Surgical Management

of Colonic Inertia

Jacob A. McCoy, M.D, David E. Beck, M.D.

Clinics in Colon and Rectal Surgery Vol. 25 No. 1/2012; 20-23
dipresentasikan oleh:
dr. Andina Destiyani Putri

Physiology of Colon Motility

Parasympatic : induce motility
Otonom innervation

Intermitten
Contraction

Sympatic : inhibit tonus

Intermitten
Contraction

Schwartsz 10th Ed

Low-amplitude, short-duration contractions occur

in bursts and appear to move the colonic contents
both antegrade and retrograde.
Bursts of motor activity delay colonic transit
Increase the time available for absorption of water
and exchange of electrolytes. .
High-amplitude contractions occur in a more
coordinated fashion and create mass
movements.
Bursts of rectal motor complexes also have
been described.

Colonic Inertia
Inability of the colon to modify stool to an acceptable
consistency and move the stool from the cecum to the
rectosigmoid area at least once every 3 days
Constipation
Reduced stool frequency
(normally 3x/week to
3x/day), indicate
straining, excessive
pushing, or a feeling of
incomplete defecation.

Slow-Transit
Constipation
Chronic Megacolon
Normal Colon
Caecum > 12 cm
Ascending colon > 8 cm
Rectosigmoid > 6.5 cm

Hypotesis : Loss of the argyrophil plexus with a marked increase in Schwann

cells indicating extrinsic damage to the myenteric plexus motility problem.
Colon and Rectum - Pelvic Floor Disorders and Constipation. In Sabbiston Textbook Of Surgery The Biological Basis of Modern Surgical Practice. 18 th ed. 2007

Colonic Inertia
Most patients are female, mean age of less than 30 years old.
Constipated as children and worsened during adolescence.
Accompany with abdominal pain, bloating, and nausea
Diagnotic tools : barium enema, biopsy, transit studies.
Traditionally, only patients with symptoms in the setting of megacolon or
megarectum were considered for operative intervention.

Colon and Rectum - Pelvic Floor Disorders and Constipation. In Sabbiston Textbook Of Surgery The Biological Basis of Modern Surgical Practice. 18 th ed. 2007

Transit Studies
No laxatives 3-4 days before the test.
Ingest a capsule containing 20 radiopaque
markers
Abdominal x-ray on each subsequent day for
a total of 7 days or until the markers are
expelled.
The capsules are quantified in three areas of
the colon: right, left, and rectosigmoid.
Normal subjects expel 80% of markers within
5 days after ingestion.
Fail to meet these criteria

Slow-transit constipation / colonic inertia

is diagnosed
Bailey

Abstract
Constipated patients that
cannot be managed medically

Goals of surgery:
Consider surgery
Total
Abdominal
Colectomy

Ileorectal
anastomosis

Laparoscopic

Change the frequency and

quality of bowel
movements.

Objectives

Colonic inertia
Constipated patients
Outlet obstruction

Options of surgical
Management

Patients Evaluation
Majority :
Female,
Mean age of 40 years old

Surgical Options
Segmental colectomy,
Subtotal colectomy with
ileosigmoid or cecorectal
anastomosis,
Total abdominal colectomy with
ileorectal anastomosis (TAC
IRA).

Surgical Options
Segmental Colectomy

Difficult
Difficult to
to determine
determine ifif only
only part
part of
of the
the colon
colon
does
does not
not function
function properly
properly rather
rather than
than the
the
entire
entire colon.
colon.
Transit
Transit studies
studies have
have not
not been
been adequately
adequately
specific
specific to
to document
document segmental
segmental dysmotility.
dysmotility.

Surgical Options
Subtotal Colectomy with ileosigmoid or cecorectal anastomosis

Persistent
Persistent or
or recurrent
recurrent constipation
constipation (up
(up to
to 33%)
33%)
Up
Up to
to 50%
50% of
of patients
patients required
required additional
additional resectional
resectional
surgery,
surgery, 28%
28% converted
converted into
into permanent
permanent colostomy
colostomy
41%
41% of
of patients
patients had
had persistent
persistent abdominal
abdominal pain
pain
Cecorectal
Cecorectal anastomosis
anastomosis has
has led
led to
to higher
higher complication
complication
rates
rates including
including cecal
cecal distention.
distention.

Surgical Options
TAC IRA
The
The anastomosis
anastomosis is
is usually
usually performed
performed at
at
the
the upper
upper rectum
rectum (at
(at or
or slightly
slightly above
above the
the
sacral
sacral promontory).
promontory).
Easier
Easier to
to perform
perform
Eliminates
Eliminates the
the risks
risks associated
associated with
with rectal
rectal
mobilization.
mobilization.
Upper
Upper rectum
rectum has
has aa good
good supply
supply and
and its
its size
size
does
does not
not limit
limit the
the size
size of
of the
the anastomotic
anastomotic lumen.
lumen.

Surgical Options - Laparoscopic

Cosmetic
Cosmetic issues
issues are
are often
often important
important
The
The smaller
smaller incisions
incisions offer
offer the
the potential
potential for
for a
a lower
lower incidence
incidence of
of
wound
wound complications,
complications, incisional
incisional hernias,
hernias, and
and adhesions.
adhesions.
The
The greater
greater fexibility,
fexibility, lower
lower costs,
costs, and
and shorter
shorter operative
operative times
times
have
have led
led many
many surgeons
surgeons to
to prefer
prefer a
a hand-assisted
hand-assisted laparoscopic
laparoscopic
technique.
technique.

Results
Surgical Management
Bowel Function
Average 1-3 movements per day.
Total colectomy 0.5 6 bowel
movements per day.
A uniform measure has not been
adopted to measure success
Success patient's opinions,
bowel frequency, symptom relief,
and measures of quality of life.
TAC IRA had an overall success
rate exceeding 90%.

Quality Of Life
Using 54- item validated
questionnaire (Gastrointestinal
Quality-of-Life Index)
81% pleased with their bowel
frequency
41% cited abdominal pain,
21% incontinence
46% diarrhea
93% stated they would undergo
subtotal colectomy again if given
a second chance

8 from 22 studies
100% success

Complications
Risks
of
colonic
resecti
on are
related
to :
The mortality related to
the colectomy in this
group of relatively
healthy patients has
been less than 1%.

Anastomosis (leak,
stricture),
Infections (wound and
intraabdominal
abscess),
Bleeding,
Anesthesia required to
accomplish the
procedure.

Complications
Recurrent or persistent constipation in up to 33% of
Constipation
Constipationpatients (underwent subtotal colectomy)
Mean of 41% of patients had persistent abdominal pain
Pain
Pain(underwent subtotal colectomy)
Postoperative incontinence in up to 52% of patients with
Incontinence a mean of 14%.
Incontinence
Conversion to a permanent ileostomy has ranged from 0
Conversion
Conversionto 28% with a mean of 5%.
Diarrhea up to 46% , usually short term. (underwent
Diarrhea subtotal colectomy)
Diarrhea
Postoperative small bowel obstruction 8 to 44% with
Obstruction surgical intervention required in 41 to 100%.
Obstruction

Summary
Colonic inertia
Total abdominal colectomy and ileorectal
anastomosis with an open or laparoscopic
technique
Good results

Be aware of the risk and potential outcomes

Thank You