PHYSIOLOGICAL TESTS TO PREDICT LONG-TERM OUTCOME OF TOTAL ABDOMINAL COLECTOMY FOR INTRACTABLE CONSTIPATION

Objective: Total abdominal colectomy (TAC) for intractable constipatio n has a variable reported success rate that decreases to 50% beyond 2 yr. We hypothesize that this inconsistent outcome can be explained by a more extensive intestinal involvement in some patients. Design: A co nsecutive sample of patients with intractable constipation had preoper ative evaluations that included both upper and lower GI studies. Stool frequency, constipation, diarrhea, abdominal pain, and laxative or en ema requirements were compared before and after operation. The study t ook place in an academic referral center and included 37 consecutive r eferred patients with severe intractable constipation and colonic dysm otility documented by radiopaque marker studies. Interventions: TAC, w ith ileoproctostomy in 34 patients and ileostomy in three. Main outcom e measures: Patients with motility abnormalities only of the lower GI tract were diagnosed as having colonic inertia (CI). Those with motili ty disorders of both the upper and the lower GI tracts were considered to have generalized intestinal dysmotility (GID) with colon predomina nce. Results: Twenty-one patients had CI, and 16 had GID. Ninety perce nt of CI patients undergoing TAC had a successful outcome with a mean of 23 bowel movements (BMs)/wk at a mean follow-up of 7.5 yr. Although 88% of GID patients had initial improvement with a mean of 19 BMs/wk at 6 months, only 13% had prolonged relief. After 2 yr, nine of the GI D patients had recurrent constipation, and three had severe diarrhea. Conclusions: This study has identified two distinct types of colonic d ysmotility, CI and GID. It has demonstrated the longterm success of TA C for CI and the importance of upper GI physiological studies to ident ify colon-predominant GID, which has a poor long-term response to TAC.