结肠慢传输盆底疝和直肠前突所致顽固性便秘的手术治疗

目的　探讨手术治疗便秘的术式。方法　对 49例结肠慢传输 /或盆底疝合并直肠前突引起便秘的病例 ,采用经腹和阴道联合手术治疗 ,分别切除病变的结肠 /或修补盆底及经阴道修补直肠前突。结果　全组痊愈 38例 (77.5 5 % ) ,显效 8例 (16 .32 % ) ,好转 2例 (4 .0 8% ) ,无效 1例(2 .0 4% ) ,总有效率 (97.96 % )。结论　经腹和阴道联合手术治疗结肠慢传输盆底疝和直肠前突所致顽固性便秘安全有效 ,是一种较好的可供选择的手术方法     

重视顽固性便秘外科治疗的术式选择

绝大多数顽固性便秘患者为混合型便秘。外科手术是在内科治疗失败后的最后手段。而单独为慢传输型便秘或单独为出口梗阻型便秘而设计的手术（结肠切除手术或经肛吻合器直肠切除术）其疗效均不理想。旨在同时纠正结肠慢传输和出口梗阻的混合型便秘病理生理紊乱的创新手术技术——“金陵术”（即施行结肠次全切除以解除患者慢传输的病因、同时又行升结肠直肠后壁侧侧吻合纠正盆底解剖和功能的紊乱以解除出口梗阻的病因）至今已施行500余例．随访结果显示出其近、远期疗效均满意,且腹腔镜下的金陵术目前已与开腹手术效果没有差别。对于顽固性便秘并发的特发性巨结肠。金陵术尤为适宜。肠造口术被用于多种以便秘为特征的成人和儿童患者．但其对便秘患者的应用当前并无循证医学的证据支持。肠瘘（以直肠吻合口瘘多见）是便秘外科手术最严重的并发症。一旦确诊．宜尽快施行近端回肠造口转流粪便。否则盆腔骶前的感染扩散可导致直肠吻合口挛缩狭窄。顺行结肠灌洗技术主要适应证是泻剂等保守治疗措施失败,且术前检查提示手术肯定无效、或患者无法接受（如儿童）而不能实施根治性手术者．虽然术后近期功能恢复较好,但远期并发症多,疗效逐渐丧失。     

结肠切除直肠悬吊盆底抬高重建术治疗重度混合型便秘的临床分析（附16例报告）

目的探讨结肠慢传输型便秘（STC）合并出口梗阻型便秘（OOC）的外科治疗方法及疗效。方法总结16例混合型便秘手术及随访资料。13例行结肠次全切除逆蠕动盲直吻合＋直肠悬吊、盆底抬高重建术,3例行结肠全切除回直吻合术＋直肠及子宫悬吊、盆底抬高重建术。结果术后无严重并发症,1例患者发生粘连性小肠梗阻。随访1～3年,每天大便次数为2～4次,Wexner失禁评分（4.8±1.6）。7例患者对手术效果满意,9例非常满意。结论结肠（次）全切除、直肠悬吊、盆底抬高重建术是治疗混合型便秘的有效方法。     

腹腔镜全结肠加部分直肠切除回直肠吻合术治疗混合型便秘25例疗效分析

目的 探讨腹腔镜全结肠加部分直肠切除回直肠吻合术治疗混合型便秘的有效性及安全性。方法 回顾性分析2020年1月至2021年1月上海交通大学医学院附属瑞金医院收治的符合手术指征的25例混合型便秘病人的临床资料,均行腹腔镜全结肠加部分直肠切除回直肠吻合术。随访观察病人术后胃肠道功能恢复情况、术后并发症、住院时间、病人满意度、便秘症状改善情况及心理状态。结果 所有25例病人均顺利完成手术,术后首次排气时间为（49.9±16.5）h,首次排便时间为（66.2±26.6）h,住院时间（9.2±4.7）d。术后病人恢复排便后呈现不同程度的大便次数增加,为（13.8±9.3）次/d。术后6个月逐步改善至（5.2±3.9）次/d,术后1年为（3.8±4.5）次/d。病人满意度为（85.3±27.9）分,便秘治疗有效率为92.0%。部分便秘病人术后仍合并焦虑和（或）抑郁状态,便秘复发病人中焦虑和（或）抑郁人群的比例明显高于便秘缓解病人,差异有统计学意义（P＜0.05）。结论 腹腔镜全结肠加部分直肠切除回直肠吻合术治疗混合型便秘安全、可行,病人术后恢复快。     

