The prevalence of constipation varies widely in the literature, ranging from 2% to 10%, which may be related to the inconsistency of diagnostic criteria for constipation. Due to the high incidence and long duration of constipation, it causes great suffering to patients, seriously affecting their quality of life and imposing a heavy burden on families and society as a whole. There is a wide variety of treatments for constipation, and most patients can achieve symptomatic relief with conservative treatment, but 5% to 10% of patients still eventually require surgical treatment. Due to the lack of high-quality evidence-based medical evidence, there has been much controversy regarding surgical treatment of constipation.
1. Constipation is not a disease, but a generic term for a large group of symptoms
There are many definitions of constipation and even conflicts between some of them, and patients and physicians do not agree on the understanding of constipation. According to experts’ opinions, the American College of Gastroenterology (ACG) Chronic Constipation Working Group proposed in 2005 to use a simple broad definition of chronic constipation, which collectively refers to various bowel abnormalities such as reduced stool frequency, difficulty in passing stool, straining to pass stool, and feeling of obstruction.
In the same year, the Rome III diagnostic criteria for functional constipation were also introduced. The Rome III diagnostic criteria are the most commonly used and widely accepted diagnostic criteria for constipation, but they are also based on expert consensus rather than evidence-based medicine. The diagnostic criteria for Rome III functional constipation are as follows.
(1) Symptoms persist for more than 6 months, and two or more of the following symptoms must be satisfied in the last 3 months: (1) straining to defecate; (2) lumpy or hard stools; (3) incomplete defecation; (4) anorectal obstruction and blockage; (5) the need for hand-assisted defecation; (6) defecation less than 3 times a week.
(2) Almost no loose stools without laxatives.
(3) Insufficient for a diagnosis of irritable bowel syndrome.
As we can see from the definition of constipation, constipation is actually a generic term for a large group of symptoms, and many diseases can cause these symptoms, rather than a specific disease. Depending on the cause, constipation can be divided into two categories: secondary constipation and idiopathic (functional) constipation. The cause of constipation should be clarified as much as possible before treatment, and functional constipation can be diagnosed only after secondary constipation has been excluded. The constipation we usually refer to is functional constipation, and the discussion in this paper is also functional constipation.
2, the classification of constipation diagnosis
Since constipation contains a large class of heterogeneous diseases and causes, the classification and diagnosis of constipation can largely reduce the heterogeneity and help the study of the mechanism of constipation, the selection of treatment options and the evaluation of efficacy. Using colonic transmission tests and rectal-anal function tests, primary constipation can be classified into the following four major categories: normal transmission constipation (NTC), slow transmission constipation (STC), outlet obstruction constipation (OOC), and mixed slow transmission/outlet obstruction constipation.
The causes of outlet-obstructive constipation are complex and often multiple factors coexist, including rectopelvic floor relaxation factors (endorectal condyloma, rectal prolapse, rectal prolapse, perineal descent, pelvic floor hernia, etc.) and paradoxical anal sphincter contraction (pelvic floor spasm syndrome, puborectal muscle hypertrophy, etc.).
The percentage of these four major types of constipation reported in the literature varies widely. nyam et al. performed colonic transport tests and rectoanal function tests in 1009 patients with constipation seen at this hospital and found that NTC accounted for 59%, STC for 13%, OOC for 25% and mixed type for 3%. In contrast, Koch et al. showed that among 90 patients with constipation, NTC accounted for only 8%, STC for 27%, OOC for 59%, and mixed type for 6%.
The reason for such a large difference in the proportion of each type of constipation in the two studies is largely related to the difference in the detection methods. high positivity rate. Other studies have reported a wide variation in the percentage of each type of constipation.
This shows that the inconsistency of diagnostic methods will lead to great differences in the classification of constipation, which greatly increases the difficulty of diagnosis and treatment of constipation classification.
3, the value of various auxiliary tests in the prediction of the efficacy of constipation surgery
At present, there is no standardized colonic transport test marker production in China, and the judgment standard is not uniform among domestic units. Because of the instability and chance of colonic transport function, its accuracy is influenced by many human factors and external factors (including changes in living environment, dietary structure, cleansing enemas and the use of laxatives), so the colonic transport test has a certain degree of unreliability and chance, which is helpful in grasping the indications for surgery, but its reliability in predicting surgical outcomes is low.
Methods for testing rectal and anal canal function include rectal and anal canal manometry, balloon expulsion test, and fecal evacuation angiography. The first two methods are mainly used in the United States, while fecal radiography is mainly used in Europe. The diagnosis of outlet obstruction constipation is closely related to the test method. Patients with constipation are detected by manometry and balloon expulsion test with a positive rate of approximately 50%, with the remaining 50% being normal voiding. These two methods do not take into account whether the rectum and pelvic floor structures are altered (e.g., large anterior rectal protrusions or intrarectal loops).
