Clinical Study Of Combined Use Of Subtotalcolectomy And Modified Duhamel Procedure In The Surgical Treatment Of Obstinate Functional Constipation

Constipation is a common symptom in clinical practice. Treatment of constipation includes dietary and behavioral approaches, pharmacologic therapy and in selected patient surgical treatment. Surgical treatment is recommended in patients with obstinate functional constipation (OFC) refractory to conservative treatment. Confirmation of indication to surgical treatment requires studies of colonic and anorectal function (colonic transit studies, studies of defecation). Quite frequently, patients with OFC have evidence of both colonic slow transit and outlet obstruction. Unfortunately, satisfaction rates after total or subtotal abdominal colectomy range from 39% to 81%. Patients with coexistent pelvic floor disorder may have higher rates of recurrent defecatory difficulty. Surgical treatment for pelvic outlet disorders is extremely disappointing and, therefore, rare. Objective and discrete disorders such as rectal prolapse, rectocele, fissures, or masses should be treated as usual, perhaps in combination with biofeedback where appropriate. OFC a challenging medical problem might warrant surgery. We studied a group of patients who have undergone subtotalcolectomy and modified Duhamel procedure for this problem. The purpose was to assess the functional success of this procedure and its impact on the gastro- intestinal quality-of-life(GIQOL) of the patients.PartⅠEfficacy of combined use of subtotalcolectomy and modified Duhamel procedure in the surgical treatment of obstinate functional constipationClinical Research 1-1: Efficacy of combined use of subtotalcolectomy and modified Duhamel procedure in the surgical treatment of 50 cases of obstinate functional constipationObjective Obstinate functional constipation (OFC) a challenging medical problem might warrant surgery. We studied a group of 50 patients who have undergone subtotalcolectomy and modified Duhamel procedure for this problem. The purpose was to assess the functional success of this procedure and its impact on the gastrointestinal quality-of-life(GIQOL) of the patients. Methods We reviewed a group of 50 patients who underwent subtotalcole-ctomy and modified Duhamel procedure for OFC from September 2000 to April 2005. Patients with OFC had one motion or less per week and were laxative-dependent. The indication for surgery was based on failure of long-term medical therapy. The selection criteria were normal colonoscopy and abnormal colon transit time (CTT) and abnormal dynamic proctography (DPG). The functional outcomes after surgery was assessed by stool frequency and GIQOL index. GIQOL index was analyzed using a 50-question survey that inquired about bowel function and included a modified 36-item GIQOL index and specific functional/emotional problems. Results Fifty patients (40 females) underwent subtotalcolectomy and modified Duhamel procedure over a year period. The mean stool frequency was four(range, 2–6) per day . One patient was early postoperative bowel obstruction. Significant improvement in lifestyle scores were recorded in the categories of physical function, social function. The overall mean GIQOL index score was 109±20 of a maximum possible score of 144 (mean score for healthy controls, 127±15). Most of these 50 patients (88 percent) were pleased with their bowel-movement frequency, but 18 percent cited abdominal pain and 6 percent had diarrhea at least some of the time. The vast majority (92 percent) of patients stated they would undergo the procedure again if given a second chance. Conclusions Modified Duhamel procedure and subtotalcolectomy for OFC is an option in selected patients and leads to progressive improvement in QOL outcomes.Clinical Research 1-2: Randomized clinical trial comparing subtotal- colectomy and combined use of subtotalcolectomy and modified Duhamel procedure of obstinate functional constipationObjective This study compared stool frequency and quality-of-life (QOL) outcomes of subtotalcolectomy and combined use of subtotalcolec- tomy and modified Duhamel procedure of obstinate functional constipation. The purpose was to assess the functional success, postoperative complica- tions, and patient satisfaction of two procedures and their impact on the gastrointestinal quality-of-life (GIQOL) of the patients. Methods Between June 2004 and December 2005,21 patients were randomized to receive subtotalcolectomy(n=10)or combined surgery (n= 21). Patients with OFC had one motion or less per week and were laxative-dependent. The indication for surgery was based on failure of long-term medical therapy. The functional outcomes after surgery was assessed by functional outcomes and stool frequency over a year period. Results The preoperative clinical manifestations of the two groups were similar. 21 patients underwent subtotalcolectomy and combined use of subtotalcolec-tomy and modified Duhamel procedure successfully over a year period. Functional outcomes with core gastrointestinal symptoms[(72.4±7.6)%vs.( 60.3±8.5)%], GIQOL index score (106.8±7.9 vs.92.1±9.6), recurrent constipation rate (9.1%vs.60.0%) satisfaction with bowel movement frequency (81.2% vs.30.0%) and quality of life (90.1%vs.40.0%) for combined use of subtotalcolectomy and modified Duhamel procedure significantly better those that for subtotalcolectomy. No statistically differ- ence between the two groups was observed for the mean stool frequency, postoperative time for recovery of the bowel function , average length of postoperative hospitalization , and the early postoperative complications, persistence of Abdominal pain, postoperative incontinence or diarrhea. Conclusion Combined use of subtotalcolectomy and modified Duhamel procedure for OFC was better improvement in stool frequency and GIQOL outcomes.PartⅡHand-assisted laparoscopic versus open subtotal- colectomy and modified Duhamel procedure for obstinate functional constipationClinical Research 2-1: Hand-assisted laparoscopic versus open subtotal- colectomy and modified Duhamel procedure for obstinate functional constipation: short-term outcomes of a randomised trialObjective This study evaluated the feasibility, safety and short-term benefits of hand-assisted laparoscopic subtotalcolectomy and modified Duhamel procedure for OFC. Methods Between June 2005and December 2006, 19 OFC patients were randomized to receive hand-assisted laparo- scopic surgery group(n=9) or open surgery group (n=10). The clinical manifestations, operation safety, recovery, complications, expenditure, short-term bowel functional outcomes and satisfaction with quality of life for the two groups of patients were comparatively analyzed. Results The preoperative clinical manifestations of the two groups were similar. 