Alleviating Debilitating, Chronic Constipation with Colostomy after Appendicostomy: A Case Study
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.
Ms. B underwent a laparoscopic-assisted sigmoid colectomy with construction of a Hartmann’s pouch and an end sigmoid colostomy. She was shown how to care for the colostomy, provided supplies, and educated on aspects of living with an ostomy (see Figure 2). As this patient had experience irrigating an appendicostomy, only a review and discussion of expectations were needed before assisting her in the actual process. No postoperative complications occurred, recovery was uneventful, and pathology of the excised sigmoid colon was normal. The patient did not experience any urologic symptoms; urinary incontinence was not in evidence. At her 10-week follow up, Ms. B was irrigating regularly via an appendicostomy, which ultimately drained through the end sigmoid colostomy on a daily basis without any difficulty. She was advised to continue antegrade enemas via the appendicostomy and received further education on colostomy management. Ms. B currently irrigates with 20 oz (300 mL) of lukewarm tap water and can achieve complete colonic evacuation in 1 hour.
The patient presented in this case report had a long-standing history of constipation with normal colonic transit and had undergone an ACE procedure at another institution. In view of persistent symptoms of difficult evacuation and a second-degree sigmoidocele, a laparoscopic-assisted sigmoid resection and end colostomy were performed. The standard surgical procedure for idiopathic constipation is total colectomy with ileorectal anastomosis.5 Children with intractable constipation have been successfully managed with appendicostomy and ACE6,7; however, little has been published regarding the use of a similar procedure in adults.8 Marshall et al7 reviewed outcomes 3 to 54 months post procedure in 32 children, 5 to 17 years old, with anorectal dysfunction. Results of a questionnaire completed by the patient’s family and personal interviews with independent nurse assessors revealed that almost two thirds of the individuals with slow transit constipation who underwent appendicostomy and ACE had a successful outcome and improved quality of life including improvement in pain, poor appetite, and soiling Good outcomes were achieved with washouts one to two times per week using appropriate solutions. According to published data, functional results obtained in adults are comparable to those in children.9 In one study,8 eight adult patients who had severe constipation with prolonged colonic transit time and two patients with daily or several times per week incontinence to solid stools were interviewed using a colorectal function questionnaire before the appendicostomy and ACE and after irrigation had been established (radiographic segmental colonic transit and scintigraphic studies also were used to determine large bowel emptying). Of the eight patients who had constipation before the operation, seven reported their constipation problems (ie, time spent defecating, oral laxative use, and need for digital evacuation of the rectum) had been much or very much reduced.
Similar findings were obtained in a study by Krogh and Laurberg9 where 16 adults were evaluated by structured telephone interview. Although four of the patients had stopped using the appendicostomy because of abdominal pain or lack of effect, 12 patients expressed high or very high overall satisfaction with the stoma. In patients with constipation, time for defecation was reduced and fecal incontinence was greatly decreased. For all 12 patients, the impact on social activities caused by bowel dysfunction was reduced and quality of life was improved.
Mild side effects, such as abdominal discomfort during instillation of irrigation fluid, are common but transient and treatment is generally well tolerated. Some studies indicate that the ACE procedure appears to be less satisfactory in stimulating stool through the colon in patients with motility disorders such as after surgery for Hirschsprung’s disease, severe chronic idiopathic constipation, or neuronal intestinal dysplasia.10 Reasons for these poorer results may be related to the lack of normal colonic peristalsis or to the fact that the success of an ACE procedure depends on 1) adequate length of bowel to act as a reservoir between washouts and 2) the absence of any distal obstruction that would impede rectal emptying, prolong washouts, or promote ongoing leakage.11 Knowing this, Ms. B underwent an end colostomy to facilitate evacuation.
The addition of an appendicostomy for antegrade irrigation in patients with end colostomy following abdominoperineal excision of the rectum has been previously described.12 However, no known reports exist of patients with a preexisting appendicostomy undergoing a colostomy with sigmoid resection to facilitate evacuation. In patients with prior colostomy,12 three of seven elected not to use the appendicostomy owing to personal preference and difficulty with tube insertion. Four of the patients continued using appendicostomy irrigation technique for 8 to 49 months. An independent nurse interviewer assessment revealed complete satisfaction even after three of these patients also tried regular irrigation methods. The patients concluded that appendicostomy irrigation using a thin catheter and syringe with 100-mL to 300-mL irrigation was superior to regular irrigation to the left colostomy using 500 mL to 1,000 mL irrigation water, a cone tip catheter, and irrigation sleeve.
The method described in this case report facilitates bowel irrigation and evacuation and can be considered in any patient with a preexisting appendicostomy who has evacuatory problems. Undoubtedly, the most important factor is patient selection13 because none of these procedures is complication-free. These procedures are indicated when symptoms are severe and disabling to the point that quality of life is affected and the patient is willing to accept changes in body image as well as perform daily care of the ostomies. Patient selection also must be mindful of individuals with adequate dexterity to manage both the insertion of a catheter into the appendicostomy and ostomy care. Other considerations involve psychosocial issues concerning body image changes. Physically, for the appendicostomy to be created, the appendix needs to be longer than the thickness of the abdominal wall. This underscores the importance of thorough preoperative evaluation. Furthermore, the procedure should be considered only when conservative treatment measures have been exhausted.
When other less invasive measures have failed to achieve desired outcomes, laparoscopic-assisted sigmoid resection and end colostomy may be a viable option to relieve the debilitating effects of chronic constipation. Patients must be screened carefully to determine their physical and emotional appropriateness for the surgery. When pathophysiological conditions permit and the patient is able to handle the postsurgical responsibilities, good outcomes can be achieved.
This article was funded in part by a research grant from the Eleanor Naylor Dana Charitable Trust Fund.