顽固性便秘合并继发性巨结肠患者围手术期的营养支持

目的 探讨围手术期肠内营养支持对顽固性便秘合并继发性巨结肠的外科治疗预后的影响.方法 回顾性分析2007年6月至2011年6月在我院接受手术治疗的78例顽固性便秘合并继发性巨结肠患者的临床资料.结果 78例患者均经过胃肠减压和全静脉营养支持治疗,34例患者肠道恢复通畅,再行2周的全肠内营养支持后择期手术(肠内营养组,enteral nutrition组).另外44例无法恢复肠道通畅者,未接受肠内营养支持治疗,直接手术(未接受肠内营养组,non-enteral nutrition组).手术方式包括金陵术(结肠次全切除+升结肠-直肠后壁侧侧吻合术)45例、金陵术+末端回肠保护性造口术6例、结肠全切除+末端回肠与直肠后壁侧侧吻合术18例、结肠全切除+末端回肠临时造口术9例.术前接受肠内营养的患者的并发症发生率(肺炎0％vs 11.4％、吻合口瘘0％vs 11.4％、吻合口出血2.9％ vs 18.2％、手术造口率0％vs 34.1％),均明显低于术前未接受肠内营养支持组的患者,2组比较,差异有统计学意义(P＜0.05).术前接受肠内营养组的患者,术后1个月的机体指标(包括体重、去脂体重、蛋白质含量、细胞内液、细胞外液、体重指数等)的改善优于未接受肠内营养组.结论 顽固性便秘合并继发性巨结肠需外科治疗,术前应尽可能恢复肠道功能,行肠内营养支持治疗,可显著降低围手术期并发症发生率.     

外科手术对顽固性便秘并继发性巨结肠的疗效研究

目的：探讨不同手术方式治疗顽固性便秘并继发性巨结肠的疗效。方法回顾性分析2007年6月至2013年1月在南京军区南京总医院全军普通外科研究所接受手术治疗的112例顽固性便秘并发继发性巨结肠患者的临床资料,全组患者便秘病程4～22年,其中74例既往接受过腹部中等以上手术。手术方式：（1）金陵术（结肠次全切除加升结肠-直肠后壁侧侧吻合术）81例,其中24例接受腹腔镜辅助金陵术,18例加末端回肠保护性造口术;（2）结肠全切除加末端回肠与直肠后壁侧侧吻合术18例;（3）结肠全切除加末端回肠临时造口术13例（6个月后行末端回肠与直肠后壁侧侧吻合术）。末端回肠保护性造口在术后6个月予以还纳。结果112例患者手术成功率100％,无手术相关死亡病例。术后出现的并发症包括术后早期腹泻90例（80．4％）、肛门疼痛和排粪不尽22例（19．6％）、尿潴留（去除导尿管后24～48 h内出现）16例（14．2％）、吻合口出血9例（8．0％）、吻合口瘘6例（5．4％）以及肠梗阻15例（13．4％）,除6例肠梗阻患者接受肠粘连松解术后症状缓解外,其余并发症均通过保守治疗恢复良好。术后随访6月,不同术式患者Wexner便秘平均评分为5．8～8．3,与术前21．4～28．7比较,明显改善（P＜0．01）。结论顽固性便秘并继发性巨结肠外科手术治疗效果良好。     

结肠慢传输型便秘24例外科治疗体会

目的 探讨结肠慢传输型便秘(slow transit constipation,STC)病人的合理手术方式.方法 回顾性分析了24例接受手术治疗的结肠STC病人的临床资料.结果 结肠次全切除、逆蠕动盲肠直肠吻合术10例,结肠大部分旷置、逆蠕动盲肠直肠吻合术8例,结肠旷置、回肠直肠吻合术4例,结肠旷置、回肠乙状结肠吻合术...     

