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  • Title: [Retrospective cohort study on subtotal colonic bypass plus colostomy with antiperistaltic cecoproctostomy in the treatment of senile slow transit constipation].
    Author: Yang Y, Cao YL, Wang WH, Zhang YY, Zhao N, Wei D.
    Journal: Zhonghua Wei Chang Wai Ke Za Zhi; 2019 Apr 25; 22(4):370-376. PubMed ID: 31054552.
    Abstract:
    Objective: To investigate the clinical efficacy of laparoscopic subtotal colonic bypass plus colostomy with antiperistaltic cecoproctostomy (SCBCAC) in the treatment of senile slow transit constipation. Methods: A retrospective cohort study was performed. Clinical data of 30 colonic slow transit constipation patients aged ≥70 years old undergoing laparoscopic SCBCAC from July 2012 to October 2016 (bypass plus colostomy group), and 28 patients undergoing laparoscopic subtotal colonic bypass with antiperistaltic cecoproctostomy (SCBAC) from February 2009 to June 2012 (bypass group) at our institute were collected. Efficacy was compared between the two procedures. Inclusion criteria: (1) meeting the Rome III diagnosis criteria for constipation; (2) confirmed diagnosis of slow transit constipation; (3) age ≥ 70 years old; (4) receiving non-surgical treatment for more than 5 years, and Wexner constipation score > 15; (5) follow-up for more than 2 years. Those with psychiatric symptoms or previous psychiatric history, obvious signs of outlet obstructive constipation, organic diseases of the colon and life-threatening cardiovascular diseases or cancer were excluded. In the bypass plus colostomy group, laparoscopy was performed via five trocars. The ileocecal junction and the ascending colon were mobilized and the ileocecal junction was pulled down to the pelvic inlet. The ascending colon was transected and the appendix was excised. The lateral peritoneum of the sigmoid colon and the rectal mesentery were dissected and the upper rectum was transected. The avil of a circular stapler was placed in the bottom of the cecum. The shaft of the stapler was placed in the rectum via the anal canal to complete end-to-side anastomosis (end rectum to lateral cecum). The end of the rectal-sigmoid colon was used for colostomy via an extraperitoneal approach to complete the operation. The following efficacy indexes were collected before surgery and 3, 6, 12, and 24 months after surgery: the number of daily bowel movements, the Wexner incontinence scale (WIS, 0-20, the lower the better), the Wexner constipation scale (WCS, 0-30, the lower the better), the gastrointestinal quality of life index (GIQLI, 0-144, the higher score, the better), abdominal pain intensity indicated by the numerical rating scale (NRS, 0-10, the lower score, the better), and the abdominal bloating score (ABS, 0-4, the lower score, the better). The complications defined as Clavien-Dindo class II or above were observed and recorded. Results: No significant differences in preoperative WCS, WIS, GIQLI, NRS, and ABS were observed between bypass plus colostomy group and bypass group (all P>0.05). All the patients successfully underwent laparoscopic surgery and no patient in either group experienced postoperative fecal incontinence. WCS and GIQLI were significantly improved (all P<0.001) at 3, 6, 12, and 