O.C. di San Vito al Tagliamento (PN)
Dipartimento di Chirurgia
U.O. di Chirurgia Generale
In convenzione con l’Università di Padova
Primario: dott. Aldo Infantino
STIPSI COLICA:
INDICAZIONI E SOLUZIONI
CHIRURGICHE
Aldo Infantino
Verona, 14-15 Giugno 2012
Fondazione “Rosa Gallo”
Stipsi
ANALISI DEI COSTI
COSTI DIRETTI
COSTI SOCIALI
Diagnosi
Terapie mediche
Terapie “paramediche”
Tickets e DRG
monetizzabili
Assenze dal lavoro
Necessità di spostamenti
Modifica della QOL
monetizzabili ?
Stipsi
IMPATTO ECONOMICO
1,2% di popolazione USA consulta un medico per stipsi ogni
anno
2,5 milioni di visite/anno: 31% medico generico,
20% internista
4% gastroenterologo
85% delle visite ha come esito
• prescrizione di esami
• prescrizione di lassativi
Sonennberg, 1989
Costo globale della diagnostica: 6,9 miliardi $ a cui aggiungere la
terapia
Stanziamento di 500 milioni $/anno per lo screening del ca.colon
AGA, 2000
Stipsi
Tempi di transito intestinale
Rx cistocolpodefecografia
Manometria anorettale - EMG
(Ecografia endoanale - PNE Test)
Stipsi colica
man. colica
man. gastrodigiunale
Stipsi mista
Ostacolo all'uscita
Stipsi da ostacolo all’uscita
Diagnostica
Studio dei tempi di transito intestinale
Cistocolpodefecografia
Manometria ano-rettale
EMG
Tests di espulsione
- palloncino
- fluido viscoso
Ecografia endoanale
PNE Test
(Elettrorettogramma)
B. V. 68 aa
Tempo di transito intestinale
è determinato da:

Plessi nervosi, muscolatura e contenuto

Ormoni

SNC (Psiche, cervello, midollo spinale e nn
pelvici)

Pavimento pelvico
UO Chir S. Vito al Tagl.
Tempo di transito intestinale

La Serotonina è aumentata nella mucosa e
nella muscolatura circolare dei paz con
stipsi
Lincoln, ‘90
Diminuzione dei livelli di VIP nel sigma dei
resecati per stipsi

TR Koch, 1988; P Milner 1990
UO Chir S. Vito al Tagl.
Tempo di transito intestinale
è determinato da:

Riduzione di neuroni VIP-positivi nelle
giunzioni ileo-colica e ceco-colica

Riduzione dei neuroni NOs-positivi nel plesso
mienterico

Aumento dei neuroni NOs-positivi nel plesso
sottomucoso
Faussone-Pellegrini MS, Infantino A, Matini P, Masin
A, Mayer B, Lise M. Neuronal anomalies and normal
muscle morphology at the hypomotile ileocecocolonic
region of patients affected by idiopathic chronic
constipation. Histol Histopathol 1999, 14: 1119-34
Cortesini C; Cianchi F; Infantino A; Lise M.
Nitric oxide synthase and VIP distribution in
enteric nervous system in idiopathic chronic
constipation.
Digest Dis Sci 1995; 40(11): 2450-5.
Intestinal transit time

The gastric, small intestinal and colonic mean transit times
were significantly longer in women.

Ageing was shown to accelerate the gastric and small
intestinal transit significantly.

In the group of men the colonic mean transit time was
unaffected by age, but middle-aged women had a significantly
slower colonic transit than young women.
Conclusion
both age and gender have to be considered
when reference values for gastric, small
intestinal and colonic mean transit times
have to be established.
Graff J, et al. Clin Physiol 2001 Mar;21(2):253-9
Intestinal transit time


Normal colonic transit time: 72 hours
Tt can be measured:
– Radioopaque markers study
– Scintigraphically