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目的 探讨结肠慢传输型便秘的诊断及治疗方法，提高诊治水平。方法 对部分顽固性便秘病人的临床症状，结肠软内镜检查，结肠传输试验和排粪造影等的检查结果进行分析，对52例确诊为结肠慢传输型便秘者，进行了手术治疗。其中全结肠切除，回肠与直肠吻合术14例，次全结肠切除，盲肠与直肠吻合术34例，左半结肠切除4例。结果 结肠慢传输型便秘的病理检查可肠壁神经丛有变性，减少，回直肠吻合术后病人大便次数偏多，多数＞3次／日，个别病人半年内每天大便20次左右，半年后次数逐渐减少。左半结肠切除术后仍有排粪困难；而盲直肠吻合术效果较好，多数病人大便1－3次／日。结论 结肠慢传输型便秘的病人行次全结肠切除，盲直肠吻合术效果较好。     

顽固结肠慢传输性便秘16例的临床分析

目的：探讨顽固性结肠慢传输性例秘的合理治疗方法。方法：总结顽固性结肠慢传输性便秘患者经X线钡灌肠以及排粪造影检查,结合临床特征而决定手术切除冗长结肠12例,4例非手术治疗,其中冗长横结肠4例,冗长乙状结肠12例。伴直肠前凸3例,重度直肠膨出,盆底下降1例,4例患者中3例经肛修复,1例经腹修复,重建盆底。3例乙状结肠冗长扭转行急诊手术。结果：11例患者恢复良好,有1例高龄患者仅行扭转乙状结肠复位而于术后10d死亡,随访3年,1例有肠粘连症状,1例切口感染,4例非手术治疗症状未缓解。结论：顽固性结肠慢传输性便秘冗长结肠是其原因之一,需早期手术切除,伴有直肠前凸,盆底下降可一期手术修复,如待急诊肠扭转再手术,则危险较大、甚至危及生命,而非手术治疗症状不得缓解,且造成药物依赖。     

肠系膜下动脉高位结扎后顽固性便秘21例临床分析

目的分析进展期乙状结肠癌或直肠上段癌行根治性切除术后顽固性便秘的致病因素,并总结其治疗经验。方法对江汉大学附属医院胃肠外科2004年1月至2014年12月收治的共21例顽固性便秘病人临床资料进行回顾性分析。结果所有病例既往均为进展期乙状结肠癌或直肠上段癌于外院行根治性手术,原手术均明确记录为肠系膜下动脉高位结扎。术后2~4年(平均3.4年)逐渐出现顽固性便秘,以腹痛、腹胀、大便次数减少及排便困难为主要临床表现。所有病例术前行X线钡剂灌肠造影均显示一共同特征,即结肠脾曲未游离,降结肠未切除,降结肠结肠袋消失,犹如小肠;结肠传输试验均提示为慢传输型,排粪造影均未见出口梗阻。12例再次接受手术,余9例因个人因素放弃手术,仍选择保守治疗(灌肠或口服泻药通便)。所有病人均随访至今,随访时间24~168个月,平均87.8个月,手术组术后效果显著,1年内均恢复正常排便(1~2次/d);而保守治疗组便秘症状无改善。结论乙状结肠癌或直肠上段癌根治术中行肠系膜下动脉高位结扎,而未游离结肠脾曲行包括降结肠、乙状结肠和直肠腹膜返折以上部分肠切除。其后果是部分病人降结肠慢性缺血,结肠形态及生理功能退化,导致顽固性便秘发生(慢传输型便秘)。其有效治疗为再手术行降结肠切除,横结肠-直肠吻合。     

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??Application and evaluation of Jinling procedure in the treatment of refractory mixed constipation JIANG Jun. Department of General Surgery, Nanjing General Hospital of Nanjing Military Command, Affiliated Jinling Hospital of Nanjing University School of Medicine, Nanjing 210002,China
Abstract Surgery is indicated for refractory constipation when medical therapy failed. Among patients receiving surgical interventions, the mixed constipation accounts for 56.3%—90.2% approximately. While the special type of constipation is undetermined, no standard surgery has been reported. Jinling procedure developed by Department of General Surgery, Nanjing General Hospital of Nanjing Military Command can solve the coexistence of obstructive defecation and slow-transit constipation in one operation and get better clinical outcome.     

