Surgical Management of Constipation

Abstract

Constipation is a substantial clinical problem, accounting for 2.5 million office visits and $1.6 billion in attributable costs annually. Patients presenting with symptoms of constipation should undergo a thorough diagnostic evaluation and consideration for a medical or surgical treatment plan because of its complex pathophysiology. In addition to understanding the anatomy and physiology of defecation, a thorough history and physical examination are critical in the management of the often variable and subjective symptoms patients report in association with this diagnosis. Functional constipation can be broadly divided into two categories: disorders of colonic motility (slow-transit constipation) and disorders of defecation (outlet obstruction constipation). In addition to a meticulous perineal and rectal examination, radiopaque marker testing (Sitzmark’s test), wireless motility capsule test, anorectal manometry, defecography (fluoroscopic, magnetic resonance imaging), and electromyography are tests that can aid in the diagnosis of this disorder. Although a variety of diagnostic tools can be used to differentiate disorders of motility from disorders of defecation or outlet obstruction constipation, the possibility of concurrent etiologies for constipation should be recognized as appropriate management depending on the underlying physiology. For example, a total abdominal colectomy with ileorectal anastomosis or diverting loop ileostomy are reasonable options to treat slow-transit constipation, whereas other etiologies of constipation are better managed with nonoperative therapies such as pelvic floor physical therapy and biofeedback. In addition, functional constipation should be distinguished from irritable bowel syndrome or symptoms related to colorectal malignancies or rarer diseases such as Hirschsprung’s disease.