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1、Constipation:The Evolving Role for Surgery,Outline,Normal defecationDefinition of constipationIncidenceHistory and evaluationSurgical optionsColectomyBypassAntegrade colonic enemaStomaSacral nerve stimulation,Normal Defecation,Colonic and rectal motility Reservoir function of the rectumRectal Sensat
2、ion Expulsion,Talley et al,Am J Gastroenterol,1996;Zhou et al,Chinese Med J,2007.,Incidence,Prevalence of 2-28%in Western populationsEstimated 30 million affected25.92%prevalence in Chinese adolescentsWomen men1/2 women and 1/3 men age 65Management of constipation costs$29 billion annually in the US
3、$800 million spent on laxatives each year,American Gastroenterological Association,Gastroenterol,2000.,Constipation:Rome III Criteria,Duration 3 months Symptom onset at least 6 months prior to diagnosis2 or more of the following symptoms 25%of the time Excessive straining Lumpy or hard stoolsSensati
4、on of incomplete evacuation Sensation of anorectal obstruction/blockageManual maneuvers to assist in defecation 3 unassisted defecations per week Rare loose BMs without laxatives,Etiology of Constipation,LifestyleMedicationsMedical illnessNeurologicEndocrine/MetabolicPsychiatricPrimary disease of th
5、e colon/anorectumCancerHirschsprungs diseaseProctitisFissure,Nyam et al,Dis Colon Rectrum,1997.,Chronic Idiopathic Constipation,Slow transit constipation(11%)Ineffective colonic propulsionPelvic outlet obstruction(13%)Paradoxical puborectalis contractionRectoceleCombined(5%)IBS-C(71%),Bharucha,Best
6、Pract Res Clin Gastroenterol,2007.,Pathophysiology of Slow-Transit Constipation,Structurally normal colon and rectumBlunted gastrocolic response to mealsReduced colonic response to morning wakingImpaired phasic colonic motor activityDecreased HAPCsvelocity,frequency,amplitudeIncreased periodic recta
7、l motor activity Paucity of interstitial cells of CajalDecreased level of motilinConcurrent upper GI motility disorder(77%),Detailed History,Onset/duration of constipationSymptomsfrequency,consistency,size,strainingLifestyleDiet,exerciseChangesComorbidities,past surgeriesMedicationsObstetric history
8、Psychiatric history(sexual abuse)Family history,Factors Suggestive of STC,Female Onset in childhood or adolescence20-30sExcessive laxative useGynecologic complaintsIrregular mensesOvarian cystsGalactorrhea 2 BMs per week,Physical Examination,Abdominal examTenderness,distentionMass,palpable stool,her
9、niaPelvic examPelvic organ prolapse with strainDigital examinationRectocelePerineal descentVoluntary relaxation of the sphincter,Diagnostic Studies,Laboratory evaluationColonoscopy/barium enemaColonic transit studyScintigraphyMarker studiesManometry/balloon expulsionDefocography vs.dynamic MRISmall
10、bowel transit,Hinton et al,Gut,1969.,Radiopaque Marker,Hinton et al(1969)Single capsule containing 24 markersX-ray on day 5X-ray on day 1,3,and 5(segmental)Single capsule on three successive daysX-ray on day 4Slow transit=Retention of 20%of markers by day 5,Normal,Colonic Inertia,Outlet obstruction,
11、Sitz Marker Transit Study,Treatment:Medical,Lifestyle modificationFiber supplementationAdequate hydrationRegular exerciseMedication minimizationCorrection of metabolic abnormalitiesPsychiatric evaluationPharmaceuticalLaxatives,enemasPelvic floor physical therapy/Biofeedback,When to Perform Surgery?,
12、After a complete history and physicalAfter the completion of appropriate testing After failed diet and fluid optimizationAfter failed aggressive medical management and bowel habit trainingAfter failed physical rehabilitationWhen constipation severely affects QOLMollen et al4.8%fulfill criteria to be
13、 offered surgery,Treatment:Surgical,Subtotal colectomy with anastomosisIleorectalIleosigmoidCecorectal Antiperistaltic cecorectal(Sarli)Ileoanal Segmental colectomyColonic bypassIleorectal anastomosisAntiperistaltic cecoproctostomyAntegrade colonic enemaStomaSacral nerve stimulation,GoalIncrease the
14、 frequency of BMs and relieve associated symptoms.,Feng and Jianjiang,Am J Surg,2008;Di Fabio,Dis Colon Rectum,2010.,Subtotal Colectomy,Arbuthnot Lane1908Ileorectal anastomosis20%mortality,64%success Ogilvie1931Cecorectal anastomosisMortality0-15%MorbiditySmall bowel obstruction(9-71%)Diarrhea+/-fec
15、al incontinence(10-40%)Persistence of constipation(10-30%)Persistence of abdominal pain and bloatingPoorer QOL reported following IRA for STC than for Crohns and cancer patientsDespite a similar satisfaction with the procedure,Pinto and Sands,Gastrointest Endoscopy Clin N Am,2009.,Results of Subtota
16、l Colectomy with IRA,Pinto and Sands,Gastrointest Endoscopy Clin N Am,2009.,Subtotal Colectomy with CRA,AdvantagePreservation of the ileocecal valve/terminal ileumAbsorption of water,electrolytes,vit B,bileDecreased incidence of excessive daily BMsDisadvantageCecal distentionRecurrence of constipati
