Subtotal colectomy with antiperistaltic cecoproctostomy for selected patients with slow transit constipation-from Chinese report

Nonpharmacologic Treatment of Chronic Constipation

Functional constipation is a common clinical diagnosis that affects approximately 14% of the world's population. Non-pharmacological therapies often represent the initial steps in management and may include lifestyle adjustments or changes such as physical activity and diet. Pharmacological options have been used when the non-pharmacological approach has been ineffective. Biofeedback therapy, surgery, sacral nerve stimulation, botulinum toxin injection, and vibrating capsules can be considered in scenarios where the laxatives are ineffective. Biofeedback therapy is highly effective and safe in treating dyssynergic defecation, which affects more than half of patients with chronic constipation. This paper overviews non-pharmacological therapies for functional constipation.

Surgery for chronic idiopathic constipation: pediatric and adult patients - a systematic review

BACKGROUND

Chronic idiopathic constipation (CIC) is a substantial problem in pediatric and adult patients with similar symptoms and workup; however, surgical management of these populations differs. We systematically reviewed the trends and outcomes in the surgical management of CIC in pediatric and adult populations.

METHODS

A literature search was performed using Ovid MEDLINE, Embase, Scopus, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov between January 1, 1995 and June 26, 2020. Clinical trials and retrospective and prospective studies of patients of any age with a diagnosis of CIC with data of at least 1 outcome of interest were selected. The interventions included surgical resection for constipation or antegrade continence enema (ACE) procedures. The outcome measures included bowel movement frequency, abdominal pain, laxative use, satisfaction, complications, and reinterventions.

RESULTS

Adult patients were most likely to undergo resection (94%), whereas pediatric patients were more likely to undergo ACE procedures (96%) as their primary surgery. Both ACE procedures and resections were noted to improve symptoms of CIC; however, ACE procedures were associated with higher complication and reintervention rates.

CONCLUSION

Surgical management of CIC in pediatric and adult patients differs with pediatric patients receiving ACE procedures and adults undergoing resections. The evaluation of resections and long-term ACE data in pediatric patients should be performed to inform patients and physicians whether an ACE is an appropriate procedure despite high complication and reintervention rates or whether resections should be considered as an initial approach for CIC.

Cecorectal (CRA) versus ileorectal (IRA) anastomosis after colectomy for slow transit constipation (STC): a meta-analysis

INTRODUCTION

We conducted this meta-analysis, to compare cecorectal (CRA) and ileorectal anastomosis (IRA), regarding perioperative safety and efficacy, in patients submitted to colectomy for refractory slow transit constipation (STC).

METHODS

This study followed the Cochrane Handbook for Systematic Reviews of Interventions and the PRISMA guidelines. To identify all eligible records, a systematic literature search in the electronic scholar databases (Medline, Scopus, Web of Science) was performed.

RESULTS

Overall, 5 trials and 291 patients were included in this meta-analysis. Pooled comparisons confirmed the comparability of the two techniques regarding perioperative complications (p = 0.55). CRA was associated with a shorter operation (p = 0.0004) and hospitalization duration (p = 0.001). Although there was no difference in terms of gastrointestinal symptoms, functional outcomes, and patient satisfaction, CRA resulted in lower long-term Wexner scores (p < 0.0001).

CONCLUSION

Due to several study limitations, further large-scale RCTs are required to verify the findings of the present meta-analysis.

Surgical outcomes of subtotal colectomy with antiperistaltic caecorectal anastomosis vs total colectomy with ileorectal anastomosis for intractable slow-transit constipation

BACKGROUND

Few studies have compared the surgical outcomes of different surgical procedures currently used to treat refractory colonic slow-transit constipation (STC), despite the increase in the number of cases. This study aimed to analyse the long-term surgical outcomes of subtotal colectomy with antiperistaltic caecorectal anastomosis (SC-ACRA) vs total colectomy with ileorectal anastomosis (TC-IRA) for severe STC.

METHODS

Between January 2005 and January 2015, we retrospectively collected clinical data of 55 patients who underwent TC-IRA (n = 35) or SC-ACRA (n = 20) for severe STC at our institution. The post-operative functional outcomes between the two groups were compared.