Similar informations
Metacalf AM et al, Gastroenterology. 1987;92:40–47
Stivland T et al, Gastroenterology. 1991;101:107–115
Colonic Constipation
Anorectal manometry
There is no uniform criteria for defining
manometric abnormalities
No pathognomonic data
No differences between Colonic
constipation and Outlet obstruction
SS Rao et al, Gastroenterologist 1996
Constipation
Anorectal manometry
Clinical and physiological findings, and
possible aetiological factors of rectal
hyposensitivity.
Gladman MA, Scott SM, Williams NS,
Lunniss PJ. Br J Surg. 2003;90:860-6
Rectal hyposensivity and sensory threshold volumes
elevated beyond the normal range:
– 33% of patients with rectocele
SS Rao et al, Gastroenterologist 1996
– 40% of rectal intussusception
– 53% of patients with no mechanical obstruction evident on
defecography.
This suggests that damage to the rectal wall can be associated
and not only consequent to rectal intussusception.!!!!!
STIPSI
23 donne con prolasso utero-vaginale
– età media 57 aa
23 donne con inc. urinaria da stress
– età media 57 aa
27 controlli
– età media 52 aa
Il 48% delle donne con prolasso uterovaginale erano stiptiche (<2/settimana)
contro l’8% dei controlli (p<0.001)
C Spence-Jones et al Br J Obstet 1994
Subtypes of constipation: sorting out the confusion.
Prather CM. Rev Gastroenterol Disord. 2004;4 Suppl 2:S11-6.
 up to a 50% overlap between patients with slowtransit constipation and irritable bowel syndrome
 approximately 10% of patients evaluated
exhibiting both slow transit and pelvic floor
dyssynergia
 50% of pts with pelvic floor dyssynergia also
found to have slow transit
Wang J, Luo MH, Qi QH, Dong ZL. Prospective study of biofeedback
retraining in patients with chronic idiopathic functional constipation.
World J Gastroenterol 2003;9:2109-13
Fifty patients (8 with slow transit constipation, 36
with obstructed defecation and 6 with mixed one)
have been dealt with biofeedback training:
70% of patients found biofeedback helpful and 62%
improved, irrespective of the type of constipation
The results were related to psychological
state rather than anorectal tests.
Appendicostomia con lembo cutaneo
F.I. 1935
21.7.2005
Cecostomy button for antegrade
enemas: survey of 29 patients.
Becmeur F, et al J Pediatr Surg. 2008 43:1853-7.
percutaneous laparoscopic Trap-door button
29 pts, 18 m, aged 3-21 yrs (mean 8.5 yrs) -3 sigmoidostomy
Fec. Incontinence
Myelomeningocele
n = 10
anorectal malformations
n = 11
caudal regression syndrome
n=1
22q11 syndrome
n= 1
Hirschsprung dis + encephalopathy with
convulsions
n=1
Constipation with encopresis
sacrococcygeal teratoma
n=1
cerebral palsy
n=1
acquired megarectum with psychiatric and
social disorders
n=3
an easy and major complication-free procedure.
Trap-door device by the pts or with the help of the parents
for antegrade enemas is effective and satisfactory.
It improves the quality of life and is reversible.
Stipsi e NMS
UO Chir S Vito al Tagl
NEUROMODULAZIONE SACRALE E STIPSI
“Permanent sacral nerve stimulation for treatment of
idiopathic constipation”
Kenefick N.J. et al., Br. J. Surg. 89, 882-888, 2002
Quattro pazienti di sesso femminile
Follow up medio 9 mesi (range 1-16)
• Risultato del PNE test mantenuto in 3/4 pazienti
• Incremento della frequenza delle defecazioni
• Riduzione della difficoltà a scaricare
• Miglioramento dello score di Wexner e della QOL
• 1/2 pazienti hanno variato il tempo di transito
• Incremento della pressione basale ed in contrazione
• Riduzione della soglia di sensibilità, dell’urgenza e del
massimo volume tollerato
Sacral Nerve Neuromodulation for the Treatment of
Lower Bowel Motility Disorders
Kennefick NJ Ann R Coll Surg Engl. 2006 November; 88(7): 617–623
IMPIANTO DEFINITIVO
Stipsi cronica
16 pazienti (13 F, 3 M); età media 49 aa (30-72)
Inerzia colica
6 casi
Dissinergia ano-rettale 10 casi
PNE test eseguiti:
11 pts 1
5 pts
Sede di impianto:
S3 14 pts S4 2 pts
2
Patologie associate
Incontinenza urinaria
Ritenzione
Pat. Pelvi-perineali
Pat. sistemiche
3
6
13
2
IMPIANTO DEFINITIVO
Stipsi cronica
Durata media PNE test: 13.4 gg (range 1-28)
Follow up medio: 11,7 mesi (range 2-24)
Non si sono verificate complicanze perioperatorie
Eventi a distanza: cistiti ricorrenti (2)
dolore in sede di IPG (2)
dislocazione IPG da trauma (1)
espianto per deiscenza della ferita (1)
IMPIANTO DEFINITIVO
Stipsi cronica
Score di Wexner
IMPIANTO DEFINITIVO
Stipsi cronica
 90% riduzione dei tentativi
infruttuosi/die
 98% riduzione della difficoltà
ad evacuare
 71% riduzione del tempo
impiegato per evacuare
Numero di evacuazioni/die
100% recupero del normale stimolo
all’evacuazione
IMPIANTO DEFINITIVO
Stipsi cronica
32 pazienti
Inerzia colica
15
Dissinergia ano-rettale 17
Follow up medio: 18 mesi (range 3-48)
Non si sono verificate complicanze perioperatorie
