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

Abstract

While the pharmacological armamentarium for chronic constipation has expanded over the past few years, a substantial proportion of constipated patients do not respond to these medications. This review summarizes the pharmacological and behavioral options for managing constipation and details the management of refractory constipation. Refractory constipation is defined as an inadequate improvement in constipation symptoms evaluated with an objective scale despite adequate therapy (ie, pharmacological and/or behavioral) that is based on the underlying pathophysiology of constipation. Minimally invasive (ie, rectal irrigation and percutaneous endoscopic colostomy) and surgical therapies are used to manage refractory constipation. This review appraises these options, and in particular, percutaneous endoscopic colostomy, which as detailed by an article in this issue, is a less invasive option for managing refractory constipation than surgery. While these options benefit some patients, the evidence of the risk: benefit profile for these therapies is limited.

Anatomy, physiology, and updates on the clinical management of constipation

“…Patients with refractory constipation (unresponsive to various therapeutic options) can respond to trans-anal irrigation, which involves the introduction of water (70-1,000 mL) into the rectum and sigmoid colon. The response rates are significant (30-65%), so this can be used effectively as a conservative option before considering invasive treatments (Emmett, Close, Yiannakou, & Mason, 2015;Wilkinson-Smith et al, 2018). Indeed, surgery is a last resort and is reserved for only a small number of unresponsive patients, as it can cause more harm than good and will not guarantee restoration of neuromuscular function (Wilkinson-Smith et al, 2018).…”

“…The response rates are significant (30-65%), so this can be used effectively as a conservative option before considering invasive treatments (Emmett, Close, Yiannakou, & Mason, 2015;Wilkinson-Smith et al, 2018). Indeed, surgery is a last resort and is reserved for only a small number of unresponsive patients, as it can cause more harm than good and will not guarantee restoration of neuromuscular function (Wilkinson-Smith et al, 2018). If colonic resection is chosen for STC, the main complications involve adhesional small bowel obstructions.…”

“…Dyspareunia can result from surgical approaches to the rectovaginal region (Alimi, Iwanaga, Oskouian, Loukas, & Tubbs, 2018). For CIC, sacral neuromodulation can restore neuromuscular function (73% satisfaction; range: 57-87%) (Wilkinson-Smith et al, 2018). A multidisciplinary team in a specialized unit is highly recommended if surgery is decided upon.…”

Patient dissatisfaction with medical therapy for chronic constipation or irritable bowel syndrome with constipation: analysis of N‐of‐1 prospective trials in 81 patients

“…3,5 Defining "satisfaction with therapy" or "adequate relief of symptoms" for patients with CC is extremely important in clinical practice for several reasons: new and more expensive medication can be initiated when the older/cheaper treatments have failed, 6 diagnostic algorithms suggest that functional diagnostic tests should be reserved to patients with inadequate response to laxatives, 7 andlast but not least-more invasive therapeutic approaches have to be used in patients refractory to adequate therapies. 8 Recently, a consensus of experts has set standardised criteria for assessing the failure of treatment to provide an adequate relief of symptoms in patients with CC 9 : inadequate bowel frequency, no improvement of stool consistency and straining on most occasions have been proposed to reflect treatment failure. Another approach to establish treatment failure has been to define a symptom severity scale with a threshold below which symptoms are considered as not improved.…”

More movement with evaluating colonic transit in humans

“…Indeed, the colon accounts for a major part of the mouth‐to‐anus transit time. Assessments of colonic transit enable a diagnosis of slow transit constipation in patients who do not have a defecatory disorder, followed by colectomy for carefully selected in patients whose symptoms are refractory to laxatives ,. Colonic transit assessments are also useful to understanding the pathophysiology of disease and the pharmacodynamic effects of new medications …”