19 patients underwent combined use of subtotalcolectomy and modified Duhamel procedure success-fully over a month period. One patient in the hand-assisted laparoscopic group was converted to open surgery. The mean operation time for hand-assisted laparoscopic surgery was significantly longer than that for open surgery(284.2±26.3vs.247.4±20.5,P=0.008). The mean blood loss, length of incision, times of analgetic injection, first flatus time, time to ground activity and hospital stay in hand-assisted laparoscopic group was 141.5±65.4ml, 10.8±1.3 cm, 1.8±0.6d, 4.2±0.6d, 3.5±0.4d, 9.8.±2.3d respectively, which was significantly lesser or shorter than those in open group(P<0.05).No significant difference between the two groups was observed for the early postoperative complications, expenditure, short-term bowel functional outcomes and satisfaction with quality of life (P>0.05). Conclusions In spite of being time comsuming as compared with open surgery, hand-assisted laparoscopic subtotalcolectomy and modified Duhamel procedure for OFC is a safe, feasible procedure, which achieves the same bowel functional outcomes and satisfaction with quality of life as open surgery and leads to quick postoperative recovery.Clinical Research 2-2: Immune response to hand-assisted laparoscopic and open combined use of subtotalcolectomy and modified Duhamel procedure in patients of obstinate functional constipation: a randomised trialObjective This study was designed to compare the alterations of immune function after hand-assisted laparoscopic and open subtotalcolec- tomy and modified Duhamel procedure for OFC. Methods Between June 2005 and December 2006, 19OFC patients were randomized to receive hand-assisted laparoscopic surgery group(n=9)or open surgery group(n= 10). C-reactive protein (CRP), TNFα, IL-6, IgG, IgM, IgA, CD3cells, CD4cells, CD8cells and lymphocytes in peripheral blood were counted and compared on the 3rd day before operation, 1st and 4th day after operation. The clinical manifestations, operation safety, recovery, complications, short-term bowel functional outcomes and satisfaction with quality of life for the two groups of patients were comparatively analyzed. Results The preoperative clinical manifestations and immunological function of the two groups were similar. Nineteen patients underwent combined use of subtotalcolectomy and modified Duhamel procedure successfully over a month period. In open operation group, IgG level, IgM, IL-6 and CRP on the 1st day after operation, CD3cells, CD4cells, CD8cells,CD4/CD8, IL-6 and CRP on the 4th day after operation were all significantly lower or higher than those on the 3rd day before operation respectively(P<0.05, P<0.01). In hand-assisted laparoscopic surgery group, IL-6 level and CRP on the 1st day after operation were significantly higher than those on the 3rd day before operation respectively(P<0.01,P<0.05). There were signifycant difference in IL-6 level and CRP on the 1st day after operation, CD3cells, CD4cells, CD8cells,CD4/CD8 and CRP on the 4th day after operation between two groups(P<0.01,P<0.05). One patients in the hand-assisted laparoscopic group were converted to open surgery. The mean operation time for hand-assisted laparoscopic surgery was significantly longer than that for open surgery(284.2±26.3vs.247.4±20.5,P=0.008). The mean blood loss, times of analgetic injection, first flatus time and hospital stay time in hand-assisted laparoscopic group was 141.5±65.4ml, 1.8±0.6d, 4.2±0.6d, 9.8.±2.3d respectively, which was significantly lesser or shorter than those in open group(P<0.05). No significant difference between the two groups was observed for the early postoperative complications, short-term bowel functional outcomes and satisfaction with quality of life (P>0.05). Conclusions Compared with open surgery, hand-assisted laparoscopic subtotalcolectomy and modified Duhamel procedure for OFC can diminish the systemic stress responses and immune responses and decrease the post- operative immunosuppression to patients. In spite of being time comsuming as compared with open surgery, hand-assisted laparoscopic surgery is a safe, feasible procedure, which achieves the same bowel functional outcomes and satisfaction with quality of life as open surgery and leads to quick postoper- ative recovery.Conclusion1. Combined use of subtotalcolectomy and modified Duhamel procedure in the surgical treatment of OFC is an option in selected patients and leads to progressive improvement in QOL outcomes.2. Combined use of subtotalcolectomy and modified Duhamel procedure for OFC was better improvement in stool frequency and GIQOL outcomes than subtotalcolectomy.3. In spite of being time comsuming as compared with open surgery, hand-assisted laparoscopic subtotalcolectomy and modified Duhamel procedure for OFC is a safe, feasible procedure, which achieves the same bowel functional outcomes and satisfaction with quality of life as open surgery and leads to quick postoperative recovery.4. Compared with open surgery, hand-assisted laparoscopic subtotal- colectomy and modified Duhamel procedure for OFC can diminish the systemic stress responses and immune responses and decrease the postoperative immunosuppression to patients.