Surg Today

DOI 10.1007/s00595-012-0464-6

ORIGINAL ARTICLE

Functional outcomes and quality of life in patients treated

with laparoscopic total colectomy for colonic inertia
Omar Vergara-Fernandez Rab Meja-Ovalle Noel Salgado-Nesme
Nathalie Rodrguez-Dennen Javier Perez-Aguirre Vctor Hugo Guerrero-Guerrero
Juan Carlos Sanchez-Robles Miguel Angel Valdovinos-Daz

Received: 9 July 2012 / Accepted: 2 October 2012

Springer Japan 2013

Abstract
Purpose To assess the functional outcomes and quality of
life in patients with laparoscopic total colectomy for slowtransit constipation (STC).
Methods All patients undergoing laparoscopic colectomy
with ileorectal anastomosis for colonic inertia at two
referral centers were analyzed. Their preoperative, intraoperative and postoperative details were recorded with a
one-year follow-up. Their quality of life was assessed using
the SF-36 questionnaire.
Results Between 2004 and 2007, 710 patients were
evaluated. Eight female patients (1.1 %) fulfilled the criteria for STC without obstructive defecation syndrome.
Their mean age was 38 years 15 (range from 22 to 62).
The conversion rate was 12.5 %. The morbidity rate was
37.5 %, and mortality was nil. The preoperative abdominal
pain was 6.6 0.3 and had decreased to 3.6 2.3 postoperatively (P = 0.008). At 1 year, the defecation frequency per week had increased from 0.84 0.24 to
6.75 3.4 (P = 0.001). Three patients developed

O. Vergara-Fernandez (&)
R. Meja-Ovalle

N. Salgado-Nesme
N. Rodrguez-Dennen
Division of Surgery, Colorectal Surgery Service, Instituto
Nacional de Ciencias Medicas y Nutricion Salvador Zubiran,
CP 14000 Mexico City, Mexico
e-mail: omarvergara74@hotmail.com
J. Perez-Aguirre
V. H. Guerrero-Guerrero

J. C. Sanchez-Robles
Colorectal Surgery Service, Central Military Hospital,
Mexico City, Mexico
M. A. Valdovinos-Daz
Gastroenterology Department, GI Motility Disorders Service,
Instituto Nacional de Ciencias Medicas y Nutricion
Salvador Zubiran, Mexico City, Mexico

nocturnal leakage (37.5 %). Eighty-eight percent of the

patients recommend the procedure. All parameters of the
SF-36 questionnaire had improved at the one-year followup examination.
Conclusion Laparoscopic colectomy for slow-transit
constipation is safe and increased the number of evacuations per week. Although nocturnal leakage may occur,
these patients experience improvements in their quality of
life.
Keywords Colon
Inertia
Laparoscopy
Colectomy

Quality of life

Introduction
Constipation is a common symptom affecting between 2
and 34 % of the general population in Western countries.
This disease is responsible for over 2.5 million medical
consultations per year in the United States, and predominantly affects females with risk factors such as physical
inactivity, low socioeconomic status, a limited education,
depression, and those with a history of sexual abuse [1, 2].
Constipation has been defined as the incapacity to
evacuate the bowel in a complete and spontaneous form at
least three or more times a week. In addition, most patients
with constipation present one or more of the following
symptoms: hard infrequent stools, excessive straining, a
feeling of incomplete evacuation, excessive time attempting to evacuate or as dissatisfaction with defecation [36].
This condition has been classified in three types:
(1) constipation with normal colonic transit, (2) constipation
with slow colonic transit, and (3) outlet obstruction. Slowtransit constipation (STC) is characterized by a loss in the
motor activity of the bowel, occurring more frequently in

123

Surg Today

young females, and is commonly manifested by one or

fewer bowel movements per week. The diagnosis is made
with a colonic transit study showing a delay in the emptying of the radiopaque markers, and excluding the existence of outlet obstruction [3, 5, 7, 8].
In cases that are resistant to medical management, total
colectomy has proven to be a definite treatment, with
success rates up to 85 %. With the advent of minimally
invasive techniques, this surgery has been proven to be safe
and to have greater short-term benefits [5, 920]. The
objective of our study was to demonstrate the functional
results, morbidity and the changes in the quality of life with
a 1-year follow-up in patients who underwent a laparoscopic total colectomy for colonic inertia.

