Alleviating Debilitating, Chronic Constipation with Colostomy after Appendicostomy: A Case Study
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Patients suffering from long-standing constipation usually complain of straining with bowel movements, the sensation of incomplete evacuation, scybalous stools, digitation, enemas, constant use of laxatives, and stool frequency of less than three times per week. Diagnostic tests for chronic constipation often include intestinal transit studies, balloon expulsion, anorectal manometry, defecography, and anal sphincter electromyography. Organic causes of constipation such as obstructing tumor should be excluded. The initial treatment usually includes dietary fiber supplementation, dietary instruction, adequate fluid intake, enemas, and laxatives. Biofeedback training and botulinum toxin type A injections are also noninvasive treatment options that can be offered, especially for patients with for paradoxical puborectalis contraction.1
Surgical management of primary constipation is rarely recommended. Surgical options include ACE for a select group of patients (those with disabling disease who failed other/conservative treatment), stoma, and correction of various anatomic abnormalities that usually coexist (such as rectocele, sigmoidocele). Antegrade continence enema, which involves creating a non-refluxing catheterizable stoma by reversing and reimplanting the appendix to act as a conduit between the cecum and the skin, was first described by Malone et al2 in 1990. To date, this procedure has gone through various modifications either to simplify the technique or to achieve a continent appendiceal stoma that is not prone to stenosis. One modification is to vary the appendicostomy by performing an antireflux procedure with open placement of a button cecostomy tube.3,4 However, in some patients where evacuation is still difficult, a colostomy may be beneficial. A case study of a chronically constipated female patient who initially underwent an ACE procedure with poor results secondary to evacuatory problems shows that a laparoscopic sigmoid resection and an end colostomy can yield good results.
Ms. B, a 51-year-old, non-married Caucasian woman, presented with a history of difficult rectal evacuation associated with intermittent lower quadrant pain. Although her past medical history was significant for partial lateral internal sphincterotomy, lumpectomy for left breast cancer, and an L5 disc herniation, she was in otherwise fairly good health. Current medications included clonazepam, acyclovir, tamoxifen, and aspirin.
Ms. B was frustrated with frequent pain, abdominal distention, and inability to move her bowels without the use of enemas and/or digitation. Two years prior, Ms. B had an ACE procedure for a long-standing history of constipation refractory to medical treatment (see Figure 1). Additional previous treatment included fiber supplements, regular irrigation with normal saline, biofeedback, and botulinum toxin type A injections for paradoxical puborectalis contraction — all without any significant improvement. Her bowel frequency was once per week and she required regular digitations. Further evaluation revealed normal colonoscopy, gastrograffin enema, colonic transit study, anal manometry, and electromyography. Her defecogram revealed a redundant non-emptying second-degree sigmoidocele with partial relaxation of the puborectalis muscle.
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