RESULTS

There were no significant differences in age (P = 0.655), sex (P = 0.234), period of constipation (P = 0.105) and defecation frequency (P = 0.698) between the TC-IRA and SC-ACRA groups. During a median follow-up period of 72 months (range, 12-120 months), there were no significant differences between the TC-IRA and SC-ACRA groups regarding the median number of bowel movements per day [3 (1/6-7) vs 3 (1/6-5), P = 0.578], Cleveland Clinic Florida Constipation Score [2 (0-20) vs 2 (0-19), P = 0.454], Cleveland Clinic Incontinence Score [0 (0-5) vs 0 (0-2), P = 0.333] and Gastrointestinal Quality of Life Index [122 (81-132) vs 120 (80-132), P = 0.661]. Moreover, there was no significant difference in the incidence of post-operative complications between the two groups (37.1% vs 25.0%, P = 0.285).

CONCLUSIONS

Our findings indicate that both TC-IRA and SC-ACRA are effective treatments for severe STC, with similar long-term outcomes.

Subtotal colonic bypass plus colostomy with antiperistaltic cecoproctostomy for the treatment of slow transit constipation in an aged population: A retrospective control study

AIM

To compare the efficacy, improved quality of life, and prognosis in patients undergoing either subtotal colonic bypass with antiperistaltic cecoproctostomy (SCBAC) or subtotal colonic bypass plus colostomy with antiperistaltic cecoproctostomy (SCBCAC) for the treatment of slow transit constipation.

METHODS

Between October 2010 and October 2014, aged patients with slow transit constipation who were hospitalized and underwent laparoscopic surgery in our institute were divided into two groups: the bypass group, 15 patients underwent SCBAC, and the bypass plus colostomy group, 14 patients underwent SCBCAC. The following preoperative and postoperative clinical data were collected: gender, age, body mass index, operative time, first flatus time, length of hospital stay, bowel movements (BMs), Wexner fecal incontinence scale, Wexner constipation scale (WCS), gastrointestinal quality of life index (GIQLI), numerical rating scale for pain intensity (NRS), abdominal bloating score (ABS), and Clavien-Dindo classification of surgical complications (CD) before surgery and at 3, 6, 12, and 24 mo after surgery.

RESULTS

All patients successfully underwent laparoscopic surgery without open surgery conversion or surgery-related death. The operative time and blood loss were significantly less in the bypass group than in the bypass plus colostomy group (P = 0.007). No significant differences were observed in first flatus time, length of hospital stay, or complications with CD > 1 between the two groups. No patients had fecal incontinence after surgery. At 3, 6, and 12 mo after surgery, the number of BMs was significantly less in the bypass plus colostomy group than in the bypass group. The parameters at 3, 6, 12, and 24 mo after surgery in both groups significantly improved compared with the preoperative conditions (P < 0.05), except NRS at 3, 6 mo after surgery in both groups, ABS at 12, 24 mo after surgery and NRS at 12, 24 mo after surgery in the bypass group. WCS, GIQLI, NRS, and ABS significantly improved in the bypass plus colostomy group compared with the bypass group at 3, 6, 12, and 24 mo after surgery (P < 0.05) except WCS, NRS at 3, 6 mo after surgery and ABS at 3 mo after surgery. At 1 year after surgery, a barium enema examination showed that the emptying time was significantly better in the bypass plus colostomy group than in the bypass group (P = 0.007).

CONCLUSION

Laparoscopic SCBCAC is an effective and safe procedure for the treatment of slow transit constipation in an aged population and can significantly improve the prognosis. Its clinical efficacy is more favorable compared with that of SCBAC. Laparoscopic SCBCAC is a better procedure for the treatment of slow transit constipation in an aged population.

Searching for a definition for pharmacologically refractory constipation: A systematic review

BACKGROUND AND AIM

Surgery and other non-pharmacological treatments such as sacral nerve stimulation are used for the treatment of difficult-to-treat chronic constipation. Novel pharmacological therapeutic agents are also being introduced. To evaluate the efficacy of these treatments, it is imperative to have a consistent definition of pharmacologically refractory constipation. A systematic review of studies on refractory, difficult-to-treat or surgically treated constipation was carried out to determine the criteria that various authors used to define this group of patients.

METHODS

A systematic review was performed for literature published from June 2005 to June 2015 using PubMed, Cochrane, and Scopus databases, as well as manual searches. Studies on patients with refractory or intractable constipation were extracted. Criteria used for defining refractory constipation, as well as pharmacological agents tried including dosage, frequency, and duration, were reviewed.

