Clinical Effects Of Jinling’s Procedure For Refractory Constipation And Its Influence On Nutrition And Intestinal Microbiota

Part I:Objective:To assess the effectiveness and safety of Jinling procedure for refractory mixed constipation. Method:All patients receiving Jinling procedure from Jan2008to May2011were included. Primary outcomes including, Wexner constipation score, satisfaction rate, Gastrointestinal Quality of Life Index (GIQLI), morbidity and adverse events were documented at baseline and at3,6,12and24month follow-up.Results:Total353patients who accepted Jinling’s were included in this resasrch. Satisfaction rate at3,6,12and24month follow-up were78.2%,91.06%,93.4%,93.6%. A significant reduction(p<0.05) in GIQLI was observed between baseline (19.76±4.64) and3months(8.26±2.18),6months (5.40±2.16),12months follow up(4.58±2.27) which was maintained at24months follow up(4.63±2.20, p>0.05). A significant reduction in GIQLI was observed between baseline (63.97±9.51) and3months (mean49.22±4.99). And compared to baseline, GIQLI gradually improved over time wih significance (P<0.05) at6(mean91.05±12.28),12(mean122.12±4.44) month follow up which maintained at24months (mean122.65±3.59). Adhesive intestinal obstruction was the primary complication and bleeding in anastomotic stoma was the secondary. Conclusions:Our clinical practice demonstrates that Jinling procedure is safe and effective for refractory slow-transit constipation associated with outlet obstruction, with minimal major complications, significant improvement of quality of life and high satisfaction rate after two-year follow up.Part Ⅱ:Aim:To investigate the nutritional status and homeostasis of refractory constipation patients pre-and post-Jinling’s procedure over a12months follow up.Methods:98refractory constipation patients receiving Jinling procedure were enrolled in the study. The Gastrointestinal Quality of Life Index (GIQLI), Wexner’s constipation scorces, stool frequency, body composition and serum albumin, transferrin, prealbumin, fibronectin and major electrolytes were recorded and analyzed with paired-sample t test. Result:Nutritional status of constipation patients was normal. With the effective improvement on functional outcome, frequently stool and diarrhea were profound during the early stage after Jinling procedure. Compared with preoperative nutritional status, nutrition at1month follow up showed significant decrease in all parameters and improved at3month. No significant difference was found at both6month and12month follow up compared with preoperative baseline. Electrolyte disturbances were found in few patients without clinical symptoms. Conclusion:Jinling procedure is an effective procedure on refractory constipation. Although subtotal colectomy is performed, Jinling procedure doesn’t jeopardize the nutritional status and electrolyte balance of constipation patients. Part III:Objective:To investigate changes in fecal flora of severe constipation patients before and six months after Jinling procedure. Methods Feces and mucosal samples of5healthy peoples and17severe constipation patients before and six months after Jinling procedure were collected, and used for total bacterial DNA extraction.16S rRNA gene based denaturing gradient gel electrophoresis (DGGE) and Real-time PCR techniques were employed for qualitative and quantitative analysis of microbiota. ResultsCompared with healthy, the DGGE analysis showed that no significant changes in the structure of predominant microbiota in all samples before and after Jinling procedure. There was no specific band both in profiles. After Jinling procedure, Shannon indices significantly increased in fecesl samples and similarity (Dice) coefficient decreased. Real-time PCR analysis showed that the number of predominant bacteria(Firmicutes, Bacteriodetes, Clostridiumcoccoidesgroup and Clostridium leptum subgroup)had no significant difference compared with healthy both in feces and mucosa;and the number of total bacteria, Firmicutes, Bacteriodetes and Clostridium leptum subgroup decreased postoperatively while were maintained in mucosa. The number of Bifidobacterium and Lactobacilliusof feces and the number of Bifidobacterium of mucosa decreased significantly preoperatively comparing with healthy, all of whom increased after the surgery. The number of methanogensof mucosa decreased preoperative and returned to normal postoperative.Conclusions:With the effectiveness in treating refractory constipation, Jinling procedure was also beneficial to intestinal flora. The number of methanogens of mucosa has potential links with the intestinal mobility.