Materials and methods

We included all patients diagnosed with constipation due to
slow intestinal transit from January 2004 to December
2007 at two referral centers in Mexico City. All patients
were diagnosed with constipation and slow colonic transit
according to the Roma II criteria [6].
The colonic transit studies were performed with radiopaque markers and were defined as positive when 20 % or
more of the markers were localized in the colon after 96 h.
Prior to surgery, the small-bowel transit time with barium
was examined in all patients (normal \5 h), as well as
defecating proctography and anorectal manometry [2].
Patients with obstructive problems of the pelvic floor were
excluded from the study.
All surgeries were performed by colorectal surgeons
using a laparoscopic approach. The quantification of pain
was analyzed using a Visual Analog Scale rating from 0 to
10, in which no pain was correlated with 0 and severe pain
with a 10. Detailed written informed consent was obtained
from all of the subjects after a full explanation of the
procedure. All patients received mechanical intestinal
preparation with polyethylene glycol, and also received per
oral (erythromycin and metronidazol) as well as intravenous (ceftriaxone and metronidazol) antibiotics prior to the
procedure as antibiotic prophylaxis. The surgery was performed with five port access and ultrasonic coagulation
shears for the colonic dissection. The vascular pedicles
were transected with staples and vessel sealing devices.
The resection of the colon was performed at the rectosigmoid junction with a laparoscopic intestinal stapler. The
anastomosis was done using a 29 circular stapler. All
patients were subjected to a hydropneumatic test to verify
the hermeticity of the anastomosis.
The patients quality of life was evaluated using an SF36 questionnaire which included questions related to
physical function, role physical, physical pain, general

123

health, vitality, social function, role emotional and mental

health. Once the questionnaire was applied to the patients,
a summary calculation and a linear transformation were
performed to obtain a score within a scale from 0 to 100
[21, 22].
The symptoms, number of evacuations, laxative use and
the quality of life were all evaluated prior to the surgery, as
well as at a 1-year follow-up examination. All patients
were asked if they would recommend the procedure.
Statistical analysis
The results are expressed as the medians or means
standard deviation. The Chi-square test was used for nonparametric variables and Fishers exact test was used for the
quantitative measurements. All statistical calculations were
performed with the aid of a computer software program
(SPSS version 16, SPSS Inc. Chicago Illinois, USA).
A P value \0.05 was considered to be significant.

Results
Between 2004 and 2007, 710 patients were evaluated for
constipation in two referral centers. Eight female patients
(1.1 %) fulfilled the criteria for STC without obstructive
defecation syndrome. All patients were included after a
failure of medical treatment. The mean age of these
patients was 38 years 15 (range 2262 years). The
anastomoses performed were end-to-side in three and endto-end in five patients. A conversion to open surgery was
needed in one of the patients (12.5 %). None of the patients
had anastomotic leakage detected by the hydropneumatic
test performed during surgery. With regard to the surgical
variables, the median skin incision length was 5 cm (range
47 cm), the median length of the operation was 240 min
(range 150320 min), and the median intraoperative blood
loss was 100 ml (range 50180 ml). Abdominal distention
was present in seven patients before the surgery and in
three after the surgery (87.55 vs. 37.5 %, P = 0.034). The
quantification of preoperative abdominal pain was
6.6 0.3 (range from 4 to 8) and decreased to 3.6 2.3
postoperatively (range from 2 to 8; P = 0.008). The
number of patients with nausea prior to surgery was six,
and had decreased to two after the procedure (P = 0.157).
Vomiting during a 1-week period was reported by four
patients before the surgery and by only one patient after
surgery (P = 0.034). None of the patients was incontinent
to gases, liquids or solid stool before or after the procedure.
Three patients presented with nocturnal leakage after the
surgery (37.5 %).
The median bowel movements per week, the quantity of
laxatives used per day and the percentage of patients who

Surg Today

used maneuvers to assist evacuation are shown in Table 1.

The median length of hospital stay was 5 days, with a
range of 415 days. The global morbidity was 37.5 %,
among which were one case of intestinal subocclusion, one
anastomotic leak and one internal hernia. These last two
patients required a new surgical intervention (25 %). The
intestinal subocclusion was managed conservatively. There
was no mortality. The median small-bowel transit time was
120 min (range 80480), and it was delayed in one patient
(480 min). This patient manifested repetitive cases of
subocclusion (12.5 %). Eighty-eight percent of our patients
reported an improvement of their symptoms and would
recommend the procedure. An evaluation of their quality of
life before and 1 year after the surgery is shown in Table 2.

