Surgery for constipation: systematic review and practice recommendations

Abstract

Aim This manuscript forms the final of seven that address the surgical management of chronic constipation (CC) in adults. The content coalesces results from the five systematic reviews that precede it and of the European Consensus process to derive graded practice recommendations (GPR).Methods Summary of review data, development of GPR and future research recommendations as outlined in detail in the 'introduction and methods' paper.Results The overall quality of data in the five reviews was poor with 113/156(72.4%) of included studies providing only level IV evidence and only four included level I RCTs. Coalescence of data from the five procedural classes revealed that few firm conclusions could be drawn regarding procedural choice or patient selection: no single procedure dominated in addressing dynamic structural abnormalities of the anorectum and pelvic floor with each having similar overall efficacy. Of one hundred 'prototype' GPRs developed by the clinical guideline group, 85/100 were deemed 'appropriate' based on the independent scoring of a panel of 18 European experts and use of RAND-UCLA consensus methodology. The remaining 15 were all deemed uncertain. Future research recommendations included some potential RCTs but also a strong emphasis on delivery of large multinational highquality prospective cohort studies.Conclusion While the evidence base for surgery in CC is poor, the widespread European consensus for GPRs is encouraging. Professional bodies have the opportunity to build on this work by supporting the efforts of their membership to help convert the documented recommendations into clinical guidelines.

Chronic idiopathic constipation in adults: epidemiology, pathophysiology, diagnosis and clinical management

“…23 This patient group may benefit from total colectomy with ileorectal anastomosis. 88 Outcomes can be very good when strict selection criteria are applied, with high levels of patient satisfaction and improvements in quality of life reported. 89 Surgery is not suitable for patients with IBS-C, or for those with pure DD.…”

Percutaneous endoscopic colostomy for adults with chronic constipation: Retrospective case series of 12 patients

“…Surgical procedures for chronic refractory constipation include total colectomy with ileorectal anastomosis and subtotal colectomy with ileosigmoid/ colorectal anastomosis. 7,12 Mean success rate for these interventions is reported to be high, around 89%. 7 However, postsurgical adverse events are described in up to 45% of patients.…”

“…[1][2][3]5,[7][8][9] Previous reports demonstrate variable efficacy of these surgical treatment entities, and morbidity of these procedures is high. 7,[10][11][12] Less invasive and potentially reversible procedures such as sacral neuromodulation and tibial nerve stimulation have been disappointing with respect to efficacy. [13][14][15][16][17] Therefore, exploration of potentially efficacious minimally invasive therapeutic alternatives for refractory constipation is warranted.…”

When all seems lost: management of refractory constipation—Surgery, rectal irrigation, percutaneous endoscopic colostomy, and more

“…The outcomes of all main procedures for CC were systematically reviewed in 2017 [26][27][28][29][30][31][32] (all full open access) ( Table 1). In brief, the evidence is very poor.…”

“…In 113/156 (72.4%) studies, the evidence was rated as level IV; only 4 level I RCTs were included. 29,30 Poor quality observational data are the Achilles heel of surgical research and must be acknowledged to suffer from almost every known source of bias. Furthermore, the use of global satisfaction ratings to judge outcome acknowledges the limited use of validated outcomes in all but a few studies.…”