Aldo Infantino

STIPSI COLICA:

INDICAZIONI E SOLUZIONI

CHIRURGICHE

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

Verona, 14-15 Giugno 2012 Fondazione “Rosa Gallo”

ANALISI DEI COSTI

COSTI DIRETTI Diagnosi

Terapie mediche

Terapie “paramediche”

Tickets e DRG

COSTI SOCIALI Assenze dal lavoro

Necessità di spostamenti

Modifica della QOL

monetizzabili

monetizzabili ?

Stipsi

IMPATTO ECONOMICO

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

1,2% di popolazione USA consulta un medico per stipsi ogni

anno

Sonennberg, 1989

85% delle visite ha come esito

• prescrizione di esami

• prescrizione di lassativi

2,5 milioni di visite/anno: 31% medico generico,

20% internista

4% gastroenterologo

Stipsi

Stipsi

man. colica

man. gastrodigiunale

Stipsi colica Stipsi mista Ostacolo all'uscita

Tempi di transito intestinale

Rx cistocolpodefecografia

Manometria anorettale - EMG

(Ecografia endoanale - PNE Test)

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

UO Chir S. Vito al Tagl.

Diminuzione dei livelli di VIP nel sigma dei resecati per stipsi

TR Koch, 1988; P Milner 1990

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

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.

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

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.

Graff J, et al. Clin Physiol 2001 Mar;21(2):253-9

both age and gender have to be considered

when reference values for gastric, small

intestinal and colonic mean transit times

have to be established.

Conclusion

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

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

Constipation

Anorectal manometry

Rectal hyposensivity and sensory threshold volumes

elevated beyond the normal range:

– 33% of patients with rectocele

– 40% of rectal intussusception

– 53% of patients with no mechanical obstruction evident on

defecography.

SS Rao et al, Gastroenterologist 1996

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 utero-

vaginale 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 slow-

transit 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:

The results were related to psychological state rather than anorectal tests.

70% of patients found biofeedback helpful and 62%

improved, irrespective of the type of constipation

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.

29 pts, 18 m, aged 3-21 yrs (mean 8.5 yrs) -3 sigmoidostomy

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.

percutaneous laparoscopic Trap-door button

Constipation with encopresis sacrococcygeal teratoma n = 1

cerebral palsy n = 1

acquired megarectum with psychiatric and

social disorders n = 3

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

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

16 pazienti (13 F, 3 M); età media 49 aa (30-72)

PNE test eseguiti:

11 pts 1 5 pts 2

Sede di impianto:

S3 14 pts S4 2 pts

Patologie associate

Incontinenza urinaria 3

Ritenzione 6

Pat. Pelvi-perineali 13

Pat. sistemiche 2

Inerzia colica 6 casi

Dissinergia ano-rettale 10 casi

IMPIANTO DEFINITIVO

Stipsi cronica

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

Durata media PNE test: 13.4 gg (range 1-28)

Follow up medio: 11,7 mesi (range 2-24)

Score di Wexner

IMPIANTO DEFINITIVO

Stipsi cronica

Numero di evacuazioni/die

90% riduzione dei tentativi

infruttuosi/die

98% riduzione della difficoltà

ad evacuare

71% riduzione del tempo

impiegato per evacuare

100% recupero del normale stimolo

all’evacuazione

IMPIANTO DEFINITIVO

Stipsi cronica

32 pazienti Inerzia colica 15

Dissinergia ano-rettale 17

IMPIANTO DEFINITIVO

Stipsi cronica

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.

Glia A, Akerlund JE, Lindberg G. Dis Colon Rectum. 2004 Jan;47(1):96-102

P=0.09

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.

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

Deloyers Procedure

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: 5 pts (13.5%)

postoperative ileus 4 (10.8%)

late postoperative complications: 7 pts (18.9%)

postoperative ileus 4 (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

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