Chronic constipation is a disease that seriously disturbs the physical and mental health of human beings, and with the continuous development of economy and society, its incidence is increasing year by year. A survey in Beijing, Tianjin and Xi’an regions of China on elderly people over 60 years of age showed that chronic constipation was as high as 15% – 20%. A randomized, stratified and graded survey of adults aged 18–70 years in Beijing showed that the prevalence of chronic constipation was 6.07%, with women being more than 4 times that of men. The etiology of chronic constipation is complex, and it is related to various factors such as lifestyle, dietary habits, psychosomatic, drug use and somatic organic diseases, etc. Among them, constipation without obvious organic lesions or secondary to metabolic diseases, systemic diseases or drug factors and characterized by functional changes is called functional constipation, and functional constipation accounts for more than half of the patients with constipation. Li Yuanxin, Department of General Surgery, 309th PLA Hospital
I. Diagnostic criteria of chronic functional constipation.
In the summer of 2006, the International Rome Collaborative Committee issued a series of diagnostic criteria for Rome III functional gastrointestinal diseases on the basis of Rome II. Functional constipation refers to persistent difficulty in defecation, reduction in the number of stools or a sense of incomplete defecation, and the intestinal tract itself and systemic organic causes and their factors need to be excluded:.
Rome III criteria for functional constipation.
1. 2 or more of the following must be met:
a . Stressful bowel movements (at least 1 in 4 bowel movements); b. Lumpy or hard bowel movements (at least 1 in 4 bowel movements); c. A feeling of incomplete defecation (at least 1 in 4 bowel movements); d . Anorectal obstruction and/or blockage (at least 1 in 4 bowel movements); e . Need for manual manipulation (e.g., finger-assisted defecation, pelvic floor support for defecation) to facilitate defecation (at least 1 out of every 4 defecations): f . Defecation less than 3 times per week.
2. little to no loose stools without laxatives.
3. Insufficient conditions for the diagnosis of irritable bowel syndrome.
Symptoms have been present for at least 6 months prior to diagnosis, and the above criteria have been met for the last 3 months.
II. Typing and examination of chronic functional constipation
Chronic functional constipation is divided into 3 categories according to the pathophysiological mechanism of defecation kinetics: (1) slow-transmission colonic constipation, or slow-motion constipation, mostly associated with tortuous, redundant and coiled deformities of some colon segments, congenital or acquired reduction or absence of ganglion cells in the intestinal wall; (2) functional outlet obstruction type constipation, mostly caused by anomalies in the anus and rectum anatomical structure resulting in the loss of coordination of the internal and external rectal sphincter and (2) functional outlet obstruction constipation, mostly caused by the anatomical abnormalities of the anus and rectum resulting in the loss of coordination of the internal and external rectal sphincter and defecation power disorders, such as pelvic floor loss delay syndrome and pelvic floor relaxation syndrome, etc.; (3) mixed constipation, the presence of both colonic transmission disorder and outlet obstruction, a large number of case studies found that the proportion of mixed type of long-term constipation can reach more than 99%, which is due to the mutual causation of two factors: colonic transmission disorder and outlet obstruction, easily forming a vicious circle.
The main tests for chronic functional constipation are.
1. metabolic and biochemical tests to rule out constipation caused by systemic metabolism and other diseases.
2. electronic colonoscopy or barium enema to exclude organic lesions of the colon. 3.
3. colonic transmission test: commonly used impermeable X-ray markers, swallowed with a test meal containing 20 markers at breakfast, after a certain time interval (for example, 24h, 48h, 72h after taking the markers), an abdominal film is taken to calculate the rate of elimination. Under normal circumstances, most of the markers were excreted by 48-72 h after taking the markers. According to the distribution of the markers on the abdominal film, it is a simple and feasible method to assess whether the constipation is of slow transmission type or outlet obstruction type.
Anorectal manometry: commonly used perfusion manometry to detect the resting pressure of the anal sphincter, the systolic pressure of the external anal sphincter and the relaxation pressure during force discharge, the presence of anorectal inhibition reflex after intrarectal gas injection, and also to determine the perception function of the rectum and the compliance of the rectal wall. It is also useful to evaluate the anal sphincter and rectum for power and sensory dysfunction.
5. Colonic pressure monitoring:A transducer is placed into the colon and colonic pressure changes are monitored continuously for 24-48h under relatively physiological conditions. It is useful to determine the presence or absence of colonic weakness and to guide the treatment.
6. balloon expulsion test (BET): A balloon is placed in the rectum, inflated or filled with water, and the subject is made to expel it. It can be used as a screening test for the presence of expulsion disorder, and further examination is needed for positive patients.
7. barium defecography BD: simulated stool is instilled into the rectum, and the functional changes of the anus and rectum during defecation are dynamically observed under radiation, which can be used to understand whether the patient has concomitant anatomical abnormalities, such as anterior rectal distension and intestinal overturning.
8. Other: such as pelvic floor electromyography, which can help clarify whether the lesion is myogenic. Pubic nerve latency measurement can show the presence of nerve conduction abnormalities. Anal ultrasound endoscopy can understand whether the anal sphincter is defective, etc.
III. Comprehensive treatment of chronic functional constipation
The causes of chronic functional constipation are complex and require comprehensive treatment combining multiple modalities, and individualized treatment for different patients in order to obtain satisfactory results.
1. General treatment: including lifestyle modification, improvement of diet structure and proper exercise.
(1) Lifestyle adjustment: develop the habit of regular bowel movement, quit smoking and alcohol, and avoid drug abuse.