24 months after surgery in both groups. At 12 months after surgery, the number of bowel movements was significantly less in bypass plus colostomy group than that in bypass group [(2.4±0.7) times vs. (3.4±1.2) times, t=4.048, P<0.001]. At 3, 6, 12 and 24 months after surgery, the improvement of GIQLI in bypass plus colostomy group was significantly better than that in bypass group (all P<0.001). At 24 months after surgery, GIQLI in bypass plus colostomy group and bypass group was 122.3±5.3 and 92.8±16.6, respectively, with a significant difference (t=9.276, P<0.001). At 12 and 24 months after surgery, NRS in bypass plus colostomy group was significantly better than that in bypass group (both P<0.001). At 24 months after surgery, NRS in bypass plus colostomy group was 0.9±0.7, while that in bypass group was 3.7±2.7. There was a significant difference between two groups (t=5.585, P<0.001). At 6, 12 and 24 months after surgery, the improvement of ABS in bypass plus colostomy group was also significantly better than that in bypass group. At 24 months after surgery, ABS in bypass plus colostomy group was 0.6±0.6, while that in bypass group was 2.5±1.0, with a significant difference between two groups (t=8.797, P<0.001). At 1 year after surgery, barium enema examination was performed in all the patients of both groups. The barium emptying time was (21.2±3.8) hours and (95.8±86.2) hours in bypass plus colostomy group and bypass group respectively. The former group was significantly better than the latter group (t=4.740, P<0.001). Conclusions: Laparoscopic SCBCAC is an effective and safe procedure for the treatment of senile slow transit constipation and can significantly improve prognosis. Its clinical efficacy is better than laparoscopic SCBAC. 目的： 探讨腹腔镜次全结肠旷置造口逆蠕动盲直肠端侧吻合术治疗老年慢传输型便秘的临床疗效。 方法： 采用回顾性队列研究方法，收集解放军联勤保障部队第九八九医院全军肛肠外科研究所于2012年7月至2016年10月期间、对收治的年龄≥70岁的结肠慢传输性便秘患者采用腹腔镜次全结肠旷置造口逆蠕动盲直肠端侧吻合术进行治疗的病例资料（旷置造口组30例），并收集2009年2月至2012年6月间采用腹腔镜次全结肠旷置逆蠕动盲直肠吻合术治疗的同类患者临床资料（旷置手术组28例）比较两种术式的疗效。病例纳入标准：（1）符合便秘罗马Ⅲ诊断标准；（2）结肠慢传输性便秘诊断明确；（3）年龄≥70岁；（4）非外科手术治疗5年以上、且Wexner便秘评分>15分；（5）术后随访超过2年。排除有精神症状或既往有精神病史、有明显出口梗阻性便秘症状、患有结肠器质性疾病以及患有威胁生命的心血管疾病或癌症者。旷置造口组手术采用5孔法，游离回盲部和升结肠，使回盲部放低到盆口，横断升结肠，切除阑尾；分离乙状结肠外侧腹膜，游离直肠系膜，横断直肠上部；管状吻合器抵钉座放入盲肠底部，经肛门送入吻合器枪身与盲肠底部完成端侧吻合；于左下腹部经腹膜外提出直肠乙状结肠断端行腹壁造口术，完成手术。疗效指标包括术前和术后3、6、12、24个月的每天排粪次数、Wexner肛门失禁评分（0~20分，分数越小越好）、Wexner便秘评分（0~30分，分数越小越好）、胃肠生活质量指数（0~144分，分数越大越好）、腹痛强度评分（0~10分，分数越小越好）和腹胀评分（0~4分，分数越小越好），观察是否存在Clavien-Dindo分级Ⅱ级及以上并发症。 结果： 旷置造口组与旷置手术组患者性别、年龄、体质指数、术前Wexner便秘评分、Wexner肛门失禁评分、胃肠生活质量指数、腹痛强度评分和腹胀评分比较，差异均无统计学意义（均P>0.05）。说明两组间基线资料均衡，具有可比性。两组患者均成功完成了腹腔镜手术，术后均未发生排粪失禁。术后3、6、12、和24个月，两组患者Wexner便秘评分、胃肠生活质量指数较术前均明显改善（均P<0.001）。术后12个月时，旷置造口组每天排粪次数明显少于旷置手术组[（2.4±0.7）次比（3.4±1.2）次，t=4.048，P<0.001]。术后3、6、12和24个月的胃肠生活质量指数，旷置造口组的改善明显优于旷置手术组（均P<0.001），术后24个月时，旷置造口组胃肠生活质量指数为122.3±5.3，而旷置手术组则为92.8±16.6，两组比较，差异有统计学意义（t=9.276，P<0.001）。术后12和24个月时的腹痛强度评分，旷置造口组改善也明显优于旷置组（均P<0.001），术后24个月时，旷置造口组腹痛强度评分为0.9±0.7，而旷置手术组则为3.7±2.7，两组比较，差异有统计学意义（t=5.585，P<0.001）。术后6、12和24个月时的腹胀评分，旷置造口组的改善同样明显优于旷置手术组，术后24个月时，旷置造口组腹胀评分为0.6±0.6，而旷置手术组则为2.5±1.0，两组比较差异有统计学意义（t=8.797，P<0.001）。术后1年钡餐检查，旷置造口组排空时间为（21.2±3.8）h，明显优于旷置组的（95.8±86.2）h，两组比较，差异有统计学意义（t=4.740，P<0.001）。 结论： 腹腔镜次全结肠旷置造口逆蠕动盲直肠端侧吻合术治疗老年慢传输型便秘安全有效；其疗效优于单纯次全结肠旷置逆蠕动盲直肠侧侧吻合术。.
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