Chronic transport constipation (STC) is a kind of chronic and persistent constipation, which is caused by multiple causes of intestinal motility dysfunction and delayed intestinal content transmission, with chronic, primary and functional characteristics. The cause of constipation is not yet fully understood, and the main clinical manifestations are low frequency of stool, no peristaltic sensation, no bloating and no bowel movement, and only the symptoms of bloating and inability to eat due to long-term non-defecation, which seriously affect the quality of life of modern people. Slow transmission type constipation is a more difficult to treat chronic intestinal diseases, the treatment of slow transmission type constipation in the past to conservative medical treatment, but conservative treatment can only temporarily relieve the symptoms, often difficult to cure, and may even cause the aggravation of symptoms or other complications, the long-term results are not satisfactory. In recent years, surgical procedures have gradually achieved remarkable results in the treatment of slow-transport constipation. In recent years, our hospital has adopted surgical treatment for constipation patients clearly diagnosed as slow-transmission type by colon transport test and fecal imaging, and achieved satisfactory results, and the recent status of diagnosis and treatment of STC is summarized below.
1, the diagnosis of slow-transmission constipation.
Systematic examination of patients is required to gradually clarify whether chronic, primary, functional, slow-transmission constipation is present. Diagnostic criteria for patients with slow-transmission constipation refer to the Interim Criteria for the Diagnosis and Treatment of Constipation developed by the editorial board of the Chinese Medical Journal. Those who met the following criteria were included for observation.
(1) Abnormal colonic transport test, 72h colonic emptying rate less than 80%, markers scattered in each colon;
(2) Exclusion of outlet obstruction and abnormal colonic morphology by fecal imaging;
(3) Exclude constipation due to organic lesions and major abdominal surgery;
(4) Dry stools and effortful evacuation;
(5) Prolonged intervals between bowel movements;
(6) Duration of the disease is more than 6 months.
A simple method to determine slow-transmission constipation is the colonic transit test, in which the subject abstains from taking laxatives and other medications that affect bowel function from 3 days prior to the test. One capsule containing 20 markers is taken on the day of the test, and one abdominal radiograph is taken every 24 hours until 80% of the markers are excreted (maximum of 5 abdominal radiographs; the number of radiographs should be reduced in unmarried women). Observe the distribution of markers to determine the presence of slow-transmission constipation is very helpful.
2.Treatment of slow-transmission constipation
The diagnosis and treatment of slow-transmission constipation has attracted widespread attention in society, and the clinical diagnosis and treatment level of constipation and basic research in China are constantly improving. Currently used in the treatment of constipation of Western medicine can be divided into stimulant laxatives, solvent laxatives, osmotic laxatives and lubricating laxatives. It is mainly symptomatic treatment, and the effect is not ideal.
①General treatment: For patients with chronic constipation, eliminate doubts, establish confidence, and should adjust lifestyle, such as maintaining daily activities, leaving ample time for defecation, adhering to regular bowel habits, and not missing bowel movements. Psychological support, increasing dietary fiber and encouraging more water intake can avoid dry stools due to excessive absorption of water and salt by the colon.
②Volumetric: It is a non-starchy polysaccharide concentrate and is suitable for patients who do not consume enough dietary fiber. Non-absorbable sugars and polysaccharide alcohols: such as lactose and lactitol, both synthetic disaccharides, are not absorbed by the small intestine.
③Salt laxatives: such as sodium sulfate, magnesium hydroxide, magnesium raffinate or magnesium sulfate, the laxative mechanism is mainly osmotic effect.
④Anthracenes: such as senna, aloe vera, Myrica fragrans bark and Frangipani bark are plant derivatives with many similarities. These compounds are inactive glycosides, which are not absorbed or changed when they pass through the small intestine, but are hydrolyzed into active molecules by bacterial glycosidases when they enter the colon and exert laxative effects. The laxative effect of anthracene laxatives has been confirmed and is not harmful to the body when applied in proper doses, and its effect is rapid, especially as a temporary single dose of laxative effect, and can be applied to any situation. Patients with chronic constipation can try the method twice a week, but the efficacy may vary greatly between individuals.
⑤ Polyphenolic (diphenylmethane) compounds: including phenolphthalein, bisacodyl and sodium bisulfate are still in use.
