(Baotou Poverty Alleviation Hospital, Baotou, Inner Mongolia 014060)
The clinical manifestations of patients with intractable constipation are variable and recurrent, and there are large individual differences. Since the pathophysiological factors associated with IBS are multifaceted, the complex clinical symptoms cannot be explained by a single pathophysiological mechanism, and an effective treatment plan has not yet been found, and there is still no drug that is completely effective in the treatment of patients with chronic constipation. The treatment should be individualized according to the severity of the patient’s symptoms, the frequency of attacks and the type of symptoms. The choice of treatment methods and medications should be individualized and symptomatic. Xu Liyang, Department of Surgery, Baotou Poverty Alleviation Hospital
I. Psychological treatment
Psychosocial factors play a role in the pathogenesis of chronic constipation and are non-negligible factors leading to the triggering, aggravation and persistence of symptoms. Therefore, the use of psychological-behavioral interventions is an adjunct to treatment. Psychological treatment is a treatment method that uses psychological theories and techniques to change patients’ incorrect cognitive activities and improve their psychosomatic disorders and abnormal behaviors by means of language, expressions, and demeanor and behavior. Psychological treatment requires doctors to follow scientific principles and compassionately correct patients’ poor cognition and coping strategies, help patients understand the benign nature of their illness, establish correct cognition of the illness, improve patients’ ability to cope and tolerate emergency events related to symptom onset, and improve patients’ quality of life. Cognitive therapy with the goal of rebuilding correct cognition should be targeted and should be used as the basis for pharmacological treatment and other therapeutic measures.
II. Diet therapy
The prevalence of individual differences in complex reactions to meals suggests that those patients with a significant relationship to food intolerance should be carefully evaluated for the choice of diet type and avoid foods that cause them gastrointestinal discomfort as much as possible. Previously, it was considered that the recommendation to increase the fiber content of the diet, from the literature found this condition, adjusting the intake of fiber and the intake of adequate amounts of fluids. If excessive gas production is the main symptom should develop a diet that reduces gas production, such as foods such as cabbage and beans.
Third, drug treatment
The treatment drugs mainly include the regulation of intestinal motor function, correction of visceral sensory abnormalities and improvement of central emotion drugs, the specific medication is described separately.
Fourth, surgical treatment
Surgical treatment of constipation has a history of more than 100 years, but the real need for surgical treatment belongs to the minority. And surgical treatment has a certain recurrence rate. It is generally believed that surgery is only considered when strict non-surgical treatment is ineffective, the symptoms seriously affect the patient’s life and work, and the patient has a strong demand for surgery.
In the application of colectomy to treat colonic transmission disorder type constipation, the indications for surgery should be strictly grasped: (1) the colon is really inert and there is conclusive evidence of delayed passage; (2) there is no evidence of outlet obstruction; (3) the anal canal function is normal; (4) there are no obvious symptoms of anxiety, irritability and depression and other psychological disorders; (5) there are no signs of total gastrointestinal tract dysmotility.
The choice of surgical modality and its efficacy are as follows.
1, total colectomy, ileorectal anastomosis The procedure is a common surgical modality for the treatment of colonic transmission disorder type constipation, and the efficiency is generally between 50% and 100%, with an average of about 83%. The most common complication is small bowel obstruction, with an average incidence of 12%; about 10% of constipation symptoms recur after surgery; about 1/3 of the patients have uncontrollable diarrhea; some patients also have abdominal pain, abdominal distension and fecal incontinence after surgery.
2, total colectomy, ileal storage pouch anastomosis Colon transmission disorder type constipation patients with intestinal transmission dysfunction may spread to the rectum, causing rectal emptying dysfunction, total colectomy, ileal storage pouch anastomosis should be performed, the average efficiency is about 80%. So far, the number of cases in which this procedure is applied to treat colonic transmission disorder type constipation is still few, and there is no long-term follow-up data; in addition, the operation can be complicated by anastomotic stricture, anastomotic fistula, and even fecal incontinence, etc. Some patients eventually have to undergo permanent ileostomy, so it should be applied with caution.
3, partial colectomy part of the colon transmission disorder constipation patients with slowed intestinal transmission is limited to the local colon, especially the left hemicolectomy, removal of the affected intestinal segment to treat colon transmission disorder constipation, the scope of removal should exceed the affected intestinal segment to ensure that the ganglion and lesioned intestinal segments are all removed, the average efficiency is 69%. The efficiency is 69% on average. The complications of surgery are less, but the constipation is easy to recur after surgery.
4, total colectomy, cecum-rectal anastomosis Some patients with colonic transmission disorder constipation often have uncontrollable diarrhea after performing total colectomy, for this reason, patients with colonic transmission disorder constipation perform total colectomy, cecum-rectal anastomosis, the ileocecal flap should be preserved to reduce the occurrence of diarrhea; this procedure is only considered when the function of cecum, ascending colon and rectum are normal.
This method has the advantages of simple operation, small trauma, fast postoperative recovery, and low complication rate, but there is no definite conclusion on the significance of the open colon with neuromuscular lesions, the long-term changes of the open colon, and the possible delay in diagnosis if other diseases appear. This procedure needs further observation.
6.Modified open colon surgery Parallel suture between cecum and sigmoid colon (or rectum) and 3 anti-reflux mucosal flaps are sewn above the anastomosis, which solves the problem of easy fecal reflux in open colon surgery.
7.Ileostomy This procedure has the greatest functional destruction and the worst postoperative quality of life, which is generally unacceptable and is not used in principle.
At present, the treatment of “outlet obstruction type constipation” is more reported at home and abroad, such as: puborectalis syndrome (PRS) refers to the behavioral disorder of abnormal contraction or failure to relax the puborectalis muscle during defecation, which is easy to diagnose but difficult to treat. Botulinum toxin (BTX) was ineffective for biofeedback treatment, and 30 U of botulinum toxin A (BTX-A) was injected into the abnormally contracted puborectalis muscle bilaterally under ultrasound guidance. The number of spontaneous bowel movements increased from 0 to 6 per week after treatment. There was significant symptomatic improvement, which did not cause overkill or permanent sphincter damage, but reduced abnormal contractions of the puborectalis muscle and restored normal bowel function. However, since the toxin loses its effectiveness in 3 months, the injection must be repeated to maintain the efficacy. Commonly used surgical procedures for puborectalis spasticity syndrome include posterior cut of the puborectalis muscle and autografting of the internal muscle of the closed foramen. The near-term results are satisfactory, with immediate postoperative relief of constipation, but the long-term results are not so good in a few patients. The treatment of anterior rectal bulge rectal bulge repair is carried out more often, and although there are various surgical methods, the efficacy is similar and there seems to be little debate. In recent years, the development of PPH surgery has provided a new method for the treatment of anterior rectal distension and endorectal prolapse, which has been reported both at home and abroad, but there is a lack of long-term outcome follow-up.
It is noteworthy that many scholars have questioned the surgical treatment of constipation. In particular, some of the patients treated surgically have had insignificant or even ineffective symptom relief, and individual patients have had their symptoms worsened after surgery, which has confused many surgeons. With the development of science and technology, standardize the diagnosis and treatment in order to achieve reasonable examination and treatment and rational use of health resources.
Author:Xu Liyang, August 1958, Male, Baotou, B.S., University
Title: Chief Physician
Director of Baotou Anorectal Disease Society.
Speciality: treatment of tumor and anorectal diseases.
Phone：13848282518