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??Clinical outcome between Jinling procedure and total colectomy with ileorectal side-to-side anastomosis for refractory mixed constipation: A prospective controlled trial FENG Xiao-bo??JIANG Jun??DING Wei-wei??et al. Research Institute of General Surgery??Nanjing General Hospital of Nanjing Military Command??Affiliated Jinling Hospital of Nanjing University School of Medicine, Nanjing 210002??China
Corresponding author??JIANG Jun??E-mail??jiangjun6987@163.com
Abstract Objective To compare the morbidity and efficacy between Jinling procedure and total colectomy with ileorectal side-to-side anastomosis in the treatment of refractory mixed constipation. Methods A total of 156 cases of refractory mixed constipation admitted between February 2009 and December 2010 in Nanjing General Hospital of Nanjing Military Command were analyzed. Group A was performed Jinling procedure. Group B was performed laparoscopic assisted total colectomy with ileorectal side-to-side anastomosis. Results Primary outcomes included operation time, first flatus time, Wexner constipation score, gastrointestinal quality of life index (GIQLI), stool frequency, incidence of diarrhea, diarrhea severity, satisfaction, contentment, serum electrolyte level and surgical complications were observed after operation 1 months, 3 months, 6 months, 12 months until 24 months. Postoperative Wexner constipation score and GIQLI both in two Groups were improved significantly compared with preoperative data (P<0.05). Postoperative stool frequency??incidence of diarrhea??contentment??Wexner constipation score??GIQLI and progress of recovery of Group A were superior to Group B (P<0.05). There was no significant difference in postoperative surgical complication between 2 groups (P??0.05). The incidence of adhesive ileus in Group B was higher than Group A significantly. Conclusion Jinling procedure is superior to total colectomy with ileorectal side-to-side anastomosis in clinical outcome for refractory mixed constipation. Patients can get better quality of life and satisfaction besides relieving the constipation.     

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??Pay attention to the standardized diagnosis and treatment of refractory constipation LI Ning. Department of General Surgery, Nanjing General Hospital of Nanjing Military Command, Affiliated Jinling Hospital of Nanjing University School of Medicine, Nanjing 210002,China
Abstract The primary factors impacting outcomes of patients with refractory constipation include the non-standardization of diagnosis, operative and non-operative therapy. The treatment of refractory constipation should be based on systematic examines and evaluation. After grading and typing the patients according to the cause of the disease, we could then determine the therapeutic regimen and principle. Non-operative therapy is the first choice for refractory constipation, we should use an individual systematic therapy which contains dietary therapy, psychological treatment, biofeedback therapy, optimal stepped medication and regulation of biological metabolism instead of the traditional medicine mainly therapy. Operative therapy is the last choice after the non-operative therapy has failed, and then most of the patients have developed to refractory mixed constipation. The surgery procedure specifically designed for isolated slow-transit constipation or obstructive defecation cannot achieve ideal effect. To treat severe refractory constipation in patients with combined slow-transit constipation and obstructive defecation, a new surgical procedure (named “Jinling procedure” in our hospital) was developed. The Jinling procedure combines subtotal colectomy and side-to-side cecorectal anastomosis, aiming to solve the coexistence of obstructive defecation and slow-transit constipation in one operation. Initial and long term results have been promising. With the development of laparoscopy and the further rationalization of surgical treatment for constipation, the minimally invasive surgery would play an important role in treating constipation.     

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??Long term outcomes and quality of life after Jinling procedure for adult Hirschsprung’s disease WANG Lin, JIANG Jun, DING Wei-wei, et al. Research Institute of General Surgery, Nanjing General Hospital of Nanjing Military Command, PLA, Nanjing University School of Medicine, Nanjing 210002, China
Corresponding author: JIANG Jun, E-mail: jiangjun6987@163.com
Abstract Objective To evaluate the safety, effectiveness and quality of life of Jinling procedure for adult Hirschsprung’s disease. Methods The clinical data of 25 cases performed Jinling procedure for adult Hirschsprung’s disease between June 2008 and December 2011 in Nanjing General Hospital of Nanjing Military Command were analyzed retrospectively. Results The mean postoperative period followed up had been (3.0±1.1) years until June 2013. All the operations were successful. No surgical related death was reported. Adverse events mainly included diarrhea, anus pain, anastomotic leakage, small intestinal obstruction and postoperative urinary retention. Most of the complications could be managed conservatively. A significant improvement in Wexner constipation scale, bowel function score and gastrointestinal quality of life index was obtained after Jinling procedure (P<0.01). All the patients were satisfied with the outcomes. Conclusion Jinling procedure is safe and effective for adult Hirschsprung’s disease and patients’ quality of life index after Jinling procedure is very high after long term follow-up.     

