(i) Colonic resection for STC has a history of nearly 100 years and is recognized as an effective treatment.
Ockenmann C synthesized the results of 408 colon resections for STC in the literature, and the success rate was high. Colon resection is not an etiologic treatment, but an invasive symptomatic treatment, and still has a certain failure rate, so first of all, it is necessary to strictly control the indications for surgery:
①Severe STC (stool <2 times/week) with a duration of at least 2 years and failure of strict non-surgical treatment for more than 1 year.
②Excluding constipation due to secondary and organic pathology.
(iii) there is definite evidence of colonic atelectasis and good anal canal tone.
(iv) A comprehensive psychological and psychiatric assessment of the patient must be performed before surgery to exclude mental or psychological constipation; (v) The patient himself has a strong desire for surgery.
(ii) Choice of surgical modality.
The current surgical modalities for the treatment of slow transmission type constipation of the colon are as follows.
1, total colectomy, ileorectal anastomosis: is the classic foreign treatment of STC, advocates mainly believe that this procedure can achieve the highest rate of improvement of constipation, but there are certain complications. Surgical results: 46% of good results, 19% of improvement, 35% of ineffective; 80% of abdominal distension, 40% of postoperative abdominal pain; 38% of diarrhea, 14% of fecal incontinence; adhesional intestinal obstruction can be as high as 50%.
2. Subtotal colectomy: It is suitable for patients with STC who have only colonic transmission disorder, and the ascending colon is removed to the middle and upper rectum, and cecum (or ascending colon) rectal anastomosis is performed. Pluta et al [4] reported an efficiency of 70% to 90% and a 10% recurrence rate after surgery. The recurrence cases were precisely due to the retention of the cecum, and the constipation recurred due to the dysfunction of the cecum, and the constipation was resolved after reoperation to remove the cecum. If intraoperative exploration reveals significant dilatation, thinning and reduced peristalsis of the terminal ileum, partial ileal resection should be performed at the same time. The extent of ileal resection should not exceed 1 m, otherwise there is a risk of severe diarrhea.
3, partial colectomy: most scholars believe that the recurrence rate of postoperative constipation is high and the efficacy is poor, so this surgical procedure is less used.
4.Total colectomy: The entire large intestine is removed from the end of the ileum to the dentate line, and the intestinal reconstruction methods include ileostomy, ileoanal anastomosis and ileal J-Pouch anastomosis. Ileostomy has many complications and is only used for a short period of time when complications such as anastomotic leakage occur; ileoanal anastomosis is rarely used in China, and foreign literature reports that 20% to 35% of patients have diarrhea or anal incontinence after surgery, requiring long-term antidiarrheal agents to control defecation; ileal storage pouch anastomosis for bowel reconstruction is highly traumatic, complicated and has many complications, and is not used as a routine treatment for constipation. Only limited to total colectomy ileorectal anastomosis unsatisfactory or surgical failure when applied.
5, colonic open, cecum rectal retroperistaltic end-lateral anastomosis: simple surgery, less traumatic, mostly used in the elderly and frail, can not tolerate major surgery.
Surgical method: After entering the abdomen, free the ileocecal part and part of the ascending colon appropriately, so that the ileocecal part can be moved down to the pelvic cavity, 7-10 cm above the ileocecal union, the ascending colon is closed with the gastrointestinal linear closure device switch without cutting off the ascending colon, separating the mesentery, removing the appendix, placing the anastomotic nail holder (head end) in the cecum from the tip of the ileocecal flap, dilating the anus and placing the anastomotic body through the anus, about 5-8 cm from the peritoneal reflexion, as the anastomosis. ～When the anastomosis is tightened, the cecum is drawn into the pelvic cavity, and the bottom of the cecum and the right anterior lateral wall of the rectum are anastomosed with the anastomosis to complete the end-lateral anastomosis of the cecum and rectum, and the abdominal cavity is flushed and a drainage tube is placed in the pelvic cavity.
