便秘（英文）.ppt
Constipation:The Evolving Role for SurgeryOutline Normal defecation Definition of constipation Incidence History and evaluation Surgical options Colectomy Bypass Antegrade colonic enema Stoma Sacral nerve stimulationNormal Defecation Colonic and rectal motility Reservoir function of the rectum Rectal Sensation ExpulsionTalley et al,Am J Gastroenterol,1996;Zhou et al,Chinese Med J,2007.Incidence Prevalence of 2-28%in Western populations Estimated 30 million affected 25.92%prevalence in Chinese adolescents Women men 1/2 women and 1/3 men age 65 Management of constipation costs$29 billion annually in the US$800 million spent on laxatives each yearAmerican Gastroenterological Association,Gastroenterol,2000.Constipation:Rome III Criteria Duration 3 months Symptom onset at least 6 months prior to diagnosis 2 or more of the following symptoms 25%of the time Excessive straining Lumpy or hard stools Sensation of incomplete evacuation Sensation of anorectal obstruction/blockage Manual maneuvers to assist in defecation 3 unassisted defecations per week Rare loose BMs without laxativesEtiology of Constipation Lifestyle Medications Medical illness Neurologic Endocrine/Metabolic Psychiatric Primary disease of the colon/anorectum Cancer Hirschsprungs disease Proctitis FissureNyam et al,Dis Colon Rectrum,1997.Chronic Idiopathic Constipation Slow transit constipation(11%)Ineffective colonic propulsion Pelvic outlet obstruction(13%)Paradoxical puborectalis contraction Rectocele Combined(5%)IBS-C(71%)Bharucha,Best Pract Res Clin Gastroenterol,2007.Pathophysiology of Slow-Transit Constipation Structurally normal colon and rectum Blunted gastrocolic response to meals Reduced colonic response to morning waking Impaired phasic colonic motor activity Decreased HAPCsvelocity,frequency,amplitude Increased periodic rectal motor activity Paucity of interstitial cells of Cajal Decreased level of motilin Concurrent upper GI motility disorder(77%)Detailed History Onset/duration of constipation Symptomsfrequency,consistency,size,straining Lifestyle Diet,exercise Changes Comorbidities,past surgeries Medications Obstetric history Psychiatric history(sexual abuse)Family historyFactors Suggestive of STC Female Onset in childhood or adolescence 20-30s Excessive laxative use Gynecologic complaints Irregular menses Ovarian cysts Galactorrhea 20%of markers by day 5NormalNormal Colonic InertiaColonic InertiaOutlet Outlet obstruction obstruction Sitz Marker Transit Study Treatment:Medical Lifestyle modification Fiber supplementation Adequate hydration Regular exercise Medication minimization Correction of metabolic abnormalities Psychiatric evaluation Pharmaceutical Laxatives,enemas Pelvic floor physical therapy/BiofeedbackWhen to Perform Surgery?After a complete history and physical After the completion of appropriate testing After failed diet and fluid optimization After failed aggressive medical management and bowel habit training After failed physical rehabilitation When constipation severely affects QOL Mollen et al4.8%fulfill criteria to be offered surgeryTreatment:SurgicalSubtotal colectomy with anastomosis Ileorectal Ileosigmoid Cecorectal Antiperistaltic cecorectal(Sarli)Ileoanal Segmental colectomyColonic bypass Ileorectal anastomosis Antiperistaltic cecoproctostomyAntegrade colonic enemaStomaSacral nerve stimulationGoalIncrease the frequency of BMs and relieve associated symptoms.Feng and Jianjiang,Am J Surg,2008;Di Fabio,Dis Colon Rectum,2010.Subtotal Colectomy Arbuthnot Lane1908Ileorectal anastomosis 20%mortality,64%success Ogilvie1931Cecorectal anastomosis Mortality0-15%Morbidity Small bowel obstruction(9-71%)Diarrhea+/-fecal incontinence(10-40%)Persistence of constipation(10-30%)Persistence of abdominal pain and bloating Poorer QOL reported following IRA for STC than for Crohns and cancer patients Despite a similar satisfaction with the procedurePinto and Sands,Gastrointest Endoscopy Clin N Am,2009.Results of Subtotal Colectomy with IRAN=FI(%)Diarrhea(%)SBO(%)BM/dSuccess(%)F/U(mo)Nylund400-42.5372.5132Fitz Harris75214638-8146.8Webster5545838912Zutshi641.5720-77129Pikarsky50176202.5100106Pinto and Sands,Gastrointest Endoscopy Clin N Am,2009.Subtotal Colectomy with CRA Advantage Preservation of the ileocecal valve/terminal ileum Absorption of water,electrolytes,vit B,bile Decreased incidence of excessive daily BMs Disadvantage Cecal distention Recurrence of constipation Abdominal pain 50%conversion rate to IRA(Pemberton et al)Iannelli et al,Surg Endoscop,2005.Subtotal Colectomy with Antiperistaltic CRA 14 patients Increased bowel frequency 1.2 0.6/week to 4.8 7.5/day Continence 78.5%Perfect 14.2%1 soiling episode/week Postoperative complications21.4%One reoperationFeng and Jianjiang,Am J Surg,2008.Subtotal Colectomy with ISA or CRA 45 ISA/34 CRA Mean follow up of 2 years Persistent constipation,laxative use 6.7%vs.26.8%(p0.05)Enema use 2.2%vs.11.8%(p0.05)Fecal incontinence 2.9%vs.0%(p0.05)Overall satisfaction 93.3%vs.73.5%OBrien et al,