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??Diagnosis and treatment of acute lower gastrointestinal hemorrhage in Crohn’s disease: A report of 73 cases LI Guan-wei??REN Jian-an??WANG Ge-fei??et al. Department of General Surgery??Nanjing General Hospital of Nanjing Command??Nanjing 210002??China
Corresponding author??REN Jian-an??E-mail??jan@medmail.com.cn
Abstract Objective To investigate the risk factors for Crohn’s disease (CD)-associated acute lower gastrointestinal hemorrhage (ALGIH) and evaluate its outcome following treatments. Methods The clinical and follow-up data of 73 cases of CD patients suffering from ALGIH admitted from January 2007 to June 2013 in Jinling Hospital were analyzed retrospectively. Results A total of 1374 cases of CD were admitted in Jinling Hospital. The proportion of cases affected by ALGIH was 5.3%. In the multivariate logistic regression analysis??left colon involvement and previous hemorrhage history were significant factors that independently impacted the frequency of ALGIH. Eight cases abandoning therapy or with death were excluded. Thirty-six cases successfully stopped ALGIH by medical treatment while 29 cases underwent surgery. During the follow-up??ALGIH recurred in 17 cases with conservative therapy, compared with only 6 cases after surgery. The cumulative probability of rebleeding in those had surgical intervention was lower than those receiving conservative therapy. Conclusion Left colon involvement and previous hemorrhage history were independent risk factors affecting ALGIH in CD. The rebleeding is common.Thus further investigations are warranted to discover the optimum treatment.     

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??Capsulized fecal microbiota transplantation for the treatment of slow transit constipation: A therapeutic analysis of 15 cases TIAN Hong-liang, DING Chao, MA Chun-lian, et al. Department of General Surgery??Jinling Hospital??Medical School of Nanjing University??Nanjing 210002??China
Corresponding author??LI Ning??E-mail: liningrigsnju@163.com
Abstract Objective To evaluate the efficacy and safety of capsulized fecal microbiota transplantation (FMT) for slow-transit constipation (STC). Methods A total of 15 patients with STC in Jinling Hospital, Medical School of Nanjing University were enrolled in the study,who received capsulized FMT for 3 days, and followed up for 12 weeks after treatment. Rate of clinical remission, Bristol Stool Form Scale, Wexner constipation scale, and bowel movement per week were evaluated at each study visit. Results Compared with pre-FMT treatment, the rate of clinical cure and remission based on clinical activity at week 12 was 40% (6/15) and 53.3% (8/15) , respectively. The patients’stool frequency increased significantly [(2.2 ± 1.5) times/week vs. (3.1 ± 2.1) times/week] after 12 weeks of treatment. Meanwhile, Bristol scale [(6.7±1.3) vs. (5.1±1.8)], Wexner constipation scores demonstrated a significant reduction [(13.7 ± 3.5) vs. (10.1 ± 2.3)] and GIQLI score increased remarkably [(87.2 ± 14.6) vs. (110.9 ± 10.5)]. Those differences were significant statistically (P??0.05). Capsulized FMT efficacy was stable and no serious adverse events occurred during the whole follow-up. Conclusion Capsulized FMT is safe and effective for the treatment of STC, and short-term treatment effect is good.     

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??New advances in the treatments of traumatic hemorrhagic shock DING Wei-wei, ZHU Wei-ming. Research Institute of General Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing 210002, China
Corresponding author: ZHU Wei-ming, E-mail??juwiming@126.com
Abstract Trauma remains the leading cause of mortality. With the development of new devices and new drugs?? more severe trauma patients got more advanced treatments and survived from lethal disasters. In addition to surgical hemostatic techniques?? knowledge of new advances about the pathophysiology of traumatic hemorrhagic shock should also be well mastered by surgeons. This can help us be expert in critical illness.     