(2) Promote a balanced diet, increase dietary fiber in appropriate amounts, and drink more water.
a. High-fiber diet: Dietary fiber itself is not absorbed and can absorb water in the intestinal cavity, thus increasing stool volume, stimulating the colon and enhancing power. Foods rich in dietary fiber include wheat bran or brown rice, vegetables, pectin-rich fruits such as mangoes and bananas, etc.
b.Appropriate amount of water: drink more water, so that the intestinal tract to maintain sufficient water, conducive to fecal discharge.
c. Adequate amount of B vitamins: using foods rich in B vitamins can promote the secretion of digestive juices, maintain and promote intestinal peristalsis, which is conducive to bowel movements. Such as coarse grains, yeast, beans and their products, spinach, cabbage contains a large amount of folic acid, has a good laxative effect.
d. Increase easy gas-producing food: eat more easy gas-producing food, promote intestinal peristalsis to speed up, conducive to defecation; such as onions, radish, garlic, etc.
e. Increase the supply of fat: appropriate to increase the high-fat food, vegetable oil can directly laxative, and decomposition products fatty acids have stimulated intestinal peristalsis. Seed kernels of dried fruits (such as walnut kernels, pine nuts, various melon seeds, almonds, peach kernels, etc.), which contain a large amount of oil, has the effect of lubricating the intestinal tract and laxative.
(3) Proper and correct exercise Mainly to enhance the strength of the abdominal and pelvic muscles. Standing position can do in situ high leg walk, deep squatting and standing, abdominal and back exercises, kicking exercises and turning exercises. Supine position, can take turns to lift a leg or lift both legs at the same time, lift to 40 °, a short pause and then put down. Take turns flexing and extending both legs to imitate the bicycle movement. Lift both legs in a circle from the inside out as well as sit-ups. Brisk walking and jogging can promote intestinal peristalsis and help relieve constipation. Deep and long abdominal breathing can promote gastrointestinal motility. Abdominal self-massage: lie on your back, bend your knees, rub your hands together, put your left hand flat on your belly button, put your right hand on the back of your left hand, take your belly button as the center, and press clockwise. Do this 2 to 3 times a day for 5 to 10 minutes each time.
2. Drug treatment
(1) pro-gastrointestinal drugs: such as mosapride has a pro-gastrointestinal dynamic effect.
(2) laxatives, mainly.
Volumetric laxatives: magnesium sulfate, sodium sulfate, methylcellulose, agar, etc.
Stimulant laxatives: senna, castor oil, diethylstilbestrol, etc.
Fecal softeners: liquid paraffin, lactulose, etc.
Intra-rectal administration: glycerin suppositories, open syringes, etc.
3. Biofeedback therapy: Biofeedback therapy is the use of specialized equipment to collect information on their own physiological activities to be processed, amplified, and displayed with familiar visual or auditory signals, so that the cerebral cortex and these organs to establish feedback links, through continuous positive and negative attempts to learn to control physiological activities at will, and to correct physiological activities that deviate from the normal range, so that patients achieve The purpose of “changing oneself”. It may be effective for constipation with rectoanal and pelvic floor muscle dysfunction.
4. Cognitive therapy Cognitive therapy is suitable for patients with constipation accompanied by anxiety or even depression and other psychological factors or manifestations of the disorder, so that the patient can eliminate tension and give antidepressant and anti-anxiety treatment if necessary.
5. Surgery For patients with severe obstinate constipation, the above treatment is ineffective, the condition is serious enough to consider surgery, but the selection of surgical cases must be careful.
Indications for surgery: (1) typical clinical manifestations, more than 5 years of standard conservative treatment is ineffective. (2) Colon transmission test confirms the presence of total or segmental colon slow transmission or colonic weakness on colon manometry. (3) Routine examination to exclude organic disease of the large intestine.
The main surgical procedure is resection of the dysfunctional colon and intestinal reconstruction. Currently, total colectomy, lateral ileorectal anastomosis and subtotal colectomy, lateral anastomosis of ascending colon and rectum (Jinling’s operation) are commonly used. A large sample of case-control studies of patients with constipation who underwent jinling were better than conventional total colectomy in terms of frequency of bowel movements, incidence of diarrhea, procedural satisfaction, gastrointestinal quality of life score, Wexner constipation score, and recovery progress. With the rapid development of laparoscopic technology, in recent years, laparoscopic performing gingivectomy has become more and more mature, because of its many minimally invasive advantages of less trauma, less blood loss, faster recovery and less pain, which is favored by the majority of patients and doctors. Compared with open traditional open surgery, the time to start eating, the number of days of hospitalization and the overall complication rate of patients undergoing laparoscopic jinling are significantly lower after surgery, and patients suffer significantly less pain, while the efficacy is comparable to that of traditional open surgery. Therefore, laparoscopic minimally invasive surgical treatment is the best option for patients with chronic functional constipation if internal medical treatment is not effective.
We currently apply the minimally invasive laparoscopic jinling technique to cure many patients with persistent constipation.
Figure 1 The extent of surgical resection by Jinling operation
Figure 2 Lateral anastomosis of the posterior wall of the ascending colon and rectum by Jinling’s operation
Figure 3 Our completed laparoscopic jinling operation. The total colon and posterior wall of the rectum were completely freed laparoscopically, and the total colon was resected by dragging out through a small transverse incision in the lower abdomen. Note that the colon and rectal mesentery are intact, and the vessels of each colorectal intestinal segment have been laparoscopically clamped and cut with the application of a Hemo-lock vascular clip.