(6) Decontamination agent: dioctyl sodium sulfosulfosuccinate as a stool softener, the efficacy of which needs further study.
(7) liquid paraffin: a mineral oil, can soften the stool, its emulsion is widely used in clinical practice.
(8) Prokinetic drugs: controlled studies have shown that cisapride can reduce the dosage of light laxatives when combined with other light laxatives, and can continue to play an improving role when cisapride is discontinued. However, there is no evidence to date that cisapride can be used as a routine treatment for constipation.
(2) Other treatments: non-absorbable liquids used as colonic irrigation agents, such as polyethylene glycol 4000, are used clinically as laxatives to achieve better results. Moreover, its electrolyte-containing solution can be used as intestinal cleanser. In addition, there are also methods to change intestinal bacteria, enemas, anal suppositories and behavioral therapy.
(3) Chinese medicine treatment: This disease belongs to the category of “constipation” in Chinese medicine, and its causes are mostly due to heat, Qi stagnation, cold condensation and deficiency of Qi, blood and fluid resulting in abnormal large intestine conduction function. The use of Chinese medicine comprehensive therapy dialectical analysis of symptomatic treatment of slow transmission type constipation, the efficacy is remarkable.
(4) Surgical treatment
(1) Total colectomy ileorectal anastomosis.
②Sub-total resection of colon and ascending rectal anastomosis. The efficacy is not lower than that of total colectomy ileorectal anastomosis, but the incidence of postoperative diarrhea is significantly reduced because the ileocecal flap is preserved.
(iii) Colonic open-heart surgery. The operation is less traumatic and has quick recovery, but there are problems of severe fecal reflux from the open colon, significant abdominal distension and pain, and the need for regular colonic hydrotherapy for evacuation.
④ Partial colectomy. Preoperative barium enema and colonic transport test clarified that the slow transmission site of the colon was located in the descending colon and sigmoid colon, and good results were achieved by performing left hemicolectomy.
⑤ Under laparoscopic subtotal colectomy, the patient recovered quickly after surgery and the surgical bruises were small, which is worth promoting when the conditions allow.
3.Summary
Defecation is a complex physiological process, which is related to diet, living habits and mental condition, etc. STC may be caused by total colon, segmental colon or accompanied by slow transmission of small intestine. The root cause of slow-transmission constipation lies in the weakening of colonic dynamics, and drug treatment is effective in the short term but cannot cure it. Through long time clinical observation and exploration, Wu Xiansheng and Ma Longan [3] concluded that patients should have the following conditions before surgical treatment.
(i) The diagnosis is confirmed by two or more colonic transmission tests;
②Patients require surgery after more than 6 months of ineffective or poor results of systematic conservative treatment;
③ fiberoptic colonoscopy to exclude organic lesions;
④Barium enema angiography has the basis of colonic dystrophy;
⑤ Normal peristaltic function of small intestine;
(6) Exclude outlet obstructive constipation and constipated irritable bowel syndrome. The classic procedure for chronic transmission constipation is total colectomy and ileo-rectal anastomosis, which is most frequently reported in the domestic and foreign literature, with an efficacy of 50-100%, but about 30% of patients have intractable diarrhea and 10% of patients have recurrent constipation. In recent years, when performing colectomy in patients with slow-transmission constipation for which conservative treatment is ineffective, a new surgical method has been designed to address the problem of diarrhea complications after total colectomy, namely: subtotal colectomy and anastomosis of the cecum or ascending colon and rectum; or left hemicolectomy and distal anastomosis of the transverse and sigmoid colon; both procedures preserve part of the colon and effectively prevent the appearance of recalcitrant diarrhea. Postoperative stools are mostly 2 to 3 times a day, which prevents recurrence and provides better bowel control. Mastering the indications for surgery, both procedures are effective and are the main surgical modality for the treatment of slow-transmission colonic constipation.
In conclusion, slow-transmission constipation is an organic lesion with reduced and degenerated colon plexus cells; it is clearly diagnosed by fecal imaging and whole bowel transmission time examination, and in patients with slow-transmission constipation for whom conservative treatment is ineffective, adequate resection of the diseased colon and preservation of part of the remaining functional colon can effectively treat constipation and effectively prevent the occurrence of diarrheal complications. However, some patients still have poor postoperative results, so the long-term efficacy of surgery and the extent of surgical resection for slow-transmission constipation need to be further discussed.