Discussion
The majority of patients with constipation are treated with
simple measures such as changes in their diet and the use of
laxatives; however, when the condition proves to be
recalcitrant, it is imperative to rule out secondary causes,
among which may be metabolic, organic or pharmacological factors. Chronic primary constipation is present in up
to 9.9 % of patients; these are the ones who must be
evaluated for the possibility of surgical treatment. Total
abdominal colectomy with ileorectal anastomosis is the
Table 1 Number of bowel movements, laxatives used and defecatory
maneuvers used before and after surgery
Outcomes

Before
surgery

One-year
follow-up

No. of evacuations per

week*

0.84 0.24
(12)

6.75 3.45
(112)

0.001

Laxatives used per day*

4.12 (39)

0.37 (03)

0.0001

% patients with auxiliary

defecatory maneuvers

62.5

25

0.157

* Mean (range)

Table 2 Evaluation of the quality of life before and after surgery

using the SF-36 questionnaire
Before surgery

One-year follow-up

Physical function

37.5 17.7

88.7 10.2

Role physical

37.5 17.6

83.3 14.4

0.002

Bodily pain

21.6 20.2

81.2 24.6

0.009

General health

18.5 17.9

77.12 18.88

Vitality

10 13

83 14.4

0.0001

0.001
0.0001

Social function

18.7 23.9

85.7 28

Role emotional

37.5 20.9

93.7 12.5

0.001
0.0001

Mental health

41.2 25.03

87.14 12.8

0.001

surgical procedure that has demonstrated to have the best

results in such patients [7, 911, 23, 24].
Laparoscopic colonic surgery has been clearly demonstrated to have postoperative benefits. Especially in the
case of young patients with colonic inertia, as was the case
in our series, this approach also has cosmetic benefits.
Also, there is the theoretical advantage of decreasing the
number of adherences, post-incisional hernias and better
long-term preservation of fertility [1320].
Pitarsky et al. assessed the functional outcomes of 50
patients with open total colectomy and ileorectal anastomosis, with a follow up of 106 months. All patients showed
excellent results, although 20 % of patients required hospitalization due to intestinal occlusion and 10 % underwent
a new surgical procedure [12]. In our series, there was one
case of intestinal subocclusion and one internal hernia. The
first patient was successfully treated with a conservative
approach and the latter required a new intervention. Our
global rate of reinterventions was 25 %. Regarding the
overall postoperative satisfaction, the results of several
studies were variable, reporting figures ranging from 39 to
100 % [9, 10, 24]. One year after the surgery, 88 % of our
patients reported an improvement of their symptoms and
mentioned that they would recommend the procedure.
Knowles et al., in a review of 32 studies, found that the
surgery was successful in 86 % of cases by evaluating the
degree of global satisfaction. The number of bowel
movements after the surgery was 2.9/week, with a range
from 1.3 to 5/week, and with the presence of diarrhea in
14 % of patients. In our series, the mean number of
evacuations per week was 6.7, which was significantly
higher compared with the preoperative status. The percentage of patients with fecal incontinence in this review
was 14 %, while none of our patients were incontinent
before or after the procedure. They found that the results
were worse in patients with generalized gastrointestinal
dysmotility disorders presenting with recurrent constipation, intractable diarrhea and intestinal obstruction affecting up to 70 % of the colon [24]. One patient in our series,
with delayed small bowel transit, presented with repetitive
episodes of subocclusion. As has been demonstrated in
other series, we consider that the selection of patients for
this surgery is of the utmost importance, reinforcing the
significance of excluding patients with slow small bowel
transit for this procedure.
The mortality rate reported in the literature regarding
this surgery ranges from 0 to 15 %. A group of authors
concluded that, due to inadmissible morbidity and mortality rates, this surgery is not advisable, and should not be
performed [25]. Despite the fact that there was one anastomotic leakage, there was no mortality in our series. The
patient presented the anastomotic leakage on the fifth
postoperative day and was treated with closure, a proximal

