Persistent Constipation Following Rectopexy and Biofeedback
The patient is a 34-year-old woman with difficult defecation for many years. Symptoms didn't improve with a high-fiber diet. She underwent rectopexy 2 years ago, with no improvement. Anal manometry revealed no relaxation of puborectalis (defecatory dyssynergia). She has tried relaxation exercises as well as biofeedback for more than 8 months with no improvement in her symptoms. What would be your recommended approach to managing this patient?
Laparoscopic or transabdominal rectal dissection with intra-abdominal fixation (rectopexy) is used to correct rectal prolapse. However, rectopexy operation does not always guarantee elimination of constipation symptoms. Despite generally excellent results with regard to the correction of the prolapsed rectum, approximately half of patients continue to complain of severe constipation following the procedure. In these patients, recurrence of rectal prolapse should be excluded, although reported recurrence rates are relatively low (< 5%). Patients should also be investigated for other postoperative anatomic and physiologic pelvic floor abnormalities, including postoperative autonomic neuropathy, loss of rectal compliance, and pelvic floor dyssynergia (as in the case presented). A possible rendered neuropathic sigmoid colon secondary to rectal dissection and/or division of the lateral ligaments during the rectopexy operation may also contribute to postoperative constipation symptoms, and some reports suggest a benefit with the addition of sigmoid colon resection to rectopexy operation. However, patient selection criteria and the overall long-term outcome of this approach are not clear.
As in all cases of chronic intractable constipation, colonic function (ie, transit time) should be assessed because abnormal colonic motility may be a factor in the pathophysiology of rectal prolapse and can contribute to pre- and postoperative constipation symptoms. It has been shown that colonic motility disorders are common in patients with rectal prolapse prior to surgery and that although rectopexy reduces the overall colonic pressure, it fails to restore high-amplitude propagated contractions or improve colonic transit.
With regard to the failure of biofeedback therapy, a recent critical review of 38 studies on biofeedback treatment of constipation reported a mean success rate of about 70%. A meta-analysis of these studies revealed differences in outcome between different biofeedback protocols. For example, the mean success rate (78%) of studies using pressure biofeedback was superior (P = .018) to the mean success rate (70%) for studies using electromyography biofeedback. However, there were no differences in mean success rates between studies using different types of electromyography protocols (ie, intra-anal vs perianal electromyography). This review suggests an expected failure rate with biofeedback therapy of approximately 30%. However, these data also suggest that pelvic floor retraining using a different biofeedback protocol may be beneficial.
Finally, if treatable anatomic and/or physiologic abnormalities are not identified or do not respond to therapy, and the patient continues to be symptomatic despite aggressive medical therapy, a surgical approach for severe intractable constipation (eg, colectomy with or without an ostomy) may be considered -- but only as a last resort.
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