Operative management of severe constipation.

This report investigates the concept that severe constipation requiring major abdominal surgery may result from one of three common causes: 1) colonic inertia, 2) pelvic hiatal hernia, or 3) both colonic inertia and pelvic hernia. This study evaluates the symptoms, anatomy and outcome in 201 patients with severe surgical constipation treated by a single surgeon. In 2042 patients with constipation referred to one colon and rectal surgeon, 211 major abdominal surgical procedures were performed on 201 patients for severe constipation between 1989 and 1999. There were 187 women and 14 men. Mean age was 49 years (range, 9-84). Five high-risk patients had ileostomy; 196 had major colonic surgery for anatomic or physiologic causes of constipation, excluding malignancy, diverticular disease, and inflammatory bowel disease. Pelvic hiatal hernia was defined as the herniation of bowel through the hiatus of the pelvic diaphragm seen on pelvic videofluoroscopy or physical examination. Of these 196 patients, 44 per cent had pelvic hiatal hernia repair (PHHR), 27 per cent had total abdominal colectomy and ileorectal anastomosis for colonic inertia, and 29 per cent had surgery for both colonic inertia and pelvic hiatal hernia. Of the 144 patients undergoing PHHR, 95 had Gore-Tex patch (W. L. Gore and Associates, Inc., Phoenix, AZ) sacral colpopexy. PHHR for pelvic hiatal hernia without colonic inertia included sigmoid resection, rectopexy, and Gore-Tex patch sacral colpopexy. Mean duration of follow-up was 20 months. Symptoms noted preoperatively included abdominal pain (84%), straining at stool (90%), incomplete rectal emptying (85%), painful bowel movements (74%), pelvic pain (69%), vaginal bulge (55%), digital assistance with evacuation (35%), and incontinence of stool (38%). Outcome assessed by symptom relief was successful in 89.1 per cent of patients. 8.6 per cent of patient conditions were unchanged, and 2.3 per cent were unsatisfied with the outcome. There were no postoperative deaths. The complication rate was 6.1 per cent (small bowel obstruction, 7; anastomotic leak, 2; ureteral stenosis, 2; and patch erosion, 1). In our experience, severe surgical constipation can be due to colonic inertia, pelvic hiatal hernia, or both. Careful preoperative evaluation identifies these disorders, and surgical therapy aimed at correction of anatomic and physiologic defects results in high patient satisfaction and improvement in bowel function.