In contrast, in patients with constipation detected by fecal imaging, the positive rate of impaired fecal evacuation is about 25%, and about 20% have no abnormal findings; the remaining 55% have alterations in rectal and pelvic floor anatomy that may affect defecation.
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4.Controversy and consensus on surgical treatment of constipation
Since the mid-1980s, attempts have been made to treat constipation through surgery, and many new surgical approaches have emerged, which have generally achieved some efficacy. However, the effectiveness of surgery for various types of constipation, the incidence of complications and recurrence rates vary widely in the literature. In this regard, special attention needs to be paid to the fact that although many authors report excellent results and few or no complications for their recommended surgical modalities, the results of clinical applications in other hospitals are not satisfactory, a situation that is particularly prominent in the domestic literature.
Therefore, in recent years, the treatment of chronic constipation has reverted more to non-surgical treatment, and the controversy over whether surgery should be performed and which surgical approach should be used has increasingly drawn the attention of clinical surgeons.
4.1 Choice of surgical modality for slow-transit constipation Among the various types of chronic constipation, surgical results for slow-transit constipation (STC) are relatively good. There are various surgical approaches, including simple total or partial colectomy, which can achieve the therapeutic goal by shortening the pathway of intestinal contents transit; partial colectomy with more adequate freeing of the rectum and reconstruction of the pelvic floor, which can simultaneously solve the problems of colonic weakness and outlet obstruction; and partial colectomy, freeing of the rectum posteriorly, and anastomosis of the colon with the distal rectum posteriorly.
This type of surgery is more effective in solving constipation, but it is very invasive. In addition to the high surgical complications, another tricky problem is how to grasp the length of colon resection. If the length of resection is insufficient, constipation will not be relieved and the surgery will be ineffective; if the length of resection is too long, recalcitrant diarrhea will often occur and the patient’s quality of life will be even worse. However, as of now there is no satisfactory predictor.
Total colectomy and ileorectal anastomosis are the most reported in foreign literature and the most effective procedure to improve difficult defecation, with postoperative constipation improvement rate up to 90%~100%, but the incidence of postoperative diarrhea is as high as 33.3%. Subtotal colectomy and ascending colorectal anastomosis is the most performed procedure in China, which preserves important functions such as absorption of water, bile, vitamin B12 and electrolytes because the terminal ileum and ileocecal valve are preserved.
The author’s department treated more than 100 cases with this procedure. The number of bowel movements within 6 months after surgery was 3-5 (median 4) and after 6 months after surgery was 1-5 (median 2). 90% of the patients had formed or semi-formed stools, and the results were relatively satisfactory. The key to this procedure is to preserve the appropriate length of the ascending colon and rectum. From our clinical experience, it is appropriate to preserve 5-10 cm of the ascending colon. If the length of the colon is too long, the effect of postoperative constipation treatment is not good, and if it is too short, the effect of reducing the occurrence of diarrhea is not obvious.
The extent of rectal resection should be cut to the middle and upper rectum; if it is too low, it increases the incidence of postoperative anastomotic leakage and the risk of injury to the autonomic plexus in the pelvis.
Given that most patients with intractable constipation have both pathophysiological alterations of slow colonic transport and outlet obstruction, surgical results targeting STC alone are less than optimal. Some authors have addressed the problem of outlet obstruction simultaneously by removing part of the colon while freeing the rectum and elevating and reconstructing the pelvic floor. This procedure was used in more than 80 patients with mixed constipation in our hospital to repair the combined pelvic floor hernia, sacro-rectal separation, anterior rectal protrusion and other loose pelvic floor changes in one stage, with an efficiency of 90%.
JI Wu et al. combined a modified Duhamel procedure and subtotal colectomy for the treatment of chronic intractable constipation, with a subtotal colectomy first, preserving 10 cm of the ascending colon and the rectum at the level of peritoneal reflex. A tunnel was separated along the posterior rectal wall to the level of the anal raphe, and the posterior rectal wall was punctured at the level of the internal anal sphincter. A tubular anastomosis is used to perform a transanal end-lateral anastomosis of the ascending colon and the posterior rectal wall. The anterior wall of the ascending colon is incised transversely at the level of the rectal dissection. The lower edge of the ascending colon incision is interrupted with the posterior wall of the rectal stump by sutures.
