| Chronic constipation is a common syndrome. The domestic incidence ofconstipation is3%-17.6%. With the changing of life habits and diet, the increasingagement in the recent years, the incidence of constipation has increased year by year.Chronic constipation can be divided into two kinds: organic and functional. Thefunctional constipation is a benign disease, which can be divided into slow transit,outlet obstruction and mixed constipation. Chronic constipation is initially colonicslow transit or outlet obstruction. Owing to improper treatment, prolonged course, thetwo pathological types affect and reinforce each other, becoming a vicious cycle.Approximately10%of patients develope into a mixed intractable constipation, whooften need surgical treatment for the poorly effect of conservative treatment. The aimof surgery for intractable constipation is to relieve symptoms and improve quality oflife. Therefore it demands a higher surgical result. Previously the surgery is onlydesigned for colonic slow transit or outlet obstruction, including total and subtotalremoval of the colon or local surgery transperineal. However the effects are far fromsatisfactory with poor long-term efficacy and high recurrence rate.Nanjing General Hospital General Surgery Institute has carried out the clinicalresearch of intractable constipation surgical treatment since2000, innovativelydesigne Jinling surgery which resects colon subtotal with ascending colon and rectalside-to-side anastomosis. It can correct two pathophysiological disorders of colonic slow transit and outlet obstruction. The pelvic floor is reconstructed after Jinlingprocedure. There are increased frequency of defecation, anal bulge and othersymptoms short-term postoperative. But defecation feel is often influenced bysubjective factors, we hope that the combination of the objective indicators to assesschanges in bowel function after Jinling procedure.Anorectal manometry is essential indicators of bowel function. It is currently themost widely used for clinical anorectal diseases detectation. There is greatsignificance for diagnosis and treatment of constipation, fecal incontinence andmegacolon, and for anorectal functional assessment postoperative. Water perfusionmanometry is currently widely used, which detecting the pressure of catheter sideholes through injected distilled water indirectly reflects the intestines pressure. Themanometry catheter is intermittently pulled out to record relatively continuouspressure. At a time it can only detect one point pressure on the bowle circle.Stimulation of water and stretching affects the accuracy of anorectal pressure. Theduration of detection is longer. Data analysis needs experienced physician. Nowsolid-state high resolution anorectal manometry system (HRM-AR): ManoScan360isapplied generally international. It entered Western market through CE and FDAstandard in2005, entered the domestic market in2010. But the application onanorectal diseases is rare. Baroreceptors are located on the manometry catheter, whichcan feel intestines pressure directly. The intensive and uniform manometry point (144)can obtain continuous high-fidelity data. Without pulling out the catheter and injectingwater, the data is more accurate and objective. Data is transformed into continuousisobaric map, which is analyzed more simply and intuitively. There is wellrelationship and repeatability between WPM and HRM.In this paper, we take advantage of the HRM-AR to study the rectum and analcanal pressure of intractable mixed constipation patients before and after Jinlingsurgery. We hope to clarify the mechanism of improvement of OOC symptoms afterJinling procedure，the relationship between clinical manifestation and anorectalpressure, guide and quantify postoperative treatment. Objective To establish a high-resolution anorectal manometry (HRM-AR) standardoperating procedures, establish the normal people high-resolution anorectal pressuredatabase of our center, apply HRM-AR to examine intractable mixed constipationpatients preoperative, assess anorectal function of patients with mixed constipationintractable.Methods From October to December2012we selected50patients with chroniccholecystitis, gallstones or gallbladder polyps, there was no history of acute onsetnearly one month. There was no constipation, diarrhea, gastrointestinal diseases,abdominal surgical history, metabolic diseases, endocrine diseases or neuropsychiatricdiseases. They all signed informed consent before HRM-AR detection. Anal motorfunction was recorded: anal resting pressure (RP), anal maximum squeeze pressure(MSP), anal high pressure zone (HPZ) and duration of sustained squeeze (DSS).Coordination of anorectal motor function was recorded: inside rectal pressure (IRP),anal residual anal pressure (RAP)，the anal relaxation rate (AR R) and rectoanalpressure gradient (RAPG). Nervous reflex included rectoanal inhibitory reflex (RAIR).Rectal sensation included rectal perception thresholds (Sensation), rectum initialdefecation threshold (Urge) and the maximum tolerated volume of rectum(Discomfort). Before Jinling procedure210patients with intractable mixedconstipation underwent HRM-AR inspection from January2010to December2011.The methods and indicators were same as the previous. We analyzed all indices ofconstipation patients with the normals to find whether there was an exception.Results We have mastered high-resolution gastrointestinal motility detection system:ManoScan360HRM, and developed standard operating procedures of the institution.The anorectal pressure data of healthy people is similar to foreign literature except theindicator of rectum maximum tolerated volume. The means are146ml and96ml respectively. Compared with the normals, constipation patients have lower RP, MSP,ARR RAIR positive rate, and higher threshold of rectal perception and initialdefecation feeling with P<0.05.Conclusion HRM-AR system is easy to operate with high sensitivity. It is bettertolerated by the subject. It can obtain a continuous high-fidelity data. There isdifference between the HRM-AR results with traditional WPM, but a good correlation.Compared with foreign normal HRM-AR results there is a good agreement.Intractable mixed constipation patients have lower anal canal resting tension, systolicand diastolic dysfunction, local nerve reflex dysfunction and elevated rectal sensationthreshold. Objective The aim is to detect postoperative discomfort of intractable