便秘（英文）课件

Constipation: The Evolving Role for Surgery Ursula Szmulowicz, MD Department of Colorectal Surgery Digestive Disease Institute Cleveland Clinic Foundation Shanghai, China March 12, 2011 Outline Normal defecation Definition of constipation Incidence History and evaluation Surgical options Colectomy Bypass Antegrade colonic enema Stoma Sacral nerve stimulation Normal Defecation Colonic and rectal motility Reservoir function of the rectum Rectal Sensation Expulsion 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 year Talley et al,Am J Gastroenterol, 1996; Zhou et al, Chinese Med J, 2007. 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 laxatives American Gastroenterological Association, Gastroenterol, 2000. Etiology of Constipation Lifestyle Medications Medical illness Neurologic Endocrine/Metabolic Psychiatric Primary disease of the colon/anorectum Cancer Hirschsprungs disease Proctitis Fissure Chronic Idiopathic Constipation Slow transit constipation (11%) Ineffective colonic propulsion Pelvic outlet obstruction (13%) Paradoxical puborectalis contraction Rectocele Combined (5%) IBS-C (71%) Nyam et al, Dis Colon Rectrum, 1997. 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%) Bharucha, Best Pract Res Clin Gastroenterol, 2007. 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 history Factors 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 5 Hinton et al, Gut, 1969. Normal Colonic Inertia Outlet 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/Biofeedback When 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 surgery Treatment: Surgical Subtotal colectomy with anastomosis Ileorectal Ileosigmoid Cecorectal Antiperistaltic cecorectal (Sarli) Ileoanal Segmental colectomy Colonic bypass Ileorectal anastomosis Antiperistaltic cecoproctostomy Antegrade colonic enema Stoma Sacral nerve stimulation GoalIncrease the frequency of BMs and relieve associated symptoms. 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 procedure Feng and Jianjiang, Am J Surg, 2008; Di Fabio, Dis Colon Rectum, 2010. Results of Subtotal Colectomy with IRA N=FI (%)Diarrhea (%) SBO (%) BM/dSuccess (%) F/U (mo) Nylund400-42.5372.5132 Fitz Harris 75214638-8146.8 Webster5545838912 Zutshi641.5720-77129 Pikarsky50176202.5100106 Pinto 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) Pinto and Sands, Gastrointest Endoscopy Clin N Am, 2009. 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 reoperation Iannelli et al, Surg Endoscop, 2005. 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) Fecal incontinence 2.9% vs. 0% (p0.05) Overall satisfaction 93.3% vs. 73.5% Feng and Jianjiang, Am J Surg, 2008. Predictors of Failure? Small bowel intestinal dysmotility Antroduodenal manometry Lactulose breath hydrogen test Undiagnosed obstructive defecation syndrome Psychiatric illness Previous sexual abuse Persistent abdominal pain 88% (abused) vs. 0% (nonabused) OBrien et al, Dis Colon Rectum, 2009; Beck et al, S Med J, 1989. Segmental Colectomy Reduction in diarrhea and fecal incontinence? Reduction in SBO? Scintigraphy to determine segmental transit Not widely available Confirms marker study results of total transit Good patient compliance Not currently recommended High incidence of recurrent/persistent constipation (16-18%) New-onset diarrhea (14-18%) Pinto and Sands, Gastrointest Endoscopy Clin N Am, 2009; Lundin et al, Br J Surg, 2002. Result of Segmental Resection 28 patients with a median of 50 months of follow up 26 left hemicolectomy 6 with suture rectopexy Outcome 5 required additional surgery due to persistent constipation Impaired rectal sensation Slower rate of evacuation on preop defocography Significant improvement in function but not in abdominal pain or bloating Persistent diarrhea3.6% 60.7%-Excellent or good result 82.1%-Recommend to a friend or relative Lundin E et al, Br J Surg, 2002. Colonic Bypass First introduced by Pinedo et al. Laparoscopic ileosigmoid anastomosis in two patients Advantages Minimal dissection Lower incidence of SBO? Disadvantage Colonic bacterial overgrowth? Increased incidence of colon cancer? Pinedo et al, Dis Colon Rectum, 2008. Results of Subtotal Colonic Bypass Subtotal colonic bypass with antiperistaltic cecoproctostomy 18 patients (72% female) with 17 mo f/u No mortality or small bowel obstruction 6 month follow up 80% improved QOL, 17% unsatisfactory 72%Normal BMs (average 1.8 per day) 17%Diarrhea requiring medications 6%Constipation requiring laxatives 6%No change in constipation Wang et al., Int J Colorectal Dis, 2010. Antegrade Colonic Enema Malone1990 Children with neurogenic disorders and fecal incontinence Creates a nonrefluxing conduit for intermittent catheterization Cecum or appendix Allows for colonic irrigation, resulting in rapid and controlled evacuation of the large bowel contents Stomal stenosis Sinha et al, Pediatr Surg Int, 2008; Pinto and Sands, Gastrointest Endoscopy Clin N Am, 2009. Antegrade Colonic Enema For patients who do not want a colectomy For patients at risk of fecal incontinence Does not preclude further surgery Results of ACE: Adult 32 patients with 37 conduits performed 54% appendix 5% laparoscopic Complications (88%) Minor revision38% Major revision38% Success 47% in use at a median of 36 months 50% in use at 5 years Reversal for stenosis, leakage, or persistent constipation 59% at a median of 13 months 8% reversed after 24 months End stoma (9), colectomy (3) Lees et al, Colorectal Disease, 2004. Ileostomy Rarely performed as an initial intervention for constipation Usually follows failure of subtotal colectomy Poor candidates for more major abdominal surgery Results of Ileostomy 24 patients with a mean follow up of 47 months 92% slow transit constipation End stoma38% Trephine20.8% Stoma complications53.4% (overall) Retraction25% Peristomal sepsis12.5% Parastomal hernia8.3% Stoma pain8.3% Persistent constipation4% Stoma revision29.1% at a mean of 49 months Stoma reversal16.6% (4) at 3.3 months Recurrent constipation (2) Authors favored the trephine loop stoma Scarpa M, Colorectal Disease, 2005. Sacral Nerve Stimulation? Not currently approved for constipation in the US Modulation of extrin