Surgery for constipation: systematic review and clinical guidance (2017)

The surgical treatment of functional and pelvic floor disorders has often been a “Cinderella” subject, both in terms of the health care and academic agendas. Historically this status may have been in part be due to the complexities of the treatment of such conditions, due to their multidisciplinary nature, cutting across three main surgical specialties (coloproctology, urology & gynaecology), as well as necessitating input from colleagues in medical, nursing, physiotherapy, radiology and clinical physiology specialties. It does, however, in no way reflect the prevalence of the disorders or their burden on both the individual or society as a whole. Not surprisingly this problem has led to wide variation in clinical practice and a degree of uncertainty among those who fund or reimburse healthcare as to exactly what constitutes acceptable evidence based surgical care, resulting in some declining to fund some treatments at all. As multidisciplinary working has become the norm within modern health care systems, its application to functional and pelvic floor disorders has changed resource provision and led to a renewed interest in their aetiology and treatment strategies resulting in a profound transformation of academic endeavour in the field. The two decades since Horton's polemic editorial regarding the “comic opera” of surgical research 1, has generated a focus on the performance and publication of the gold standard of intervention assessment, the randomised controlled trial. More complex to perform in the setting of surgery, compared with pharmaceutical studies for example, the past decade alone has seen several high quality multicentre studies investigating surgical interventions within the field of functional and pelvic floor disorders, but mainly related to faecal incontinence and rectal prolapse 2-5. Despite the high prevalence and demand on health care resources, surgical treatments for chronic constipation have not received the same in-depth assessment, with placebo controlled trials of novel pharmaceutical agents predominating. The UK National Institute for Health Research (NIHR) have funded the investigation of three types of non-drug therapies for chronic constipation (bowel retraining, anal irrigation & laparoscopic ventral mesh rectopexy for internal rectal prolapse - see www.blizard.qmul.ac.uk/capacity.html). As a prelude to these well designed but complex studies, the CapaCiTY Working Group, along with a broad consensus group derived from the ACPGBI affiliated Pelvic Floor Society and ESCP have seized the opportunity to assess the literature available on the surgical treatment of chronic constipation. The aim has clearly been to try and make sense of a confusing array of procedures described across a plethora of manuscripts and to provide a rigorous assessment of the quality of the currently available literature. In addition, the team have endeavoured to make a series of graded practice recommendations in order to facilitate the often challenging decision making relating to the care of such patients. The intention is help optimise patient outcome, minimise harm and reduce unjustifiable variation in practice. Unfortunately, there is no similar national body in the USA although the American Society of Colon and Rectal Surgeons publishes practice parameters on a variety of topics. This series of seven papers collates for the first time the evidence for five key areas of surgical practice relating to the treatment of chronic constipation: colonic resection, rectal suspension, rectal wall excision, reinforcement of the rectovaginal septum and sacral nerve stimulation. The series starts with an introductory paper that gives a detailed overview of the general methods used, search results and study characteristics. Subsequently, each of the five areas of surgical practice has its own detailed systematic review (and where appropriate meta-analysis) with summary evidence statements. The final paper is a synopsis of graded practice recommendations and crucially, recommendations for future research. Here the authors have been open and sharing suggestions for alternative appropriate study designs when randomised trials are unfeasible. For some of the more uncommon procedures multicentre international collaborative prospective cohort studies using the paradigms exemplified in previous ESCP studies may be more informative 6. We endorse the authors recommendations of appropriate outcomes reporting via core outcome data sets (http://www.comet-initiative.org/) and that the evaluation of future innovations should adhere to the principles of the IDEAL collaboration (http://www.ideal-collaboration.net/). There remains, however, the issue of health economic impact and what treatments will ultimately be funded. All healthcare systems face financial challenges and increasingly cost effectiveness is important in the decision-making process for healthcare funders. There remains much to be investigated and little work has, as yet, been directed at the assessment of surgical interventions in this context. Determining and delivering a high quality research agenda that answers the needs of patients, healthcare providers and healthcare funder alike will be welcomed by all. The focus on quality of surgical outcome, procedural safety and patient reported outcomes in this series of seven papers is to be commended. The quotidian dilemmas within coloproctology practice have been expertly summarised and sensible recommendations with reasonable consensus made. We would encourage their widespread use by multidisciplinary teams in the formation of their treatment pathways / algorithms. There remain, however, some questions that have not been addressed because they are beyond the scope of such a clearly defined review topic and they relate to the more global management controversies that pervade and area of our specialty that can be both simultaneously rewarding and frustrating. Many of the studies included in this series of manuscripts highlight the issue of complex interventions having favourable outcomes in patients who are often euphemistically described as being “carefully selected”. This nebulous term rarely relates to judiciously described preoperative evaluation protocols and results defined a priori that mandate consideration of certain operative interventions. How should such patients be investigated when debate remains regarding the interpretation of some investigations such as defaecating proctography 7 and the expense of others (e.g. wireless motility capsule) severely limits widespread dissemination 8? While non-operative management strategies form the mainstay of therapy, by what criteria should patients progress through increasingly invasive treatment options? The association of functional gastrointestinal and pelvic floor disorders with psychological diagnoses is increasingly recognised and the influence on treatment outcomes being defined 9. How psychological factors are accounted for in the decision to progress through step wise pathways of care that ultimately lead to operative intervention in many of the reported series is opaque and yet may have a profound impact on the consultation between patient and surgeon. It is reassuring to note that in this series of papers the consensus was towards mandating psychological evaluation in all those considering colectomy and should only be performed in centres with access to appropriate specialist services. Finally, what is the course of action when catastrophe strikes? The operations described within this series, including colectomy and ileorectal anastomosis, STARR, ventral mesh rectopexy and others all have something to offer the right patient with the right pathology when appropriately counselled and operated upon by the right surgeon. Despite optimal circumstances each of these operations is associated with some of the most devastating complications, including anastomotic leak, rectovaginal fistulae, intractable pelvic pain and worse. They are thankfully rare but do occur and how these situations should be managed needs clarifying. In such circumstances the role of a stoma as an active positive choice, rather than being a sign of failure, should be considered. The heuristics used by surgeons when evaluating what interventions to offer patients with functional gastrointestinal and pelvic floor disorders have not been studied, unlike in rectal cancer patients. It may be that the perceived risk benefit ratio in a benign disease (where propensity for risk-taking tends to be lower) has had a negative impact on the utilisation of some operations (e.g. STARR, TranSTARR) when on a prima facie basis, the evidence may point to benefit. Surgeons may not be the most evidence based practitioners within the broader medical fraternity, but they are rarely abject fools. The core principle of the management of patients with these conditions remains primum non nocere. Hopefully, the impressive authoritative comprehensive compendium published by Professor Knowles and his colleagues will help us achieve that goal.