17、onAbdominal pain50%conversion rate to IRA(Pemberton et al),Iannelli et al,Surg Endoscop,2005.,Subtotal Colectomy with Antiperistaltic CRA,14 patientsIncreased bowel frequency1.2 0.6/week to 4.8 7.5/dayContinence78.5%Perfect14.2%1 soiling episode/weekPostoperative complications21.4%One reoperation,Fe
18、ng and Jianjiang,Am J Surg,2008.,Subtotal Colectomy with ISA or CRA,45 ISA/34 CRAMean follow up of 2 yearsPersistent constipation,laxative use6.7%vs.26.8%(p0.05)Fecal incontinence2.9%vs.0%(p0.05)Overall satisfaction93.3%vs.73.5%,OBrien et al,Dis Colon Rectum,2009;Beck et al,S Med J,1989.,Predictors
19、of Failure?,Small bowel intestinal dysmotilityAntroduodenal manometryLactulose breath hydrogen testUndiagnosed obstructive defecation syndromePsychiatric illnessPrevious sexual abusePersistent abdominal pain88%(abused)vs.0%(nonabused),Pinto and Sands,Gastrointest Endoscopy Clin N Am,2009;Lundin et a
20、l,Br J Surg,2002.,Segmental Colectomy,Reduction in diarrhea and fecal incontinence?Reduction in SBO?Scintigraphy to determine segmental transitNot widely availableConfirms marker study results of total transitGood patient complianceNot currently recommendedHigh incidence of recurrent/persistent cons
21、tipation(16-18%)New-onset diarrhea(14-18%),Lundin E et al,Br J Surg,2002.,Result of Segmental Resection,28 patients with a median of 50 months of follow up26 left hemicolectomy6 with suture rectopexyOutcome5 required additional surgery due to persistent constipationImpaired rectal sensationSlower ra
22、te of evacuation on preop defocographySignificant improvement in function but not in abdominal pain or bloatingPersistent diarrhea3.6%60.7%-Excellent or good result82.1%-Recommend to a friend or relative,Pinedo et al,Dis Colon Rectum,2008.,Colonic Bypass,First introduced by Pinedo et al.Laparoscopic
23、 ileosigmoid anastomosis in two patientsAdvantagesMinimal dissectionLower incidence of SBO?DisadvantageColonic bacterial overgrowth?Increased incidence of colon cancer?,Wang et al.,Int J Colorectal Dis,2010.,Results of Subtotal Colonic Bypass,Subtotal colonic bypass with antiperistaltic cecoproctost
24、omy18 patients(72%female)with 17 mo f/uNo mortality or small bowel obstruction6 month follow up80%improved QOL,17%unsatisfactory72%Normal BMs(average 1.8 per day)17%Diarrhea requiring medications6%Constipation requiring laxatives6%No change in constipation,Sinha et al,Pediatr Surg Int,2008;Pinto and
25、 Sands,Gastrointest Endoscopy Clin N Am,2009.,Antegrade Colonic Enema,Malone1990 Children with neurogenic disorders and fecal incontinenceCreates a nonrefluxing conduit for intermittent catheterizationCecum or appendixAllows for colonic irrigation,resulting in rapid and controlled evacuation of the
26、large bowel contentsStomal stenosis,Antegrade Colonic Enema,For patients who do not want a colectomyFor patients at risk of fecal incontinenceDoes not preclude further surgery,Lees et al,Colorectal Disease,2004.,Results of ACE:Adult,32 patients with 37 conduits performed54%appendix5%laparoscopicComp
27、lications(88%)Minor revision38%Major revision38%Success47%in use at a median of 36 months50%in use at 5 yearsReversal for stenosis,leakage,or persistent constipation59%at a median of 13 months8%reversed after 24 monthsEnd stoma(9),colectomy(3),Ileostomy,Rarely performed as an initial intervention fo
28、r constipationUsually follows failure of subtotal colectomy Poor candidates for more major abdominal surgery,Scarpa M,Colorectal Disease,2005.,Results of Ileostomy,24 patients with a mean follow up of 47 months92%slow transit constipationEnd stoma38%Trephine20.8%Stoma complications53.4%(overall)Retr
29、action25%Peristomal sepsis12.5%Parastomal hernia8.3%Stoma pain8.3%Persistent constipation4%Stoma revision29.1%at a mean of 49 monthsStoma reversal16.6%(4)at 3.3 monthsRecurrent constipation(2)Authors favored the trephine loop stoma,Kamm et al,Gut,2010.,Sacral Nerve Stimulation?,Not currently approve
30、d for constipation in the USModulation of extrinsic neural control to colonContinuous low amplitude stimulation of sacral nerve rootsIncreased rectal sensitivity to distention?Increase in pancolonic HAPCs?Low morbidity,well tolerated,reversible,Kamm et al,Gut,2010;Carriero et al,Int J Colorectal Dis
31、,2010.,Results of SNS,Conclusions,Constipation is a common complaint.Constipation usually arises from lifestyle issues.Further evaluation is needed in select cases.Constipation symptoms must be distinguished as pelvic or colonic in origin.Most patients are treatable medically.Surgery for constipation is rarely indicated for intractable symptoms in a select patient population.Subtotal colectomy with ileorectal anastomosis remains the gold standard.Surgery for constipation is a field in evolution.Further study of the newer options is needed.,