The full length of the posterior wall of the rectum is laterally anastomosed with the ascending colon through the anus using a linear lateral anastomosis. The anterior wall of the rectal stump was then interrupted with the upper edge of the transverse incision of the ascending colon. The authors’ latest report used this procedure to treat 105 cases of severe intractable constipation without complications. 94 cases had 1 to 3 bowel movements per day after surgery, only 7 cases had 4 to 6 movements per day, 4 cases had mild constipation recurrence, and there was no fecal incontinence. However, the operation is complicated and traumatic, and whether other hospitals can achieve the same excellent results needs further observation.
4.2 Surgical treatment of outlet obstructive constipation Outlet obstructive constipation can be divided into two categories: spastic and flaccid. 1964 Wasserman first reported rice with partial excision of the puborectalis muscle to treat 4 cases of pelvic floor spasticity syndrome, and 3 cases achieved success.
After that, several scholars adopted this procedure, but the surgical efficiency ranged from 24% to 83%, with poor overall results and a high risk of anal incontinence. Therefore, most scholars still recommend conservative methods (biofeedback therapy) to treat pelvic floor spasm syndrome, and the efficiency can reach more than 70% after regular biofeedback therapy, and surgery is considered only for severe conservative treatment that is ineffective.
Although there are numerous surgical procedures, including longitudinal rectal mucosal folding, sclerotherapy, transrectal or vaginal repair, anastomotic suprahemorrhoidal mucosal loop stapling (PPH), transanal anastomotic proctocolectomy (STARR), rectal suspension, rectal suspension + sigmoid surgery, rectal suspension + sigmoid surgery, rectal suspension + sigmoid surgery, rectal suspension + sigmoid surgery, rectal suspension + sigmoid surgery, rectal suspension + sigmoid surgery, rectal suspension + sigmoid surgery, rectal suspension + sigmoid surgery, rectal suspension + sigmoid surgery, rectal suspension + sigmoid surgery. (PPH), transanal anastomotic clutch proctocolectomy (STARR), rectal suspension, rectal suspension + sigmoid resection, etc., but since the procedure can address only one and two anatomical changes;
However, because surgery can address only one and two anatomical changes; and the anatomical changes lack correlation with the severity of constipation, the results of surgery, especially the long-term results, are highly variable in the literature. Although the literature reports early efficiency rates of up to 90%, long-term recurrence rates can be more than 50%.
The STARR procedure was once widely used for the treatment of endorectal loops and anterior rectal protrusions. However, the results of STARR reported in the literature vary widely, with efficiency rates ranging from 90% in the short term to 45% at 18 months. In addition, the more frequent complications of STARR include bleeding, anal incontinence, severe anal pain, rectovaginal fistula, and even fatal pelvic sepsis, and the procedure has been used less and less abroad.
4.3 Surgical treatment of slow-transmission constipation with slow gastric or small bowel motility About 52% of STC patients have both proximal GI transmission abnormalities (34% with delayed gastric emptying, 10% with slow small bowel motility, and 8% with both gastric and slow small bowel motility), and if these patients undergo colectomy, the postoperative symptoms of abdominal distension and constipation are often not relieved and the results are poor.
Therefore, it is recommended that patients with STC should undergo relevant tests before surgery. Therefore, some scholars also believe that although the surgical effect of patients with slowed gastric or small intestinal motility is poor, still for those with particularly severe symptoms, surgery can still be considered.
4.4 Other surgical treatments For patients with severe intractable constipation who have failed conservative treatment but cannot tolerate larger surgery due to old age, frailty, poor general condition, etc., ileostomy can be considered, which can significantly improve the quality of life. Defecation has also been reported to be achieved through paracolic colonic irrigation. The procedure can be done laparoscopically with minimal surgical trauma and positive results. The method is to dispose of the appendix into a myxomatous tube for appendicostomy after removal of the appendix and then lead it out of the abdominal wall.
When enucleation is performed, defecation is usually started 1 h after the enema. 12 patients with constipation were treated with this method by Rongen et al. and all had significant improvement in defecation after surgery without complications. Because the procedure is less invasive, even if it fails, it does not affect further surgical management, but some patients cannot receive cecum fistula.
In conclusion, constipation is complex and difficult to treat, and many factors other than anatomy, including the patient’s mental and psychological state, also have a greater impact on the outcome of treatment; at present, although there is some consensus on surgical treatment of constipation, for example, if the indications are strictly grasped and reasonable surgical methods are used, surgery can improve the quality of life of patients with constipation; secondary constipation and patients with mental and psychological abnormalities are not suitable for However, the specific indications for surgery and the choice of surgical modality are still under continuous debate and exploration.