During the study period from March 2003 to May 2009, 34 patients with refractory CC were surgically treated at our center. There were 24 males (70.6%) and 10 females (29.4%) in the age range of 18-77 years (median, 45 years). Patient's characteristics are shown in . All patients had complaints of constipation and feeling of incomplete bowel evacuation for a significantly long period of time. Median duration of symptoms was 96 months (range, 12-360 months) and the median duration of medical management was 60 months (range, 6-360 months). The group wise distribution of duration of symptoms and medical treatment was almost similar except in HD patients; they were referred sooner for surgical intervention once the diagnosis was made (). HD patients were treated for significantly long period at outside hospital before referral to our center.
Patients Characteristics (N = 34)
Duration of Symptoms and Medical Therapy (Months)
All HD patients were found to have dilated colon and proximal rectum on barium enema examination. Four patients with STC showed normal small bowel transit on barium meal follow through examination. Defecography examination revealed internal intussusception in 1 (), anterior rectocele in 3 patients (), posterior rectocele in 1, posterior wall ulcer in 1 and rectocele with abnormal pelvic floor descent in 2 patients ().
Figure 1 (A) Defecography - showing anterior rectocele (white long arrow) with intra-anal intussusception (white arrow heads) and incomplete rectal evacuation during defecation, (B) Defecography - showing rectocele (white short arrow) on straining, (C) Colonic (more ...)
On CTT study all eight patients with STC revealed delayed passage of markers. Retention of more than 14 markers dispersed in colon on 60 hours X-ray was seen in 5 patients () and retention of more than 14 markers in sigmoid colon and rectum was seen in remaining 3 patients. Two patients of HD who underwent CTT revealed delayed excretion with retention of markers in sigmoid colon and rectum. Anorectal manometry showed absent recto-anal inhibitory reflex, abnormal balloon expulsion (> 200 g) and normal sphincter pressures in all HD patients. Sphincter length was 3.5 ± 1.5 cm in HD patients.
Unsuccessful surgical interventions were already performed in 8 patients elsewhere (2 in HD group and 6 in prolapse with constipation group) before referral to our center. Two patients with HD had sigmoidectomy; among rectal prolapse group, suture rectopexy and Thiersch wiring were performed on 2 patients, mesh rectopexy in 2, Fothergill's surgery for uterine prolapse in 1 and Thiersch wiring in 1 patient.
After detailed evaluation as described above, patients were taken up for surgical management (). Three patients with STC underwent total colectomy and ileo-rectal anastomosis (IRA), 4 patients underwent low anterior resection (LAR) and 1 underwent anterior resection in view of redundant sigmoid colon on barium enema study. Three out of 4 patients with HD underwent modified Duhamel's procedure while 1 had Swenson's procedure. In patients with constipation and rectal prolapse, anterior resection was done in 5 patients, resection rectopexy in 6, LAR in 7 and Delorme's procedure in 4 patients.
Flow chart showing surgical procedures, complications and early outcome among patients with refractory chronic constipation. SBM, spontaneous bowel movements.
Seven patients (20.6%) had major post operative complications (). However, there was no mortality. One patient had ureter injury in deep pelvis during modified Duhamel's procedure; requiring re-exploration and ureter re-implantation, and recovered well after the surgery. One patient had intra-abdominal bleed which manifested as drain bleed and underwent re-exploration. Three patients had adhesive small bowel obstructions, 2 of them were managed conservatively and one patient required re-exploration. Another 2 patients required re-exploration for anastomotic leak. Six patients had minor complications like wound infection (3 patients), post operative fever (1 patient) and paralytic ileus (2 patients). Out of 8 patients, who were operated elsewhere before referral to our center, 4 patients had complications, of which 3 had major complications; 2 had adhesive obstruction and 1 had ureteric injury.
Post Operative Major Complications
Follow-up information was available in 27 (79.4%) patients, and length of follow-up duration varied from 3 to 60 months (mean, 17.8 months). Median SBM significantly improved from 1 per week (range, 0-3 per week) to 14 per week (range, 7-28 per week) following surgical treatment (P < 0.00001) ( and ). Two (5.9%) patients required laxatives to facilitate the passage of stools intermittently. Overall 25 (92.6%) patients were satisfied with outcome of surgery. One patient with STC had recurrence of constipation after anterior resection. On subsequent evaluation by CTT study, the patient was diagnosed with colonic inertia and completion total colectomy and IRA was done later. This patient had average of 2 SBMs per day and remained asymptomatic for 2 years of follow-up.
Spontaneous bowel movements before and after surgical treatment (Wilcoxon signed-rank test).