1. Constipation WHO, WHAT, WHEN M62 2006 E S Kiff

2. Review: Surgery,constipation  Google: 1,730,000  Google scholar: 15,000  PubMed: 2453  Last 500 papers = August 2002  My view

3. Constipation  One of a set of SYMPTOMS of a disease that we do not understand.  Treatment modifies the symptoms – it does NOT treat the disease.  If you embark on surgery you will have to take on all the symptoms

4. 3 Main Groups  Never learnt  Dysmotility  Mechanical  Obstruction, drugs, metabolic  Locke et al Gastroenterology 2000; 119

5. Dysmotility  IBS…………………Chronic constipation….  Emotions control the motions  Parkes Weber 1900 “constipation may be due to psychical factors”

6. Mechanical – connective tissue  Perineal descent  Intussusception of rectum  Rectocoele  Everting anus  Urogynae

7. Mechanical - muscle  End stage neuropathy  Defaecation is an extrusion process

8. Others  Spinal injury  MS  Megacolon, megarectum  Drugs – antipsychotics, antidepressants, analgesics  Myxoedema  Hypercalcaemia

9. Treatments - conservative  Dietary manipulation  Perineal support  Retraining – biofeedback  Clinical psychology  Oral laxatives – osmotic, irritant, herbal  Suppositories, micro enemas  Rectal irrigation

10. Treatment - mechanical  Posterior colporrhaphy  Transanal plication  Transperineal plication  STARR procedure  Sacrocolporectopexy

11. Requirements for surgery for obstructed defaecation  Proctogram shows rectocoele +/- rectal intussusception  Normal transit study  Digitalisation useful?  Degree of perineal descent?

12. Treatment - dysmotility  Colectomy and IRA  SNS  ACE – open or endoscopic

13. Long-term results of ACE for constipation in adults. Lees et al. Colorectal Disease 2004; 6 :362-8  32 patients,26F over 10 year period  FU 36 months  28 needed 1 or more revisions  19 reversed  47% satisfactory function

14. Exclude prior to colectomy Disorders of defaecation Weak sphincters Other causes Inappropriate expectations from patient and family

15. Platell et al. AusNZJSurg 1997  96 patients -92 female had TAC+IRA  5 year FU  50% strain  51% FI  55% pain  75% bloat  35% reoperation  9% ileostomy

16. Fitzharris DCR 2003 (Minnesota)  112 patients 109 female – 10 years  Postal survey  41% pain  21% FI  46% diarrhoea  93% - would do it again

17. Colectomy  Shapes study can be misleading  Colectomy is JUST a surgical laxative  Problems –early or late – constipation or incontinence  Resolution can lead to more surgery and eventually a stoma  YOU will have done this to them

18. Ileostomy first  Allows 1 year to recover emotionally  Certainty that small bowel works  Confirms that could live with stoma if all else fails  Only when all agreed – colectomy with ileo-rectal anastomosis.  Expect to see them again…..and again…

19. Alarm bells  Attention seekers – need to be ill  Attending friend / relative  Other aids  Nursing background  Anger towards other medical staff  Medico-legal proceedings  Factitious disorder

20. Summary  Treating symptoms not the disease  Multifactorial – so be clear about what surgery can and cannot do.  Treat the whole patient  Fools rush in where angels fear to tread