Subtotal colectomy with ileosigmoid or ileorectal anastomosis is considered by many to be the surgical treatment of choice for slow-transit constipation refractory to medical management. Most surgeons restrict the use of this surgical procedure to the most extreme cases and typically operate on fewer than 10% of patients. Strict criteria for surgery include the following: chronic, severe, disabling symptoms unresponsive to medical therapy; slow transit in the proximal colon; no evidence of pseudo-obstruction; and normal anorectal function (162). Success rates are variable and depend on several factors. An extensive review of colectomy for slow-transit constipation analyzed 32 studies from 1981 to 1988 and found satisfaction rates ranged from 39% to 100% (180). Higher success rates occurred in studies in the United States (n = 11, median 94%, range 75%–100%) and prospective studies (n = 16, median 90%, range 50%–100%). Superior outcomes occurred in those who had a complete physiologic evaluation and proven slow-transit constipation. Patients with anismus had higher rates of recurrent symptoms and lower satisfaction levels (181). Poorer outcomes occurred with ileosigmoid and cecorectal anastomosis than with ileorectal anastomosis. Those with segmental resection (hemicolectomy) had the worst outcome. None of the studies had a comparison group, and outcomes were variable and lacking validated measures. Morbidity associated with the operation included small bowel obstruction (median 18%, range 2%–71%), need for reoperation (median 14%, range 0%–50%), diarrhea (median 14%, range 0%–46%), fecal incontinence (median 14%, range 0%–52%), recurrent constipation (median 9%, range 0%–33%), persistent abdominal pain (median 41%, range 0%–90%), and permanent ileostomy (median 5%, range 0%–28%). Mortality ranged from 0%–6% (182). A quality-of-life study revealed that the score correlated poorly with frequency of bowel movements. However, a lower score was seen in those patients who had persistent abdominal pain, diarrhea, fecal incontinence, and permanent ileostomies. Overall satisfaction with the procedure was very high and correlated with the quality-of-life score (183).
Surgical alternatives to subtotal colectomy include ileostomy, cecostomy with antegrade continence enemas, and sacral nerve stimulation. Subtotal colectomy has never been directly compared with ileostomy, but those who had a permanent diversion after subtotal colectomy had lower quality-of-life scores. Patients undergoing cecostomy with antegrade continence enemas can expect to have satisfactory function approximately half of the time, with most requiring additional revision procedures secondary to stomal complications (184). Although sacral nerve stimulation has primarily been used for fecal incontinence, the results of a few small studies evoke optimism for its use in chronic constipation and slow-transit constipation (146,185–187).