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??Management of pancreatic trauma: A report of 136 cases DING Wei-wei??WANG Kai??LIU Bao-chen??et al. Research Institute of General Surgery??Jinling Hospital??Medical School of Nanjing University??Nanjing 210002??China
Corresponding author??LI Jie-shou??E-mail: lijieshounj@163.com
Abstract Objective To summarize experience of management of pancreatic trauma. Methods A retrospective review was performed of all patients with pancreatic injury admitted to Nanjing General Hospital over a 10-year period between January 2008 and December 2017. Traumatic injuries of the pancreas were graded according to the American Association for the Surgery of Trauma (AAST) score. Complications and outcomes were also collected. Results A total of 136 patients diagnosed with pancreatic trauma were included. Mechanism of injury included 131 of blunt trauma and 5 of penetrating trauma. Initial diagnosis was made by computed tomography in 87 patients (64.0%)??and CT scan was proposed as the first-line diagnosis method. Thirty-seven patients (27.2%) were managed non-operatively while 99 patients (72.8%) received surgical intervention. Overall complication rate was 49.3%. The most common intra-abdominal complication was intra-abdominal abscess (27.9%)??and pulmonary infection was considered as the most common systemic complication. In-hospital mortality was 8.1% (11/136)??of which MODS caused by pancreatic necrosis??pancreatic fistula and abdominal sepsis were the main cause of death. Conclusion Low-grade pancreatic injuries could be managed with NOM (non-operative management) successfully. Pancreatic duct stent placement procedure could be applied to those patients with hemodynamically stable. Surgical drainage was suitable for low-grade pancreatic injury patients with associated intra-abdomen injury. Damage control surgery was recommended for high grade pancreatic injuries. Individualized treatment options for pancreatic trauma according to AAST grade and location of injury were recommended. An individual-centered??multidisciplinary approach was recommended in the management of pancreatic trauma??which significantly reduces mortality.     

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??Fecal microbiota transplantation for treatment of slow transit constipation: A clinical study of 20 patients TIAN Hong-liang??DING Chao??GONG Jian-feng??et al. Department of General Surgery??Jinling Hospital??Medical School of Nanjing University??Nanjing 210002?? China
Corresponding author??LI Ning??E-mail: liningrigsnju@163.com
Abstract Objective To examine the safety and efficacy of fecal microbiota transplantation (FMT) for slow transit constipation (STC). Methods Twenty patients with STC were enrolled in the prospective open-label study. All the patients were performed FMT. Autonomous defecation frequency??Wexner constipation scale, bowel movement and related adverse reaction per week around FMT were evaluated at each study visit. All the patients were followed up for 8 weeks. Results Compared with pre-FMT treatment??the patient’s stool frequency increased significantly ??(1.5 ± 1.3) times/week vs. (4.5±1.5) times/week?? after eight weeks of treatment. Meanwhile??Wexner constipation scores demonstrated a significant reduction ??(15.7 ± 3.5) vs. (7.5 ± 1.6)?? and GIQLI score increased remarkably??(84.6 ± 12.5) vs. (116.6 ± 11.5)??, which has significant difference statistically (P<0.05). There were 12 patients obtained clinical improvement and seven patients obtained clinical remission till to 8 weeks. FMT efficacy was stable and no serious adverse event occurred during the whole follow-up. Conclusion FMT is safe and effective for treating slow transit constipation and the short-term treatment effect is good.     

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??Laparoscopic surgery for Crohn’s disease: current perspectives GONG Jian-feng. Center for Inflammatory Bowel Diseases, Department of General Surgery, General Hospital of Nanjing Military Command of PLA; Nanjing Jinling Hospital, Medical School of Nanjing University, Nanjing 210002, China
Abstract Laparoscopic surgery is currently routinely performed in colorectal resections. However??Crohn’s disease??CD??represented a specific cohort due to disease related characteristics such as intestinal stricture?? fistula?? abscess?? malnutrition?? previous laparotomy?? and use of immunosuppressive agents. In non-complex CD?? laparoscopic ileocolic resection has been proven by emerging evidence to be safe and feasible?? and is associated with decreased postoperative morbidity and length of hospital stay. In complex diseases?? such as penetrating and recurrent disease?? laparoscopic resection also confers to beneficial effects in selected patients. Full preoperative evaluation and optimization are important to improve the success rate and to reduce conversion rate of laparoscopic surgery in CD patients.