RESULTS

Sixty-one studies were included in this review. Forty-eight involved surgical treatment of constipation, while 13 examined non-surgical therapies for refractory constipation. There is no generally accepted definition of refractory constipation. Authors consider constipation to be refractory when response to management is suboptimal, but there is no consensus on the choice of drug, order of usage, and dosage or treatment duration. Prior medical therapy was not mentioned at all in five studies.

CONCLUSIONS

There is need for a detailed definition of pharmacologically refractory constipation before submitting patients to invasive treatments and to evaluate new pharmacological agents.

Surgery for constipation: systematic review and practice recommendations: Results I: Colonic resection

AIM

To assess the outcomes of colectomy in adults with chronic constipation (CC).

METHOD

Standardised methods and reporting of benefits and harms were used for all CapaCiTY reviews that closely adhered to PRISMA 2016 guidance. Main conclusions were presented as summary evidence statements (SES) with a summative Oxford Centre for Evidence-Based Medicine (2009) level.

RESULTS

Forty articles were identified, providing data on outcomes in 2045 patients. Evidence was derived almost exclusively from observational studies, the majority of which concerned colectomy and ileorectal anastomosis (CIRA) rather than other procedural variations. Average length of stay (LOS) ranged between 7-15 days. Although inconsistent, laparoscopic surgery may be associated with longer mean operating times (210 vs 167 min) and modest decreases in LOS (10-8 days). Complications occurred in approximately 24% of patients. Six (0.4%) procedure-related deaths were observed. Recurrent episodes of small bowel obstruction occurred in about 15% (95%CI: 10-21%) of patients in the long-term, with significant burden of re-hospitalisation and frequent recourse to surgery. Most patients reported a satisfactory or good outcome after colectomy but negative long-term functional outcomes persist in a minority of patients. The influence of resection extent, anastomotic configuration and method of access on complication rates remains uncertain. Available evidence weakly supports selection of patients with an isolated slow-transit phenotype.

CONCLUSION

Colectomy for CC may benefit some patients but at the cost of substantial short- and long-term morbidity. Current evidence is insufficient to guide patient or procedural selection.

慢传输型便秘外科治疗进展

近年来, 慢性便秘呈缓慢上升趋势, 慢传输型便秘(slow transit constipation, STC)是慢性便秘最常见的一种类型, 外科治疗是STC治疗的重要手段. 由于目前对于STC的发病原因及发病机制尚未完全明确, 及术前缺乏精确定位病变结肠的检查方法, 导致治疗STC手术方法的多样性. 近三十年来, 随着医学技术的不断进步, STC的外科治疗不断发展, 手术方法不断创新; 手术方法经历了从简单到复杂再到个体化选择, 从单一手术方法到多种手术方法选择, 从经腹开放手术到腹腔镜微创手术. 本文从STC的术式产生和发展过程来阐述STC外科治疗疗效和进展.

Functional Disorders: Slow-Transit Constipation

Constipation is a very common complaint, with slow-transit constipation (STC) accounting for a significant proportion of cases. Old age, female gender, psychiatric illness, and history of sexual abuse are all associated with STC. The exact cause of STC remains elusive; however, multiple immune and cellular changes have been demonstrated. Diagnosis requires evidence of slowed colonic transit which may be achieved via numerous modalities. While a variety of medical therapies exist, these are often met with limited success and a minority of patients ultimately require operative intervention. When evaluating a patient with STC, it is important to determine the presence of concomitant obstructed defecation or other forms of enteric dysmotility, as this may affect treatment decisions. Although a variety of surgical procedures have been reported, subtotal colectomy with ileorectal anastomosis is the most commonly performed and well-studied procedure, with the best track record of success.

Colectomy for constipation: time trends and impact based on the US Nationwide Inpatient Sample, 1998-2011

BACKGROUND

Current guidelines include subtotal colectomy as treatment for refractory slow transit constipation.

AIM

To use the US Nationwide Inpatient Sample (NIS) (1998-2011) and longitudinal data from the State Inpatient Database (2005-2011), comparable to NIS, to examine colectomy rates, in-hospital morbidity and emergency department (ED) visits or readmissions among patients treated for constipation.

METHODS

Colectomies for any reason were identified based on the primary procedural code (ICD-9-CM 45.8x). Index hospitalisations were defined by the primary diagnosis of constipation (ICD-9-CM 564.x) associated with the primary procedural code for colectomy (ICD-9-CM45.8x) after exclusion of other diseases associated with colectomy. Demographic variables, comorbidities, complications and adverse events during the hospitalisation were captured, and ED visits and admissions were recorded for periods before and after colectomy.