123

Surg Today

loop ileostomy, antibiotics and drainage. The stoma was

closed 2 months later without any complications once the
absence of leakage was verified. We consider that an
immediate identification of this type of complications leads
to better results.
Concerning the functional results, the number of bowel
movements increased from 0.85 to 6.75 per week, which
was a statistically significant difference. The use of postoperative laxatives decreased from 4.12 to 0.37. Although
there was an improvement in terms of the use of defecatory
maneuvers, we did not observe a statistically significant
difference. These results are similar to those reported by
Mollen [26].
Symptoms such as abdominal distention, pain and
vomiting all improved after the surgery. Despite the episodes of nocturnal leakage that occurred in three of our
patients, we reinforce the fact that none presented with
fecal incontinence during the day. This differs from the
results reported by Zutshi et al. [11], who showed a
decrease in symptoms such as pain and abdominal distention, but the persistence of nausea in up to 37 % of patients,
vomiting in 50 %, and incontinence in 40 %.
The SF-36 questionnaire is an instrument that has been
considered as a standard tool in the evaluation and validation of the quality of life, and has previously been used
in patients with total colectomy due to colonic inertia
[27, 28]. The preoperative quality of life in our patients
was poor, obtaining a median below 50 in all values. As
observed in Table 2, there was an improvement in all
evaluated parameters 1 year after the surgery. Our results
contrast with those reported by Thlaer and colleagues [27],
where there was a decrease in the role physical, social
function and role emotional parameters, despite the
improvement in constipation. In a study by FitzHarris et al.
[28], the quality of life was adversely affected by the
presence of abdominal pain, diarrhea and fecal incontinence following the procedure.
Other less invasive and new treatments, such as sacral
neuromodulation or percutaneous tibial nerve stimulation,
have been described for patients with severe constipation;
however, these are not widely available, are expensive and
more studies are needed to establish their efficacy [2931].
In conclusion, in our series we observed an improvement in associated symptoms such as abdominal distention,
pain and vomiting, without the presence of fecal incontinence. Both the number of evacuations per week and the
number of laxatives used daily were improved by the
procedure. Eighty-eight percent of our patients recommended this surgery 1 year after the procedure, and
observed an improvement in all parameters regarding their
quality of life. Although there was one case with an
anastomotic leak, there was no mortality in our series.
Based on our results, we consider that the use of minimally

123

invasive total colectomy with an ileorectal anastomosis is

the procedure of choice in patients with colonic inertia, and
should be performed by experts in laparoscopic colorectal
surgery.
Conflict of interest Dr. Omar Vergara-Fernandez and co-authors
have no conflict of interest.

References
1. Kalbassi MR, Winter DC, Deasy JM. Quality-of-life assessment
of patients after ileal pouch-anal anastomosis for slow transit
constipation with rectal inertia. Dis Colon Rectum. 2003;46(11):
150812.
2. Mollen RM, Claassen AT, Kuijpers JH. The evaluation and
treatment of functional constipation. Scand J Gastroenterol.
1997;223:817.
3. Lembo A, Camilleri M. Chronic Constipation. N Engl J Med.
2003;349(14):13608. Review. [PMID: 14523145].
4. Kenefick NJ, Nicholls RJ, Cohen RG, Kamm MA. Permanent
sacral nerve stimulation for treatment of idiopathic constipation.
Br J Surg. 2002;89(7):8828.
5. Pfeifer J, Agachan F, Wexner SD. Surgery for constipation: a
review. Dis Colon Rectum. 1996;39:44460.
6. Drossman DA. The functional disorders and the Rome 2 process.
Gut. 1999;45 Suppl 2:II15. [PMID: 10457038].
7. Lane WA, Remarks ON. The results of the operative treatment of
chronic constipation. Br Med J. 1908;1(2455):12630.
8. Sonnenberg A, Koch TR. Physician visits in the United States for
constipation: 1958 to 1986. Dig Dis Sci. 1989;34(4):60611.
9. Ghosh S, Papachrysostomou M, Batool M, Eastwood MA. Longterm results of subtotal colectomy and evidence of noncolonic
involvement in patients with idiopathic slow-transit constipation.
Scand J Gastroenterol. 1996;31(11):108391.
10. Piccirillo MF, Reissman P, Wexner SD. Colectomy as treatment
for constipation in selected patients. Br J Surg. 1995;82:898901.
11. Zutshi M, Hull TL, Trzcinski R, Arvelakis A, Xu M. Surgery for
slow transit constipation: are we helping patients? Int J Colorectal
Dis. 2007;22(3):2659.
12. Pikarsky AJ, Singh JJ, Weiss EG, Nogueras JJ, Wexner SD.
Long-term follow-up of patients undergoing colectomy for
colonic inertia. Dis Colon Rectum. 2001;44(2):17983.
13. Sample C, Gupta R, Bambriz F, Anvari M. Laparoscopic subtotal
colectomy for colonic inertia. J Gastrointest Surg. 2005;9(6):
8038.
14. Kessler H, Hohenberger W. Laparoscopic total colectomy for
slow-transit constipation. Dis Colon Rectum. 2005;48(4):8601.
15. Pinedo G, Zarate AJ, Garcia E, Molina ME, Lopez F, Zuniga A.
Laparoscopic total colectomy for colonic inertia: surgical and
functional results. Surg Endosc. 2009;23(1):625.
16. Xu LS, Liu WS. A prospective, randomized, single-blind comparison of laparoscopic versus open colectomy for slow-transit
constipation. Am Surg. 2012;78(4):4956.
17. Award ZT. Laparoscopic subtotal colectomy with transrectal
extraction of the colon and ileorectal anastomosis. Surg Endosc.
2012;26(3):86971.
18. Conzo G, Allaria A, Stazione F, Rossetti G, Candela G, Mauriello
C, Santini L. Laparoscopic treatment of chronic slow transit
constipation. Report of three cases and review of literature. Ann
Ital Chir. 2012;83(2):1137.
19. Conzo G, Stazione F, Celsi S, Palazzo A, Della Pietra C, Candilio
G, Livrea A. Videolaparo-assisted subtotal colectomy with
cecorectal anastomosis in the treatment of chronic slow transit
constipation. G Chir. 2010;31(1112):48790.