mixedconstipation patients after Jinling procedure (colon subtotal resection combined withascending colon-rectal side-to-side anastomosis), further confirmed the safety andreliability of the surgery. The pelvic floor is reconstructed after Jinling procedure. Theplacement of manometry catheter changes compared with preoperative. To discuss thecatheter placement with pressure test results. Patients with intractable constipationwere followed up, detected by HRM-AR postoperative. To find the objective basis ofrectal pressure change, confirm that the jinling technique can improve the anorectalfunction of the patients with intractable mixed constipation.Method From January2010to December2011there were194constipation patientsundergoing Jinling procedure. We measured morbidity and mortality rates, Wexnerconstipation scores, longo’s outlet obstruction scores, Gastrointestinal Quality of LifeIndex, Wexner fecal incontinence score, and defecation satisfaction at baseline andafter1,3,6and12months. The follow-up rate were96.9%（188）,95.4%（185）,93.8%（182）and90.2%（175）respectively. From January to March2010we selected10consecutive patients postoperative follow-up for HRM-AR detection. At firstmanometry catheter tip was placed in the ascending colon through ascendingcolon-rectal side-to-side anastomosis, which was the group A. Then manometrycatheter was retreated into the rectal stump for HRM-AR detectation, which wasgroup B. We analyzed different manometry catheter position with the test results,made the decision of catheter placement for HRM-AR detection postoperative.650constipation patients underwent HRM-AR from February2010to January2013, inwhich162was the first month,164third month,165sixth month and159twelfthmonth postoperative. Statistical analysis was performed using paired t tests for continuous variables, Pearson’s χ2and the Fisher exact test, where appropriate. A Pvalue less than0.05was regarded as statistically signifcant.Results Stool block and defecation difficulty symptoms disappeare after Jinlingprocedure. The patients defecate without forcing, drug or enema. The Wexnerconstipation score decreased from20.28±4.37to4.29±1.85. Longo’s outletobstruction score declined from17.50±5.87to1.91±1.21significantly. Earlypostoperative there were significant diarrhea, frequent bowel movements, consistenttenesmus feeling caused by anastomotic inflammation and edema. The patients feltdiscomfort with the change of postoperative symptoms and bowel habitsphysiologically and psychologically. The GILQI score decreased significantly in thefirst month from62.30±12.19to46.60±8.39, and defecation satisfication was nothigh. With the surgical trauma healing, the number of bowel movements reduc ing, thetenesmus feeling disappearing, and the doubts on the effect of surgery releasing,GILQI scores increased to98.27±9.02, and defecation satisfaction significantlyimproved from41.0%in the first month to93.7%in the twelfth month. Wexner fecalincontinence score increased from1.20±1.07preoperative to7.10±3.17first monthsignificantly, then decreasd to1.21±0.98the twelfth month. We found no significantdifference both in the rectal sensory and motor function, and nerve reflex functionbetween A and B groups. The differences were significant in both anorectalcoordination of movement and anal canal motor function. Postoperative anal sphincterfunction was significantly impaired (RP, HPZ, MSP and DSS reduced with P<0.01,which hinted squeeze atony) in short term. Sphincter motor function graduallyrecovered after it repaired. In the short-term postoperative RP and RAP reduced, withARR synchronized reduced (P<0.01), prompted sphincter relaxation obstacles.Forward RAP further reduced with ARR increased, defecation improve associatedwith sphincter diastolic function improved. The IRP was slightly lower than thepreoperative (P=0.10), then recovered normal, which prompted Jinling surgery don’taffect it’s function although which cut off part of the rectus abdominis. RAPG is thedifference between IRP and RAP. It gradually increasing, although still negative, was higher than normal. And the proportion of anal contradiction contraction wassignificantly reduced after Jinling procedure. The RAIR positive rate decreasedsignificantly (P=0.014) in the first month after Jinling surgery. But there were still upto75%of the patients showed positive. With part of patients who could still elicitRAIR after the full rectal resection, we considered the reflection receptors located inthe rectum and perirectal pelvic floor muscles. After12months RAIR positive rategradually returned to the preoperative level, closing to the healthy, however which didnot fully return to normal.Conclusion The Wexner constipation severity score and Longo’s outlet obstructionscore decreased. While defecation satisfaction gradually increased. Jinling surgerycould significantly improve the symptoms of refractory mixed constipation patients.GIQLI obviously increased postoperative. Jinling surgery could significantly improvegastrointestinal quality of patients’ life. Wexner fecal incontinence score significantlyincreased short-term after operation, then dropped to preoperative levels. Jinlingsurgery did not increase the risk of fecal incontinence. The sphincter function wasn’tdamaged. In group A manometry catheter tip was placed in the ascending colonthrough anastomotic. Rectal manometry catheter baroreceptors located in the top ofthe side-to-side anastomosis. The rectal balloon expansion could stimulate the rectalstump, detect new rectum’s (ascending colon-rectal pouch) feeling, movement andmaximum volume, by which we could test the whole anal canal motor function.Anorectal function could be better estimated postoperative. In the short-termpostoperative anal motor function receded. It showed weakness of contraction anddiastolic obstacles, gradually systolic and diastolic function improved. Contraction ofthe anal canal contradictions significant improved over the previous. Abdominal,pelvic floor and sphincter coordination function improved at the same time. Thereceptors of RAIR might also exist in the pelvic floor muscles. With the improvementof sensory function, reflex slightly increased compared with the previous. But lostreflexes due to neurodegenerative could not restore. Rectal sensory function improvedsignificantly. Ascending colon-rectal pouch fully compensated the original reservoir function of rectum. |
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