RESULTS

Nationally, colectomies for constipation rose from 104 procedures in 1998 (1.2% of annual colectomies) to 311 in 2011 (2.4% of annual colectomies). While there were no perioperative deaths, perioperative complications occurred in 42.7% of patients during the index hospitalisation. Longitudinal data were analysed for 181 patients, with similar perioperative complications and a readmission rate of 28.9% within the first 30 days after the index hospitalisation. Resource utilisation was tracked for a median time of 630 (0-2386) before and 463 (0-2204) days after colectomy with unchanged ED visits (median: 2 vs. 2, P = 0.21), but increased hospitalisations (median: 1 vs. 2, P = 0.003).

CONCLUSIONS

Colectomy rates for constipation are rising, are associated with significant morbidity and do not decrease resource utilisation, raising questions about the true benefit of surgery for slow transit constipation.

The Relationship Between Colonic Macrophages and MicroRNA-128 in the Pathogenesis of Slow Transit Constipation

BACKGROUND

Recent evidence suggests that colonic macrophages and microRNAs play important roles in motor activity in the gastrointestinal tract. However, there are almost no data concerning colonic macrophages and microRNAs in slow transit constipation.

AIM

The purpose of this study was to investigate colonic macrophages and microRNA-128 expression in the pathogenesis of slow transit constipation in colon tissues.

METHODS

Full-thickness colonic specimens from patients undergoing surgery for slow transit constipation, due to refractoriness to other therapeutic interventions (n = 25), were compared to controls (n = 25), and the number of colonic macrophages (as evaluated by specific monoclonal antibodies) was counted. Gene expression analysis of microRNA-128 was performed by microRNA microarray and qRT-PCR. Lastly, bioinformatics analysis, coupled with luciferase reporter assays, was used to investigate the mRNA transcript(s) targeted by microRNA-128.

RESULTS

Compared to controls, 20 of 25 slow transit constipation patients (80 %) had significantly higher numbers of macrophages in colonic specimens, coupled with down-regulation of microRNA-128. Linear regression analyses showed a significant negative correlation between macrophage number and microRNA-128 expression level. Among 83 bioinformatically predicated candidates, mitogen-activated protein kinase 14 (p38α) was validated to be a direct target of microRNA-128 in human intestinal epithelial cells.

CONCLUSIONS

This study presents evidence for the negative correlation of macrophage number and microRNA-128 expression, in slow transit constipation patients, representing a possible mechanism of impaired gastrointestinal motility.

A prospective comparison of short term results and functional recovery after laparoscopic subtotal colectomy and antiperistaltic cecorectal anastomosis with short colonic reservoir vs. long colonic reservoir

Background

To observe and compare the short term results and functional recovery of laparoscopic subtotal colectomy with antiperistaltic cecorectal anastomosis (LSCACRA) in the treatment of Adult slow transit constipation (STC) with two different reservoir length: short colonic reservoir and long colonic reservoir.

Methods

All STC patients treated with LSCACRA between April 2007 and December 2011 at our institution were followed up. Patients with 2 cm to 3 cm ascending colon preserved above the ileocecal junction were designated as observation group, whereas those preserved by 10 cm to 15 cm were classified as control group. 41 cases in the observation group and 40 cases in the control group were enrolled. Preoperative and outcome parameters of patients were collected, including gender, age, body mass index, operative time , blood loss, first flatus time, hospital stay, postoperative complications, Wexner constipation scale(WCS), Wexner incontinence scale, gastrointestinal quality of life index(GIQLI), abdominal pain intensity scale(APIS), abdominal pain frequency scale(APFS) and abdominal bloating scale(ABS).

Results

Laparoscopic surgeries were successfully carried out for all patients, without any case transferred to laparotomy or death related to surgery. The operative time, blood loss, first flatus time, and days of hospital stay of the two groups did not show significant differences. We found no significant differences on complications (Clavien–Dindo grade > I) between the two groups. No patient exhibited anastomotic leak. No fecal incontinence occurred in both groups. On the 3^rd, 6^th and 12^th month after operation, the parameters of both groups significantly improved compared with the preoperative conditions (P < 0.05) except the APIS at 3^rd and 6^th month in control group. On the 3^rd, 6^th and 12^th month after operation, the Functional Recovery outcomes of WCS、GIQLI、APIS、APFS and ABS in the observation group were superior to those in the control group (P < 0.05).