Surg Today
20. Hotta T, Yamaue H. Laparoscopic surgery for rectal cancer:
review of published literature 20002009. Surg Today. 2011;
41(12):158391.
21. Zuniga MA, Carrillo-Jimenez GT, Fos PJ, Gandek B, MedinaMoreno MR. Evaluation of health status using Survey SF-36:
preliminary results in Mexico. Salud Publica Mex. 1999;41(2):
1108.
22. Vilagut G, Ferrer M, Rajmil L, Rebollo P, Permanyer-Miralda G,
Quintana JM, Santed R, Valderas JM, Ribera A, DomingoSalvany A, Alonso J. The Spanish version of the Short Form 36
Health Survey: a decade of experience and new developments.
Gac Sanit. 2005;19(2):13550.
23. Lahr SJ, Lahr CJ, Srinivasan A, Clerico ET, Limehouse VM,
Serbezov IK. Operative management of severe constipation. Am
Surg. 1999;65(12):111721.
24. Knowles CH, Scott M, Lunniss PJ. Outcome of colectomy for
slow transit constipation. Ann Surg. 1999;230(5):62738.
25. Riss S, Herbst F, Birsan T, Stift A. Postoperative course and long
term follow up after colectomy for slow transit constipationis
surgery an appropriate approach? Colorectal Dis. 2009;11(3):
3027.

26. Mollen RM, Kuijpers HC, Claassen AT. Colectomy for slowtransit constipation: preoperative functional evaluation is important but not guarantee for a successful outcome. Dis Colon
Rectum. 2001;44(4):57780.
27. Thaler K, Dinnewitzer A, Oberwalder M, Weiss EG, Nogueras JJ,
Efron J, Vernava AM 3rd, Wexner SD. Quality of life after
colectomy for colonic inertia. Tech Coloproctol. 2005;9(2):
1337.
28. FitzHarris GP, Garcia-Aguilar J, Parker SC, Bullard KM, Madoff
RD, Goldberg SM, Lowry A. Quality of life after subtotal
colectomy for slow-transit constipation: both quality and quantity
count. Dis Colon Rectum. 2003;46(4):43340.
29. Malouf AJ, Wiesel PH, Nicholls T, Nicholls RJ, Kamm MA.
Short term effects of sacral nerve stimulation for idiopathic slow
transit constipation. World J Surg. 2002;26(2):16670.
30. Maeda Y, Lundby L, Buntzen S, Laurberg S. Sacral nerve
stimulation for constipation: suboptimal outcome and adverse
events. Dis Colon Rectum. 2010;53(7):9959.
31. Collins B, Norton C, Maeda Y. Percutaneous tibial nerve stimulation for slow transit-constipation: a pilot study. Colorectal Dis.
2012;14(4):e16570.

123