This document discusses constipation and its surgical treatment. It defines constipation and reviews the Rome criteria for diagnosing functional constipation. It explores the various causes of constipation including dietary, structural/functional disorders, neurological issues, psychiatric factors, medications, endocrine/metabolic conditions, and more. Diagnostic tests are outlined including imaging, motility studies, and physiological assessments. Treatment approaches are covered such as diet, lifestyle changes, laxatives, biofeedback, botulinum toxin, sacral nerve stimulation, and various surgical options for refractory cases including antegrade continent enema procedures using parts of the intestine or colon to construct a catheterizable conduit.

1. Constipation and Surgical
treatment
Speaker: M.SAIRAN
Department of Coloproctology

2. DEFINITION OF CONSTIPATION
• Constipation comprises a number of diverse symptoms relating to frequency of bowel
movement, consistency of stools, and the ease and completeness of defecation .
• Symptoms of infrequent defecation—less than three stools per week—Correlate better
with gut dysfunction compared with symptoms of straining and incomplete evacuation
• Two or fewer stools perweek and/or straining at stool more than 25% of the time.
/Drossman/
• In 1992, this Definition was expanded to include lumpy and /or hard stools more than
25% of the time and the sensation of incomplete evacuation more than 25% of the time

3. ROME CRITERIA FOR FUNCTIONAL CONSTIPATION
Rome II criteria
constipation = yes to 2 or more of answers 1,3,5,7
excluding IBS (see below)
Rome III criteria
constipation = yes to 2 or more of answers 1,3,5,7,10,11
no to answer 4
excluding IBS
question: have you had any of the following symptoms at least one-fourth (1/4) of the time
(occasions or days) in the last three months?
1. Fewer than three bowel movements in a week
2. More than three bowel movements a day
3. Hard or lumpy stools
4. Loose, mushy, or watery stools
5. Straining during a bowel movement
6. Having to rush to the toilet to have a bowel movement
7. Feeling of incomplete emptying after a bowel movement
8. Passing mucous (slime) during a bowel movement
9. Abdominal fullness, bloating, or swelling
10. A sensation that the stool cannot be passed (i.E., Blocked) when having a bowel movement
11. A need to press on or around your bottom or vagina to try to remove stool to complete
a bowel movement

5. Chinese technique for handling constipation consisted of
massaging the abdomen with wooden rollers

6. FAULTY DIET AND HABITS
• Inadequate bulk (fiber) /эслэг хангалтгүй/
• Excessive ingestion of foods that harden stools (e.g., Cheese)
• Lack of exercise
• Ignoring call to stool
• Laxative abuse /туулга хэтрүүлэн хэрэгдэх/
• Environmental changes (e.g., Hospitalization, vacation)
ETIOLOGY

7. STRUCTURAL OR FUNCTIONAL DISORDERS
• COLONIC OBSTRUCTION
neoplasm, volvulus, inflammation (diverticulitis), ameboma,tuberculosis, syphilis, lymphogranuloma venereum,ischemic colitis,
anastomotic stricture, endometriosis
• DIVERTICULAR DISEASE
• ANORECTAL OUTLET OBSTRUCTION
Anal obstruction (stenosis, fissure)
Rectocele
Spastic pelvic floor syndrome (anismus)
• VISCERAL NEUROPATHY OR MYOPATHY
Congenital aganglionosis (Hirschsprung’s disease)
Acquired aganglionosis (Chagas’ disease)
Slow-transit constipation (colonic inertia)
Megarectum (sometimes with megacolon)
Chronic intestinal pseudo-obstruction
Acute intestinal pseudo-obstruction (Ogilvie’s syndrome) /механик саадгүй, бөглөрөлгүй гэдэс тэлэгдэх хам шинж/
• IRRITABLE BOWEL SYNDROME (VISCERAL HYPERSENSITIVITY)

8. NEUROLOGIC ABNORMALITIES (OUTSIDE COLON)
• Central nervous system (cerebral neoplasm, parkinson’s disease)
• Trauma
• Spinal cord (neoplasm, multiple sclerosis)
• Defective innervation (resection of nervi erigentes)

9. PSYCHIATRIC DISORDERS
• Depression
• Psychoses
• Anorexia nervosa
IATROGENIC CAUSES /ЭМЧИЛГЭЭНИЙ/
• Medication (codeine, antidepressants, iron, anticholinergics)
• Immobilization /удаан хугацаанд хэвтрийн дэглэмд байх/

10. ENDOCRINE AND METABOLIC CAUSES
• Hypothyroidism
• Hypercalcemia
• Pregnancy
• Diabetes mellitus
• Dehydration
• Hypokalemia
• Uremia
• Pheochromocytoma /rare tumor of adrenal gland/
• Hypopituitarism
• Lead poisoning /хар тугалганд хордох/
• Porphyria /цусны эмгэг удамшлын/
• Mucoviscidosis /уушиг, нойр булчирхайн сувагт шохойжилт үүсгэдэг эмгэг/

11. INVESTIGATION
• HISTORY
• PHYSICAL EXAMINATION
• STOOL EXAMINATION
• BIOCHEMICAL EXAMINATION (including values for electrolytes, calcium, phosphate,
urea, creatinine, triiodothyronine, and thyroxine, is necessary to exclude those endocrine
andmetabolic disorders that can cause constipation.)