Conclusion

LSCACRA has a significant effect in the treatment of STC in adult. Postoperative outcomes can be optimized by shortening the length of the preserved ascending colon above the ileocecal junction, which promise better life quality of patients. Trial registration: Chinese Clinical Trial Registry ChiCTR-OPC-14005280, 2014-09-29.

Electronic supplementary material

The online version of this article (doi:10.1186/s12876-015-0257-7) contains supplementary material, which is available to authorized users.

Colonic salvage with antiperistaltic cecorectal anastomosis

BACKGROUND

Following colon resection, the construction of a well-perfused, tension-free isoperistaltic anastomosis can be made difficult by multiple factors including prior abdominal surgery or compromised vascular supply. Here, we describe the technique of antiperistaltic cecorectal anastomosis as a method for preserving viable colon without compromising functional outcome.

TECHNIQUE

Following extensive colorectal resection, different techniques for isoperistaltic reconstruction using the cecum and ascending colon have been described, including the Deloyers procedure and limited isoperistaltic cecorectal anastomosis. However, these isoperistaltic reconstructions often require ligation of the middle colic and right colic arteries and/or sacrifice of viable distal colon to aid reconstruction. In complex situations that require preservation of normal vascular anatomy, an antiperistaltic cecorectal anastomosis can be constructed that maintains the orientation of the vascular pedicle. In addition to the preservation of the colonic arterial supply, a distinguishing feature of this technique is the substantial portion of antiperistaltic colon that is preserved and interposed to reestablish continuity.

RESULTS

In a case where it was used, construction of an antiperistaltic cecorectal anastomosis was technically successful and led to a good functional outcome.

CONCLUSION

Antiperistaltic cecorectal anastomosis should be considered as an option in colonic reconstruction for patients with extensive prior abdominal surgery or when complex anatomic issues require preservation of native vascular anatomy. In these situations, this technique offers several advantages over isoperistaltic reconstruction and may be the only option for reconstruction that uses the remaining cecum and colon.

Modified right colon inversion technique as a salvage procedure for colorectal or coloanal anastomosis

AIM

A tension-free well vascularized colorectal or coloanal anastomosis is not always possible following rectal or sigmoid resection. The study reports on the short-term and long-term outcome of a modified right colon inversion technique as a means of facilitating a low colorectal or coloanal anastomosis.

METHOD

All patients who underwent right colonic inversion, a modified Deloyers' procedure, were identified retrospectively from the prospective database of the Colorectal Department of the Royal Marsden Hospital from October 2008 to December 2013.

RESULTS

There were 14 (nine male) patients of median age 58.7 (45-75) years. The main indication was extensive diverticular disease (50%) and previous colonic surgery (21.4%). A defunctioning stoma was performed in 64.3% which was reversed in all within 3-6 months. Three (21.4%) patients developed postoperative complications (Clavien-Dindo 1-2) and none required reoperation. The median duration of follow-up was 11 months. One (7.2%) patient had one bowel movement per day, 10 (71.4%) patients had two bowel movements per day and three (21.4%) patients had three per day.

CONCLUSION

The modified right colonic inversion technique is safe and achieves intestinal continuity with a tension-free well vascularized anastomosis. Good function and low morbidity show that the procedure is a credible alternative to ileorectal or ileoanal anastomosis.

A modified total colonic exclusion for elderly patients with severe slow transit constipation

BACKGROUND

The aim of this study was to evaluate outcomes of total colonic exclusion with antiperistaltic ileorectal anastomosis (TCE-AIA) for elderly patients with slow transit constipation (STC).

METHODS

Elderly patients (defined as age >65) who underwent TCE-AIA for severe idiopathic STC between 2009 and 2012 at our institution were identified. Postoperative outcomes and routine follow-up were assessed using the Wexner constipation score (WCS), gastrointestinal quality of life index (GIQLI) and four-point postoperative satisfaction scales.

