subsided on conservative treatment.2 patients had abdominal pain and bloating which improved gradually,1 patient had recurrent constipation which was improved on laxatives, median number of motions/day was 3, with median satisfaction and success rate of about 82%.

Conclusion: Laparoscopic treatment of slow-transit constipation seems to be safe, feasible, and effective procedure with satisfactory results, with minimal postoperative complications, short hospital stay, with a faster return to social activity, along with a better cosmetic results and good functional results.

Key words: Slow-transit constipation, laparoscopic total colectomy(LTC), ileorectal anastomosis(IRA), colonic motility study, anorectal manometry.

Introduction:

Constipation is one of the most frequent gastrointestinal   symptoms,   and   one   of the most frequent reasons for medical consultation.  Basically  constipation  is related to intestinal motility disorders, pelvic floor disturbance.1 Patients often complaint of subjective feelings like incomplete evacuation, abdominal or rectal pain, firm stool consistency, and need for straining. The best definition for constipation was proposed by Whitehead.2 Two or more of the following

complaints must be present when the patient is not taking laxatives, and if symptoms persist for at least 12 months:

1) Straining on > 25% of bowel movements.

2) Feeling of incomplete evacuation after

>25% of bowel movements.

3) Scyballous stools on >25% of bowel

movements.

4) Stools less frequent than 2/ week with or without other symptoms.

Slow-transit   constipation   occurs    most commonly      in         young  women who       had

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infrequent bowel movement, the condition often starts at puberty, associated symptoms are an infrequent urge to defecate, bloating, and abdominal pain, dietary and cultural factors contribute to symptoms, in these patients   a   high   fiber   dietary,   increase stool-weight,  decrease  colon  transit  time.3

Patients with more severe slow-transit constipation have a poor response to dietary fiber  and  laxatives,  such  patients  have  a more  delayed  emptying  of  the  proximal colon, and fewer high-amplitude peristaltic contractions. Colonic inertia, a related condition is characterized by slow colonic transit. Histopathological studies have shown alterations in the number of the mynteric plexus neurons expressing the excitatory neurotransmitter substance P, abnormalities in  the  inhibitory  neurotransmitters vasoactive intestinal peptide and nitric oxide. Hirschsprung’s disease is an extreme form of slow-transit constipation with similar enteric neuropathological features.4

A thorough history and physical examination can rule out most secondary causes   of   constipation.   An   assessment of stool form can be used to estimate the extremes of colonic transit time. A careful rectal examination should be performed, the perianal area should be examined for scars, fistulas, fissures, external piles. Next the clinician should observe the perineum with the patient at rest and while the patient is bearing down, in order to determine the extent of perineal descent, digital rectal examination should determine whether fecal impaction, anal stricture, or rectal masses are present or not. Laboratory tests that may be useful include thyroid-function tests, serum calcium, glucose, and electrolytes, a complete blood count, and urinalysis.5,6

A complete colon examination is required to exclude structural diseases such as colon cancer,   which   is   done   via   colonoscopy and  barium  enema.  Physiological  testing is necessary in patients with refractory symptoms which include anorectal manometry and  balloon  expulsion,  defecography  may be  considered  if  the  results  of  these  tests are  equivocal.  The  colonic  transit  time  is

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normally less than 72 hours. Other diagnostic tests include electromyography, and pudendal nerve terminal motor latency.7,8

Management regimens include; high fluid  intake,  physical  exercise,  increased fiber intake, osmotic laxatives such as milk of magnesia, sorbitol, lactulose, colonic stimulants like bisacodyl, senna derivatives. Prokinetic agents should be preserved for patients with severe constipation. Patients with defecatory disorders should undergo retraining of the evacuation process. Patients with fecal impaction should have manual evacuation, preliminary data suggest that injection of botulinum type A toxin into the puborectalis muscle may be effective in treatment of defecatory disorders.9,10

For refractory constipation, total colonic resection and ileorectal anastomosis should be considered only if the patient does not have a defecatory disorders and only after medical therapy have failed.11

Patients and methods:

In   this   prospective   study,   7   patients were evaluated, had full investigations, and underwent laparoscopic total colectomy and ileorectal  anastomosis,  between  May  2013 and May 2015, and the study was conducted at January 2016. Patients had full preoperative diagnostic work up in the form of history taking, physical examination, colonoscopy and barium enema, CT scan, MRI, anorectal manometry, colonic motility studies, and colonic transit time estimation, to assess slow- transit constipation. All patients tried medical treatments with no or poor response, as well as defecatory disorders were absent in all patients. All the patients were fully informed about the procedure, and written consent was taken. A complete patient demographic data, preoperative  investigations,  and  operative data are illustrated in Table (1).

Operative technique: After a mechanical bowel  preparation.  The  patient  is  placed in a modified lithotomy position, and pneumoperitoneum   is   established.   Using the subumbilical 12-mm trocar the camera is inserted. Two further 12-mm and 5-mm trocars,  each  are  used  for  access  to  the

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Figure  (1):  Division  of  iliocolic  vessels, ileum.

Figure (3): Dissection of hepatic flexure.

Figure (2): Dissection of right colon.

Figure (4): Division of middle colic Vs.

Figure (5): Division of greater omentum.              Figure (6): Mobilization of splenic flex.

peritoneal cavity. In an approach from medial to lateral; the ileocolic, middle colic vessels, and the inferior mesenteric artery are divided. Medial mobilization is completed before the

sigmoid is freed up laterally Figure (1,2).12

The lateral mobilization of the descending, transverse,  and  ascending  colon  is  done with the omentum being separated from the transverse   colon   completely   Figure (3,4).

The   mesorectum   is   divided   using   the

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Figure (7): Dissection of Lt.paracolic gutter.