13. • PROCTOSIGMOIDSCOPY (may aid in the diagnosis of the solitary rectal ulcer
syndrome (SRUS), a colorectal mass lesion or intussusception. the presence of
melanosis coli will help in diagnosing laxative abuse)
• BARIUM ENEMA
Single contrast unprepared barium study
showing megacolon

14. DEFECOGRAPHY
Defecography in a normal patient. (A) At rest, x-ray film and diagram showing a normal anorectal
angle of 92. (B) During straining, x-ray film and diagram showing anorectal angle widens to 137.

15. Defecography in an incontinent patient. (A) At rest, loss of anorectal angle and widening of anal
canal, pool of barium escaping beyond anal sphincter, and pathologic descent of perineum (anus
well below pubococcygeal line) are noted. (B) During straining

16. COLONIC TRANSIT TIME

17. Colonic Inertia Pelvic Outlet Obstruction
Colon Transit Time Study

18. PSYCHOLOGICAL ASSESSMENT
(Psychiatric illnesses such as depression, obsessive–compulsive disorder, and anorexia
nervosa are independent risk factors for constipation)
ANORECTAL MANOMETRY
(anal manometry will diagnose a hypertonic internal anal sphincter (IAS) the presence of
the rectoanal inhibitory reflex (RAIR) will exclude hirschsprung’s disease (HD).
ELECTROMYOGRAPHY
(the normal response to defecation straining is reduction of electrical activity in the eas
and puborectalis and increased activity in the pubococcygeus muscles, which contract and
prevent excessive downward movement during defecation. in obstructed defecation, there
is increased activity of the eas and puborectalis during straining due to anismus)

19. TREATMENT
DIET
An empirical trial of fiber supplementation (at least 25 grams of dietary fiber daily) in the
form of unprocessed bran or psyllium should be considered at the initial presentation for all
patients with functional constipation
LIFESTYLE AND DEFECATION
Although the place of exercise has not been proven, patients should be encouraged to
take regular physical exercise. They should be asked to avoid suppressing the urge to
defecate and to avoid spending excessive time on the toilet.

20. LAXATIVES
Lubricants - such as mineral oils (liquid paraffin) may be helpful, but may cause lipoid
pneumonia and should be avoided in the elderly or patients with severe reflux.
Osmotic laxatives - are very effective, including epsom salts (magnesium sulphate),
sodium phosphate (fleettm), or lactulose, which may be used. Lactulose is a disaccharide
that is metabolized in the colon to produce methane and hydrogen gas, and this may
exacerbate bloating and flatulence.
Stimulant laxatives - include anthraquinones (senna,cascara segrada), castor oil,
diphenylamines (bisacodyl, sodium picosulphate), and surface-active agents (docusate)
may be considered for differentspecific uses and should be considered when other first-
line laxatives have failed.

21. BOTULINUM TOXIN
Botulinum toxin has been used selectively to weaken the EAS and puborectalis
muscles in constipation.
SACRAL NERVE STIMULATION

22. BIOFEEDBACK THERAPY
Goals:
a) Teach diaphragmatic breathing exercise
b) Teach anal sphincter and pelvic floor relaxation
c) Improve rectal sensation
d) Eliminate sensory delay
e) Improve rectoanal coordination
Advantages:
• Safe
• Effective
• Painless and well tolerated
• Inexpensive

26. CANDIDATES FOR
SURGICAL TREATMENT OF CONSTIPATION
• PATIENTS WITH ABNORMAL COLONIC MOTILITY WHO ARE REFRACTORY TO
CONSERVATIVE TREATMENT
• USUALLY THE LAST OPTION OFFERED
• THOROUGH EVALUATION TO EXCLUDE PAN-ENTERIC MOTILITY DISORDERS
SHOULD PRECEDE SURGICAL DECISION

27. SURGICAL OPTIONS FOR CONSTIPATION
• Ileostomy or colostomy
• Antegrade colonic enema (ACE)
• Ileo-anal pouch
• Colectomy
OUTLET OBSTRUCTION
• Partial division of puborectalis
• Botulinum A toxin
• Rectocele repair, sigmoidocele repair
• Rectal intussusception repair, STARR procedure
• Neuromodulation with sacral stimulation

28. Ileostomy & Colostomy
• Initial ileostomy may select candidates for colectomy
• For recurrent constipation after
colectomy

29. ANTEGRADE CONTINENCE ENEMA
(ACE)
• CONSTRUCTION OF A
CATHETERISABLE CONDUIT
INTO THE PROXIMAL COLON
THROUGH WHICH ENEMAS
OR IRRIGATION FLUID CAN
BE ADMINISTERED IN A
DISTAL DIRECTION TO
ACHIEVE COLON AND
RECTAL EVACUATION