RESULTS

A total of 13 elderly patients were met the inclusion criteria. Five patients (38.5%) were male, and eight patients (61.5%) were female. The mean age of this population was 74 years (range 63-82 years). The mean operative time was 55 min (range 28-32), and blood loss was minimal. The mean postoperative hospital stay was 6.7 days (range 5-12 days). The mean time until the first postoperative bowel movement was 4 days (range 2-8 days). There was no procedure-related mortality and no major in-hospital complications. The median duration of follow-up was 12.4 months (range 6-29 months). None of the 13 patients had fecal incontinence or recurrence of constipation at the follow-up end point. However, eight patients underwent colonoscopy during follow-up, and four patients presented with diversion colitis. The patients' preoperative WCS was 22.8 ± 3.3, and it had significantly improved to 5.4 ± 2.1 on 6 months after operation (p < 0.05). The preoperative GIQLI of 93.6 ± 20.5 had significantly increased to 120.8 ± 13.0 on 6 months after surgery (p < 0.05). Patient satisfaction at 6 months was very high in 11 patients and high in two patients.

CONCLUSIONS

TCE-AIA is a relatively simple procedure. It might be an effective surgical intervention for the selected elderly patients with STC.

Surgical management of colonic inertia

For the select small number of constipated patients that cannot be managed medically, surgical options should be considered. Increases in our knowledge of colorectal physiology and experience have fostered improvements in patient evaluation and surgical management. Currently, patients with refractory colonic inertia are offered total abdominal colectomy and ileorectal anastomosis, often with laparoscopic techniques. With proper patient selection, the results have been excellent for resolving the frequency and quality of bowel movements. However, symptoms such as bloating and abdominal pain, which may be related to irritable bowel syndrome rather than the colonic inertia, may persist.

Right colon to rectal anastomosis (Deloyers procedure) as a salvage technique for low colorectal or coloanal anastomosis: postoperative and long-term outcomes

BACKGROUND

After extended left colectomy, it may be difficult to take down a well-vascularized colon into the pelvis and perform a tension-free colorectal or coloanal anastomosis. The Deloyers procedure comprising complete mobilization and rotation of the right colon while maintaining the ileocolic artery may be used in this circumstance.

OBJECTIVE

The aim of this study is to report postoperative and long-term outcomes after the Deloyers procedure as a salvage technique for colorectal anastomosis or coloanal anastomosis.

DESIGN

From a prospective database, we retrospectively reviewed all patients who underwent a Deloyers procedure.

SETTING

This study was conducted at the Colorectal Unit in a tertiary referral teaching hospital.

PATIENTS

Between 1998 and 2011, 48 consecutive patients underwent a Deloyers procedure. Indications were as following: Hartmann reversal (n = 17), previous colorectal anastomosis-related complications (n = 11), diverticular disease (n = 6), left colon cancer (n = 6), ischemic colitis (n = 3), iterative colectomy for cancer (n = 3), rectal cancer local recurrence (n = 1), and synchronous colon cancer (n = 1).

RESULTS

There were 38 men and 10 women (median age at surgery, 67 years). Colorectal anastomosis and coloanal anastomosis were performed in 38 and 10 patients. Thirty-one patients had defunctioning stoma. Mortality and early morbidity rate was 2% and 23%. Three patients (6%) had severe complications (Dindo ≥ 3). There was no anastomotic leakage. Reoperation was required in 2 patients for intra-abdominal hemorrhage. The median hospital stay was 12 days. The median follow-up was 26 months. All patients had their ileostomy closed. Twenty-three percent of patients developed late complications. The median number of bowel movements per day was 3 (range, 1-7), but 67% of patients had fewer than 3. One patient required an ileostomy refashioning because of poor functional results, and 23% of patients routinely take loperamide-based medication.

LIMITATION

The retrospective nature of the study was a limitation.

CONCLUSIONS

The Deloyers procedure is safe, associated with low morbidity and good long-term functional results. It represents a safe alternative to total colectomy and ileorectal anastomosis.

Laparoscopic subtotal colectomy with antiperistaltic cecorectal anastomosis: a new step in the treatment of slow-transit constipation

BACKGROUND

Subtotal colectomy with antiperistaltic cecorectal anastomosis (SCCRA) has proved to be an effective alternative to total colectomy for the treatment of severe slow-transit constipation. The laparoscopic approach has made this procedure even more attractive. This is the first controlled trial on laparoscopic SCCRA. The study compares the laparoscopic and the open approach.

METHODS

Since 2001, all SCCRAs have been performed laparoscopically at our institution. Only severely symptomatic patients are offered surgery, after stringent patient selection. Laparoscopic SCCRA was performed following the same steps that we first described for the open approach, by utilizing a five-trocar technique. Outcome parameters were prospectively collected every 3 and 6 months. Wexner constipation and incontinence scales (WCS, WI) and gastrointestinal quality of life index (GIQLI) were adopted for functional results. We conducted a case-control study of 15 consecutive patients who underwent laparoscopic SCCRA (VL) and 15 patients previously operated on by the open approach (Op) to compare postoperative and functional outcomes.

