Treatment of refractory constipation

SURGICAL TREATMENT OF
CONSTIPATION
Saman mohammadipour M.D.
RASOUL E AKRAM HOSPITOL
COLORECTAL SURGEON
• FUNCTIONAL CONSTIPATION
• DYSSINERGIA AND PARADOX PUBORECTALIS
• PELVIC ORGAN PROLAPS AND DISEASE
• SLOW TRANSIENT COLON
• OUTLET DEFICATON SYNDROM
• SRU (SOLITORY RECTAL ULCER )
SLOW TRANSIENT COLON
OUTLET AND PELVIC DISORDER
MIXED
HISTORY AND EXAM
• MANIPULATON
• DESCEND
• DIGITAION
• URINARY PROBLEM
• HYDRO ENEMA
• INCOMPLITE EVACUATION
• PAIN
• BLEEDING
• CYCTOCELL
• RECTOCELL
• CERVICAL PROLAPS
• SOILING
• Impaction
• FECAL INCONTINENCE
• Sphincter tone, length
• Prolapse, Fissure, Fistula, Tumor,
Hemorrhoid
SLOW TRANSIENT
•
C.T.T
•
BE (BARIUM ENEMA )
•
Full G.I assessment
•
COLONOSCOPY
OUT LET OR PELVIC FLOOR
• HISTORY (DIGITATION , MANIPULATION , INCOM EVACUATION )
• MANOMETRY ( SPHINCTER TONE , RAIR)
• BALLOON EXPULSION TEST
• DEFICOGRAPHY (CYCTOCEL , RECTOCEL, ENTROCEL , DESCENT )
• COLONOSCOPY
• EMG-NCV
• Full psychological assessment
• Full assessment for metabolic and neurological diseases
Surgery should be
Highly selective
SURGERY
• Highly selective, need full evaluation
• Severe pure slow transit or ODS
• No response to medical treatment
• No esophageal, gastric, small intenstine dysmotility
• Psychologically stable
SURGERY
SLOW TRANSIENT (INERNSIA)
• RETROGRADE COLONIC ENEMA WITH PUMP
• ANTE GRADE COLONIC ENEMA WITH
APPENDICOSTOMY
• TOTAL ABDOMINAL COLECTOMY WITH ILEO RECTAL
ANASTOMOSIS.(SUBTOTAL)
RETROGRADE COLONIC ENEMA WITH PUMP
ANTE GRADE COLONIC ENEMA WITH
APPENDICOSTOMY
• LAPAROSCOPIC
• OPEN
TOTAL ABDOMINAL COLECTOMY WITH ILEO
RECTAL ANASTOMOSIS.(SUBTOTAL)
OUT LET OR PELVIC FLOOR
Falcid pelvic floor
Dys sinergia (anismus): odynia and fugax
OUTLET CASES
Biofeedback and anal physiotherapy
ABDOMINAL
Rectopexy +/- mesh
Rectopecy +/- resection
Lap / open
PERINEAL
• Conventional :
Delorm and altemeier procedure
PERINEAL
• Stapled :
STARR
TRANS STARR
PPH
MIXED
• Biofeedback and physiotherapy
• Appendicostomy
• Ostomy with irrigation
• Ostomy
PITFALL :
• Segmental colectomy
• Surgery in mixed
• Surgery in psychological patient
• surgery with ignoring patient complain
• Socioeconomic level