30. ACE Procedures
Tsang and Dudley (1995)
• Isolation of appendix
(and vascular pedicle)
• Appendix amputation
• Reversal of appendix
• Distal end anstomosed to
the cecum
• Submucosal tunnel
 non-refluxing channel
• Exteriorization of
proximal end of appendix
MALONE ANTEGRADE CONTINENT ENEMA (MACE)

31. IN SITU MALONE ANTEGRADE CONTINENT ENEMA
ACE Procedures
Imbrication of the appendiceal
base within the cecum
More convenient to perform
than original MACE
(Rink RC, et al, 1999)

32. RESULTS WITH APPENDIX BASED ACE
ORIGINAL MALONE OR IN-SITU
APPENDIX
ACE Procedures
Up to 80% success rate in children
Use of appendix is limited for adults with
constipation/incontinence
Development of various techniques for ACE
using other segments of the bowel
BUT,

33. ACE Procedures
Monti Procedure (1997)
Initially, ileum was used (Monti, 1997)
But some prefer to use left colon

34. Cf. Use of 2 tubes
ACE Procedures
Monti Procedure
Continent stoma with a Monti tube
submucosally implanted

35. ACE Procedures
Colon Flap/Extension ACE
Lateral colon flap based
on vascular arcades from
posterior artery
Flap is incised as a
rectangular flap and
tubularized in 2 layers
(Hernon CDA et al, 2005)

36. ACE Procedures
Colon Flap/Extension ACE
(Hernon CDA et al, 2005)
Cecal extension with linear Endo-GIA

37. MACEDO-MALONE ACE
• Use of flap on the left colon
• Continence valve created by
embedding the tube over
serosa lined tunnel
• Distal end anastomosed into
a V-shaped to the skin flap
to avoid stomal stenosis
ACE Procedures
(Calado AA, Macedo A, et al, 2005)

38. ILEOCECAL SEGMENT
ACE Procedures
Theoretical advantage of using the ileocecal valve
(Marsh PJ et al, 1996)

39. CONTINENT COLONIC CONDUIT
ACE Procedures
Sigmoid colon conduit Transverse colon conduit
(Williams 1994, Hughes and Williams, 1995)

40. OTHER PROCEDURES
• LAPAROSCOPIC ACE (LACE)
EVEN IF IMBRICATION IS NOT PERFORMED
MAY OFFSET THE SLIGHTLY INCREASED RISK OF
STOMA LEAKAGE THROUGH MINIMALLY
INVASIVE APPROACH
LAPAROSCOPIC CONTINENT ACE
ACE Procedures

41. CECOSTOMY
BUTTON
ACE Procedures
Percutaneously inserted cecostomy
tube, or conventional gastrostomy
button (cecostomy button)
(Shandling B et al, 1996)
Other Procedures

42. OTHER PROCEDURES
• PERCUTANEOUS ENDOSCOPIC COLOSTOMY
(PEC)
COLOSTOMY TUBE INSERTED INTO THE
DESCENDING OR SIGMOID COLON WITH THE
COLONOSCOPY IN PLACE
ACE Procedures

43. • FOR PATIENTS WITH CONSTIPATION ASSOCIATED FECAL INCONTINENCE
• ARTIFICIAL SPHINCTER + ACE
• SACRAL NERVE STIMULATION + ACE
ACE Procedures
NEW APPROACHES

44. But, the use of ACE Procedures are limited by
- Inconvenience to the patients
- No large series of data to prove their efficacy
COLECTOMY
Is the main surgical option
for constipation

45. COLECTOMY FOR CONSTIPATION
• Segmental resection
• Subtotal colectomy with ileo-sigmoid anastomosis
• Total colectomy with ileo-rectal anastomosis
• Total colectomy with ceco- rectal anastomosis
• Total proctocolectomy with ileal-pouch anal anastomosis

46. SURGICAL TREATMENT FOR CONSTIPATION
SEGMENTAL COLECTOMY
Resect which segment ?
- usually left or sigmoid
Variable results

47. Hirschsprung’s Disease:
Surgical Options
Swenson
Duhamel
Soave
Procedures,
We are not familiar with!

49. SURGICAL TREATMENT OF CONSTIPATION
SUMMARY & CONCLUSION
• LAST RESORT  CAREFUL PATIENT SELECTION IS NECESSARY
• SLOW TRANSIT CONSTIPATION
 BE AWARE OF PAN-ENTERIC MOTILITY DISORDER
• FEATURES OF COLONIC PSEUDOOBSTRUCTION
 PATHOLOGICAL DIAGNOSIS OF HYPOGANGLIONOSIS
 ASSOCIATED WITH FAVORABLE OUTCOME AFTER COLECTOMY
• HIRSCHSPRUNG’S DISEASE
 RARE SURGICAL DISEASE IN ADULTS ASSOCIATED WITH
FAVORABLE OUTCOME

50. THANK YOU FOR YOUR ATTENTION
“A surgeon is a doctor
who can operate and
who knows when not to”
- Emil Theodor Kocher (1841~1917)