RESULTS

The VL group had better postoperative outcomes (pain, ileus) while complication rates were similar. Resolution of constipation was impressive in both groups, with no significant difference at follow-up. The VL group presented with a higher number of bowel movements at 3 months (3.8 vs. 2.8, p = 0.039), resulting in a significantly higher incontinence rate at 3 months (WI 6.4 vs. 2.73, p = 0.004), although the difference was no longer significant at 1-year follow-up. The quality of life was good for both groups; the VL group showed a significant improvement at 1-year follow-up (64.18 vs. 114.79, p < 0.01).

CONCLUSIONS

Laparoscopic SCCRA confirmed the good functional results of the open approach, with no increase in morbidity rate and a faster postoperative recovery. An early higher incontinence rate did not affect quality of life.

A transanal procedure using an endoscopic linear stapler for obstructed defecation syndrome: the first Chinese experience

BACKGROUND

Transanal surgery using an endoscopic linear stapler is a recognized, but not widely performed technique for the treatment of obstructed defecation syndrome (ODS). A study of consecutive patients was conducted to evaluate the safety and effectiveness of the technique for the treatment of ODS in Chinese patients.

METHODS

From November 2008 to December 2010, 43 female patients with ODS caused by rectocele and/or rectal intussusception underwent transanal surgery using an endoscopic linear stapler in three Chinese hospitals. Clinical and functional data including the Wexner constipation score and outcome classification were analyzed retrospectively.

RESULTS

The average duration of surgery was 23 ± 4 min (range 15-30 min). Blood loss was 10 ± 2 ml (range 5-15 ml). The average postoperative hospital stay was 5 days (range 4-6 days). The pathologic findings showed that the specimen contained rectal muscle in all patients. Postoperative complications included 4 patients with transient fecal urgency, 3 patients with anorectal pain, and one patient with mild bleeding from the stapled suture line. Three patients reported minor fecal incontinence (Wexner score less than 3). During a median follow-up of 12 months (range, 3-26 months), the mean constipation score improved from preoperative 13.56 to postoperative 5.07 at 1 year (P < 0.05). The outcome at 1 year was excellent in 18 of 43 patients, good in 13, fairly good in 7, and poor in 5. Postoperative defecography was performed in 28 patients. Rectocele disappeared in 15 patients. Rectocele depth was reduced from 34 ± 4 mm preoperatively to 17 ± 3 mm postoperatively (P < 0.05).

CONCLUSION

The transanal procedure using an endoscopic linear stapler is an easy, safe, and effective option for selected patients with ODS. Long-term prospective, randomized, controlled studies are needed to confirm the advantages of this procedure in comparison with the traditional transanal and stapled transanal rectal resection (STARR) techniques.

Retrospective series of subtotal colonic bypass and antiperistaltic cecoproctostomy for the treatment of slow-transit constipation

PURPOSE

Some popular surgical methods with big trauma to treat slow-transit constipation (STC) at present are far from satisfactory. This work is aimed to evaluate the clinical and functional outcomes of a redesigned procedure of subtotal colonic bypass and antiperistaltic cecoproctostomy (SCBAC) for the treatment of STC.

METHODS

The clinical data of 18 patients with severe idiopathic STC treated with SCBAC between September 2003 and September 2008 were retrospectively analyzed. The last eight patients accepted SCBAC were assessed by short form-36 (SF-36) scores translated into Chinese to inquire upon the quality of life before and 6 months after operation.

RESULTS

There were no procedure-related deaths in this series (mortality, 0%) or any serious complication. The average follow-up period was 17 months (range, 6-60 months). There was no intestinal occlusion due to adhesions that required surgery in all these patients. Scores for all SF-36 subscales were significantly higher for patients after operation than for before operation. A high number of patients (83%) expressed a willingness to repeat the procedure given the same preoperative conditions.

CONCLUSION

Our clinical practice demonstrates that the procedure of SCBAC is effective for the treatment of severe idiopathic STC in some cases. Due to its mild trauma and less operating time, SCBAC is almost well-tolerated and compatible in all age groups, making it worthy of further practice and investigation.