chronic constipation after sigmoid resection with rectopexy

[saravamp]

Hi, In November I had my sigmoid colon removed, because it was "tortuous" and had a rectal prolape fixed.  I have had chronic constipation for 12 years, starting after I had the nissan fundoplasy surgery for severe reguritation.  My constiaption is not better after the surgery--a recent  marker study showed all markers left after 6 days.  My colon surgeon recommended a total colectomy with ileoanal anastomosis--she wanted to have my small bowel motility studied before another surgery.  Anyway my small turns out to be fine.  However, a GI surgeon talked to me about the results and he's recommending a temporary ileostomy to see if the problem is corrected.  If the ostomy works then he thinks I should proceed with the total colectomy.  I just don't know what to do--I take Miralax, zelnorn, stool softeners and MOM laxatives, but all this only works if I use and enema  and half the time I have a problem getting the enema liquid out--I am only 32  and very healthy besides this constipation.  I have been to the emergency room twice for impaction in the past month and before the surgery I had been to the emergency room quite a few times--the stool is so hard that it sometimes won't come out.  I have had the following tests:  defecography, colonoscopy (showed fibrosis--no one ever explained what the meant, so if you know that would be fantastic and mild colitis), anorectal manometry, gastic emptying and the small bowel motility test were all normal.  
My question is --is it better to have 3 surgeries--the ostomy, reversal and then colectomy, or just go for the total colectomy.?  Also one surgeon put me on a super high fiber diet--50grams a day--then the other surgeon told me to go on a low-residue diet indefinitely, which is better--I feel awful on both diets--I am so confused It's difficult having two surgeons giving different opinions.  I don't have insurace right now so getting a third opinion from a surgeon is not in the budget as I am saving for a possible surgery.
also, is it dangeroous to have that enema liquid inside me?  I get horrible cramps if I don't get it all out, and have to call in sick to work.
Thanks very much!

[Kevin Pho, MD]

I would agree with the comments below by surgeon that the colectomy should be considered if all other measures have failed.  Small studies have shown that this surgery has had satisfactory results in approximately 90 percent of patients, with small bowel obstruction or an ileus being the most common complications.  

You have been through a pretty comprensive evaluation already - one test to consider would be a rectal biopsy which can determine any rectal nerve disorder.

Followup with your personal physician is essential.

This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.

Kevin, M.D.
Medical Weblog:
kevinmd_b

[kimbacat]

I'm very sorry you are having so many problems.  I just wanted to offer 2 web sites that might help you whichever route you end up going.  they are

www.jpouch.org

www.uoa.org

the first is a source for jpouch (ileo-anal anastomosis) surgery support.  good info, discussion board, etc

the second is the United Ostomy Association web site.  again, good info and support.

take care

[saravamp]

Thanks so much for the info!  I will check out the sites, I definitley need to do some research.....I am hoping that if I decide to go with go with an ileostomy that I can have a continent ileostomy--with the internal pouch.  At this point a bag on the outside doesn't sound bad at all--I just want to be healthy :)
Hope you are well!
thanks again

[kimbacat]

that sounds like it would be a good choice for you.  the BCIR can be a relatively minor inconvience in your day to day activities.  I think the BCIR has a better valve function than a Koch pouch.  

here's a commercial web site with info on the BCIR
www.bcirostomy.com

and an active message board with a folder for people BCIR and Koch pouches

http://www.ostomysupport.info/cgi-bin/yabb/YaBB.pl

I hope you can find relief soon

[surgeon]

Doing a subtotal colectomy for severe constipation is rare but not unheardof, and sometimes makes good sense. If it's felt that your anal sphincter function is normal, then I'd think going right to that operation -- rather than a temporary ileostomy -- makes more sense. It's fairly likely to work. In the worst case -- too frequent bowel movements with poor control, you could always have an ileostomy later. But, in the two times in my career I did a subtotal colectomy for your situation, we did it in one operation without a stoma, and the results were satisfactory. In such a situation, both your surgeon and your gastroenterologist (not to mention YOU!!) need to be as certain as possible that everything non-surgical has been tried. I'm not an expert in this, but there are rare conditions in which the nerves to the rectum are diminished; it sometimes takes a rectal biopsy to look for it.

[saravamp]

Thanks to the doctor and surgoen for replying so promptly and to Kimbacat for the BCIR info.
sara