Eventi a distanza: cistiti ricorrenti (2)
dolore in sede di IPG (3)
dislocazione IPG da trauma (1)
sposizionamento elettrodo (1)
espianto (3) [deiscenza, colectomia tot., NCH]
IMPIANTO DEFINITIVO
Stipsi cronica
Conclusioni
La neuromodulazione sacrale
appare una promettente opzione nel
trattamento della stipsi cronica idiopatica
dopo
il fallimento delle terapie convenzionali
ed in alternativa alla chirurgia demolitiva
Stimolazione elettrica transcutanea
del nervo tibiale posteriore (TENS)
Elettrodo negativo viene piazzato dietro il malleolo mediale
Elettrodo positivo 10cm più in alto
Percutaneous tibial nerve stimulation for slow transit
constipation: a pilot study.
Collins B, Norton C, Maeda Y. Colorectal Dis. 2012 14(4):165-70.
18 pts, (range 21-74) with slow transit constipation previously failing maximal
biofeedback therapy participated in the study.
12 sessions of 30 minutes of percutaneous tibial nerve stimulation.
constipation score improved significantly (median 18 pre-treatment,
range 10-24, to median 14 post-treatment, range 7-22; P = 0.003).
The PAC-QOL also showed significant improvement (median 2.31, range
1.36-3.61, to median 1.43, range 0.39-3.78; P = 0.008).
Stool frequency increased (P= 0.048) and the use of laxatives decreased
(P = 0.025).
There was no change in colonic transit time (P = 0.45).
CONCLUSION:
Percutaneous tibial n stimulation has potential as an affordable and
minimally invasive treatment for slow transit constipation.
Outcome of colectomy for slow-transit constipation in
relation to presence of small-bowel dysmotility
•
the outcome of surgery was good or excellent in
7/7 patients with normal findings on antroduodenal
manometry
•
only 5/9 patients with abnormal manometry
findings attained a good result after surgery.
P=0.09
Glia A, Akerlund JE, Lindberg G. Dis Colon Rectum. 2004 Jan;47(1):96-102
Subtotal colectomy with antiperistaltic cecorectal
anastomosis in the treatment of slow-transit
constipation: long-term impact on quality of life.
Marchesi F, Sarli L, Percalli L, Sansebastiano GE, Veronesi L, Di Mauro D, Porrini
C, Ferro M, Roncoroni L. World J Surg. 2007;31(8):1658-64.
Deloyers Procedure
The GIQLI mean score for the STC group: 115.5 +/- 20.5
(mean score for healthy people 125.8 +/- 13)
Wexner constipation mean score: 20.3 to 2.6.
Regression analysis revealed a significant correlation
between GIQLI and urgency and abdominal pain
abdominal pain correlated significantly with STC
Surgical management for slow-transit
constipation
Alves A, Coffin B, Panis Y. Ann Chir. 2004 Oct;129(8):400-4
Colectomy improves slow-transit constipation  66%.
Complications:
• small bowel obstruction 25%
• abdominal pain 50%
• constipation recurrence 10%
Surgical outcomes after total colectomy with ileorectal
anastomosis in patients with medically intractable slow
transit constipation.
Sohn G, et al. J Korean Soc Coloproctol. 2011;27(4):180-7.
Retrospective review: 37 consecutive pts with STC
early postoperative complications:
postoperative ileus
5 pts
4
(13.5%)
(10.8%)
late postoperative complications:
postoperative ileus
7 pts
4
(18.9%)
(10.8%)
Pts satisfied with their surgical outcome:
27/33 (81.8%)
Laparoscopic versus open colectomy for patients with American Society of
Anesthesiology (ASA) classifications 3 and 4: the minimally invasive approach
is associated with significantly quicker recovery and reduced costs.
da Luz Moreira A, Kiran RP, Kirat HT, Remzi FH, Geisler DP, Church JM, Garofalo T, Fazio VW.
Surg Endosc. 2010 Jun;24(6):1280-6.
• Estimated blood loss, return of bowel function, length of
hospital stay, and total direct costs were decreased in the LC
group.
•
Wound infection was significantly greater with OC (p = 0.02).
• When patients with previous major laparotomy were excluded,
the two groups had similar overall morbidity.
•LC is a safe option for pts with a high ASA classification.
•LC approach  faster postop recovery, lower morbidity
rates, and lower hospital costs than the OC approach.
Total abdominal colectomy has a similar short-term outcome
profile regardless of indication: data from the National Surgical
Quality Improvement Program.
Alves-Ferreira PC, et al. Am Surg. 2011;77(12):1613-8.
cConstipated pts had more neurologic and renal complications when
compared with the IBD group (P = 0.01).
NNone of the other categories of complications were statistically different
among the diagnosis groups.
uUrinary tract infection higher in the constipation pts vs IBD (10 vs 4%, P =
0.03), no statistically significant differences among the other short-term
specific complications.
TThe 30-day complication rate after TAC is similar for chronic
constipation, neoplasia, and IBD
Da secoli si prova a modificare le funzioni del
proprio corpo per raggiungere un benessere
ottimale