Surgery for constipation: systematic review and practice recommendations

Abstract

Aim To assess the outcomes of colectomy in adults with chronic constipation (CC).Method Standardised methods and reporting of benefits and harms were used for all CapaCiTY reviews that closely adhered to PRISMA 2016 guidance. Main conclusions were presented as summary evidence statements (SES) with a summative Oxford Centre for EvidenceBased Medicine (2009) level.Results Forty articles were identified, providing data on outcomes in 2045 patients. Evidence was derived almost exclusively from observational studies, the majority of which concerned colectomy and ileorectal anastomosis (CIRA) rather than other procedural variations. Average length of stay (LOS) ranged between 7-15 days. Although inconsistent, laparoscopic surgery may be associated with longer mean operating times (210 vs 167 min) and modest decreases in LOS (10-8 days). Complications occurred in approximately 24% of patients. Six (0.4%) procedure-related deaths were observed. Recurrent episodes of small bowel obstruction occurred in about 15% (95%CI: 10-21%) of patients in the long-term, with significant burden of rehospitalisation and frequent recourse to surgery. Most patients reported a satisfactory or good outcome after colectomy but negative long-term functional outcomes persist in a minority of patients. The influence of resection extent, anastomotic configuration and method of access on complication rates remains uncertain. Available evidence weakly supports selection of patients with an isolated slow-transit phenotype.Conclusion Colectomy for CC may benefit some patients but at the cost of substantial short-and longterm morbidity. Current evidence is insufficient to guide patient or procedural selection.

Percutaneous endoscopic colostomy for adults with chronic constipation: Retrospective case series of 12 patients

“…It therefore has the potential to become a more attractive alternative, when more data become available on efficacy and complications. Surgical procedures for chronic refractory constipation include total colectomy with ileorectal anastomosis and subtotal colectomy with ileosigmoid/colorectal anastomosis . Mean success rate for these interventions is reported to be high, around 89% .…”

“…When all conservative measures fail, surgical treatments such as appendicostomy, ileostomy with colonic exclusion, or segmental or total colectomy are considered . Previous reports demonstrate variable efficacy of these surgical treatment entities, and morbidity of these procedures is high . Less invasive and potentially reversible procedures such as sacral neuromodulation and tibial nerve stimulation have been disappointing with respect to efficacy .…”

An approach to the diagnosis and management of Rome IV functional disorders of chronic constipation

“…The evidence of benefit of colonic resections is weak and almost exclusively derived from observational studies. A systematic review of 40 articles, providing outcome data in 2045 patients, reported that colectomy may benefit some patients with FC but at the cost of substantial short-and long-term morbidity [54]. Complications occur in 25% of patients.…”

When all seems lost: management of refractory constipation—Surgery, rectal irrigation, percutaneous endoscopic colostomy, and more

“…Many, if not nearly all, patients with STC have abdominal pain, and many have bloating. If these are the main symptoms, then colectomy is unlikely to help since surgery if anything worsens rather than improves these symptoms accounting for much of the postinterventional health utilization observed by Dudekula et al . Prior to colectomy, a temporary loop ileostomy may help ascertain whether symptoms emanate from the small intestine or colon.…”

“…How does PEC compare with surgical interventions for constipation? A systematic review of the latter suggested that 86% of patients were satisfied after surgery, 20%‐30% had complications, and 13% required re‐operation. By comparison, 30% of patients have complications after the Malone procedure …”