6.Subtotal colectomy reverse peristaltic cecum-rectal anastomosis: founded by Italian scholar Sarli in 1992 and used in clinical practice. The main advantages of this procedure are.
(i) Preservation of the ileocecal part and the ileocecal flap, guaranteeing the absorption of water, electrolytes, bile salts and vitamin B12, preventing the reflux of the cecum contents and improving the postoperative diarrhea symptoms.
②Preservation of the cecum and part of the ascending colon can play a role similar to that of a fecal storage pouch, which has a buffering effect on defecation.
③Easy to operate and reliable therapeutic effect.
④Since only the ileocecal part is lightly freed, the abdominal cavity is less disturbed, the surgical trauma is very mild, the postoperative recovery is fast, the complications are low, and the clinical results are satisfactory. However, its efficacy also needs to be tested in a large sample of cases, and there is no definite conclusion on what changes will occur after long-term colonic absences.
7.Modified Duhamel procedure: The procedure is performed under general anesthesia, in a lithotomy position, with a median abdominal incision to free the right hemicocele, transverse colon, descending colon and sigmoid colon, and the right ascending colon is preserved for about 10 cm, and the appendix is removed. The rectum was separated posteriorly to the level of the anal levator muscle. The free ascending colon was rotated counterclockwise, and after dilation, a tubular anastomosis was placed in the anus, and the posterior wall of the rectum was penetrated at the level of the internal rectal sphincter to perform an end-lateral anastomosis with the ascending colon, and a linear cutting anastomosis was placed through the anus, and the rectum was cut and anastomosed laterally with the ascending colon to complete the modified Duhamel procedure. The lateral anastomosis between the rectum and ascending colon should be maintained at 7-8 cm. with mild rectal protrusion and pelvic floor hernia, another pelvic floor elevation is performed.
Advantages: the modified Duhamel procedure combined with subtotal colectomy corrects the slow transmission and outlet obstruction of the colon, shortens the transmission time, and changes the perirectal structure; the ascending colon with good peristalsis replaces the function of the rectum, so that the anorectal angle is no longer reduced during defecation, and the uncoordinated contraction of the sphincter muscle no longer affects the fecal discharge; postoperative pelvic floor adhesions restrict the pelvic floor descent; this procedure The ileocecal valve is preserved, which reduces the stimulation of the rectal mucosa by digestive juices; the establishment of colonic storage pouch increases the volume of feces, which is conducive to improving fecal traits; the lateral anastomosis of ascending colon and rectum has a wider anastomosis, and the anastomotic stenosis is less likely to occur after surgery.
8, laparoscopic surgery: In recent years, with the development of minimally invasive surgery, the above-mentioned operations can be successfully implemented under laparoscopy, which has the advantages of fast postoperative recovery, small surgical scar, low incidence of postoperative adhesive intestinal obstruction, etc., and is worth promoting.
(iii) Postoperative complications.
(1) Intestinal obstruction: foreign literature reports that the incidence of small bowel obstruction is 8%-44%, most of which can be relieved by conservative treatment; preserving as much of the greater omentum as possible during surgery helps to reduce the occurrence of adhesive intestinal obstruction. In addition, thorough intraoperative hemostasis, reducing the number of traumatic separation and ligation, and preserving the rectum above the reflexion all have certain preventive significance.
2, postoperative diarrhea: more common, its incidence is about 30%, mostly in patients undergoing total colectomy, diarrhea can be more serious, but most of them can be controlled by taking antidiarrheal drugs.
Constipation: its incidence is 10% to 21%, mostly seen in patients with partial and subtotal colectomy, and the symptoms can be relieved after changing the operation to total colectomy with ileorectal anastomosis. For a small number of patients with recurrent constipation even after total colectomy, if conservative treatment is not effective, rectal resection, ileostomy or ileoanal anastomosis can be chosen.