Figure (9): Dissection of sigmoid mesentry.

Figure (8): Division of Lt colic Vs.

Figure (10): Dissection of mesorectum.

Figure (11): Transection of upper rectum.             Figure (12): Rectal stump before IRA.

harmonic  scalped,  and  the  upper  rectum is transected with either one or two passes of   the   endoscopic   linear   cutting   stabler Figure (5,6,7).  The  colon  is  exteriorized through a 5-cm Pfennenstiel incision. The terminal ileum is transected extracorporeally. After               pneumoperitoneum       has       been

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reestablished, the ileorectal anastomosis is performed laparoscopically using a double- stabling technique or end-to end anastomosis via circular stabler Figure (8,9,10,11,12).13,14

Perioperative management- data collection: All the patients underwent total laparoscopic colectomy with ileorectal anastomosis after

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Table 1: Epidemiological, and operative data of the patients.

*(mean±SD)

*EMG: Electromyography       *  PNTML; Pudendal nerve terminal motor latency

Table 2 : Postoperative complication, and outcomes.

*(mean±SD)

mechanical bowel preparation, and systemic antibiotic prophylaxis was administered. Oral feeding  is  regained  3days  post-operatively,

drains  are  removed  with  minimal  serous fluid output. Evidence of anastomotic leak or intraperitoneal collections were assessed

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clinically and radiologically. Postoperative follow up was completed for all the patients, postoperative complications are demonstrated in Table (2).

Results:

In our study, 7 patients were presented with manifestations  of  slow-transit  constipation,

6 were females (85.7%), and 1 was male (14.2%), average age of the patients was (35±15.8 years), average operative time was (80±30 min), average intraoperative blood loss was (75±30 ml), average hospital stay was (6±2.5 days). No other procedures, or concurrent operations were performed. 3 patients (42.8%) developed postoperative diarrhea and fecal incontinence which subsided  completely  after  2  weeks,  1 patient (14.2%) had minor anastomotic leak and mild intraperitoneal collection which resolved on conservative measures. 1patient (14.2%) had wound (Pfennenstiel incision) infection. No significant intraoperative, or postoperative hemorrhage was detected. The overall morbidity was 32%, and no mortality could be detected. 2 patients (28.4%) had recurrent abdominal pain and bloating which improved gradually over 2 months, 1 patient developed recurrent constipation which improved with cathertics, the median number of motions was 3/day, after about 3 weeks. After 3 months, a new colonic transit time study was performed and showed a regular transit. The median satisfaction, and success rate  was  82%  with  marked  improvement in quality of life which was detected via follow-up and clinical assessment. All the laparoscopic procedures have done after exclusion of defecatory disorders, and failure of conservative treatment. Malignancy or inflammatory bowel  diseases  were  absent by histopathological examination for all resected specimens. There was no need for reoperation in all cases.

Discussion:

Chronic slow-transit constipation represents a disabling syndrome characterized by untreatable constipation, with a higher incidence  in  young  female  patients.  The

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pathophysiology is still unclear, and a visceral neuropathy of the myoenteric plexus is supposed, together with abnormalities of neuroendocrine peptides. Less than 10% of the patientsrequire surgical management, in case  of  failure  of  conservative  treatment and only after meticulous preoperative investigations.15

A  total   colectomy   (TC)   followed   by

ileorectal anastomosis (IRA) is the most common effective and widely performed surgical operation with a success rate of approximately 90% , in spite of being associated with a significant postoperative morbidity,  in  terms  of  diarrhea,  number of daily bowel motions, soiling, fecal incontinence, and postoperative adhesion.16

In 1995 (Lillehei and Wangesteen); first described the use of mechanical cecorectal anastomosis (CRA), after subtotal colectomy (SC). The original technique consists in an end to end CRA after a 180º rotation of the cecum; after this, several modifications of such technique were described in order to avoid the possible vascular adhesions. The diffusion of laparoscopic surgery gave great impulse to this kind of operations. However, the  debate  regarding  therapeutic  choice  is still open.17

Some authorssupport the SC because the preservation of terminal ileum, ileocecal valve, and cecum allows absorption of electrolytes, bile salts, and vitamin B12, and about 2 litres of water daily, preventing the ocurrance of renal, and biliary stones, with a reduced number of daily bowel motions, and without fecal incontinence. Furthermore, the cecum seems to fill well the pelvis, reducing the risk of postoperative obstruction, or adhesions of small bowel, compared to TC and IRA. Nevertheless , in some surgeons experience with the patients submitted to TC and IRA, a disabling diarrhea , incontinence or urgency was not observed at 6 months regular follow up.18,19

The  functional  results  of  SC  and  CRA were  similar  to  those  observed  after  TC and IRA with an excellent quality of life. Furthermore , aftera mean follow up of43 months (range 23-73), a subocclusive crisis

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due to adhesions was never observed. In our study, 3 patients developed postoperative diarrhea, and fecal incontinence which resolved spontaneously after 2 weeks, 1 patient  had  minor  anastomotic leak  which also  resolved  with  conservative  measures,

2 patients developed abdominal pain and bloating, gradually improved without medical treatment. 1patient had recurrent constipation which is markedly improved on laxatives, the median number of motions 3/day, the median satisfaction, and success rate was 82%, with marked improvement in quality of life. All such results are close to those published in the literature, and encouraging the usage of laparoscopy in treatment of chronic slow- transit constipation.20

Conclusion:

Laparoscopic TC and IRA represents efficacious,  and   interesting   operation   in the treatment of slow-transit constipation. Offering a good postoperative quality of life and a reduced morbidity compared to open surgery. Total laparoscopic operation allows reduced postoperative pain and ileus, a shorter hospitalization, a faster return to social activity along with a better cosmetic results, and good medium-long term functional results.21,22

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