|563||Outcome of Colectomy for Slow-Transit Constipation in Relation to Presence of Small-Bowel Dysmotility [2004년 1월 DCR]||2011-12-23||1630|
Abdulhakim Glia, M.D., Ph.D.,1 Jan Erik Åkerlund, M.D., Ph.D.,1 Greger Lindberg, M.D., Ph.D.2
1 Department of Surgery, Karolinska Institutet, Huddinge University Hospital, Stockholm, Sweden
2 Department of Medicine, Karolinska Institutet, Huddinge University Hospital, Stockholm, Sweden
PURPOSE: A significant proportion of patients with slowtransit constipation have abnormal small-bowel motility. It is unclear whether abnormal small-bowel motility indicates worse results after surgery for slow-transit constipation. We studied the results of colectomy with ileorectal anastomosis in patients with normal and abnormal antroduodenal manometry findings.
METHODS: Seventeen, consecutive patients who had been referred for intractable constipation
and who were found to suffer from slow-transit constipation underwent subtotal colectomy. All patients underwent a set of diagnostic investigations, including whole gut transit time, anorectal manometry, antroduodenal manometry, electromyography of the anal sphincter, balloon expulsion test, and defecography. Patients were followed up after five years.
RESULTS: Patients’ median age at the time of the operation was 46 (range, 23–70) years, and the median duration of constipation was 31 (range, 11–65) years. One patient died 21 days after the operation. Three patients developed intestinal pseudo-obstruction after the operation, and two of these died during the follow-up period. Fourteen patients were available for follow-up after a median of five
(range, 4–7) years. Bowel frequency was significantly increased from a median of 0 (range, 0–2) times per week to a median of 30 (range, 10–102) times per week after surgery (P < 0.001). The incidence of abdominal pain decreased from 94 to 43 percent. Seven of 13 patients (54 percent) continued to have bloating. At long-term follow-up, 12 of 14 patients (86 percent) reported that they had an overall improvement after surgery, despite continuing pain and bloating in a significant proportion of them. The outcome of surgery was good or excellent in seven of seven patients with normal findings on antroduodenal manometry, but only five of nine patients with abnormal manometry findings attained a good result after surgery. We found a trend (P = 0.09) toward better long-term results after surgery for
slow-transit constipation in patients with a normal antroduodenal manometry before the operation.
Patients with slow-transit constipation (STC) are mainly severely constipated young women with a history of constipation since early childhood. Their bowels may open only once every three or four
weeks. They often have troublesome symptoms, such as abdominal pain, bloating, and difficult evacuations. The etiology of such idiopathic cases remains unclear. The diagnosis of slow-transit constipation relies on radiologic studies of colonic transit. Colonic transit of radio-opaque markers identifies patients with slow transit with stasis of markers in the proximal colon. However, anorectal function should be characterized to exclude outlet dysfunction. Surgery for chronic constipation has been performed. The British surgeon Sir William Arbuthnot-Lane in the early 1900s first popularized subtotal colectomy for constipation. In the absence of a pathognomonic test, we will never know whether the disease treated by Arbuthnot-Lane was the same as what we call STC. Although other
operations have been suggested, subtotal colectomy presently is the recommended operation for this condition. It has been suggested that persistent abdominal symptoms after colectomy may be caused by a more widespread involvement of the gastrointestinal tract. The presence of upper gastrointestinal
dysmotility is well documented in patients with STC. This may explain the up to 50 percent reported
incidence of intestinal obstruction postoperatively. 4 This study was designed to evaluate whether
the long-term outcome after subtotal colectomy for STC could be predicted from antroduodenal manometry findings.