不同术式治疗结肠慢传输型便秘的疗效比较

目的对比观察结肠慢传输型便秘的4种外科术式治疗效果.方法回顾性总结1990年10月至2002年11月施行的89例94例次的手术治疗资料,数据处理采用t检验.结果行结肠全切除术6例,术后短期内腹泻6例（100%）,难治性腹泻1例（16.7%）,无便秘复发;结肠次全切除术73例,短期内腹泻19例（26%）,明显低于结肠全切除术（t=1.90,P＜0.05）,无难治性腹泻,复发1例,出现吻合处梗阻1例,切口感染2例;盲直肠端侧吻合术12例,疗效与结肠次全切除术相同,但手术时间和失血量均明显少于结肠次全切除术（t=2.849和10.455,P＜0.01）;结肠部分切除术3例,均于短期内复发.本组病例无手术死亡、吻合口瘘发生.结论结肠次全切除、结肠全切除和盲直肠端侧吻合术对结肠慢传输型便秘均有满意的疗效,应根据患者的具体病情选择术式,但结肠全切除术后腹泻发生率高,结肠部分切除术疗效不肯定.     

The small intestine and colon: scintigraphic quantitation of motility in health and disease

Radioisotopes allow accurate quantitation of the pattern and effectiveness of the transit of chyme through the small and large intestines. Abnormalities of small bowel transit can be demonstrated in patients with the irritable bowel syndrome, and patients with chronic idiopathic intestinal pseudo-obstruction due to either a visceral myopathy or neuropathy. In the colon, radioisotopic studies of transit have demonstrated the site of delayed transit in some severely constipated patients. In patients with these disorders of transit, functional studies may influence the choice of medical or surgical therapy although there are few prospective studies which have established their worth in this context. Radioisotope studies can also be utilised to study the effectiveness of delivery of drugs to the small and large bowel, and to study the adequacy of rectal evacuation in patients with a defaecatory disturbance. The low radiation dose and possibility of frequent observations make radioisotope studies valuable for clinical and research studies in functional gastrointestinal disorders.     

Long-term outcome after laparoscopic and open surgery for rectal prolapse

Background Laparoscopic repair (LR) of rectal prolapse is potentially associated with earlier recovery and lower perioperative morbidity, as compared with open transabdominal repair (OR). Data on the long-term recurrence rate and functional outcome are limited. Methods Perioperative data on rectal prolapse in relation to all LRs performed between December 1991 and April 2004 were prospectively collected. The LR patients were matched by age, gender, and procedure type with OR patients who underwent surgery during the same period. Patients with previous complex abdominal surgery or a body mass index exceeding 40 were excluded from the study. Data on recurrence rate, bowel habits, continence, and satisfaction scores were collected using a telephone survey. Results A total of 111 patients (age, 56.8 ± 18.1 years; female, 87%) underwent attempted LR. An operative complication deferred repair in two cases. Among the 111 patients, 42 had posterior mesh fixation, and 67 had sutured rectopexy (32 patients with sigmoid colectomy for constipation). Eight patients (7.2%) had conversion to laparotomy. Matching was established for 86 patients. The LR patients had a shorter hospital stay (mean, 3.9 vs 6.0 days; p < 0.0001). The 30-day reoperation and readmission rates were similar for the two groups. The rates for recurrence requiring surgery were 9.3% for LR and 4.7% for OR (p = 0.39) during a mean follow-up period of 59 months. An additional seven patients in each group reported possible recurrence by telephone. Postoperatively, 35% of the LR patients and 53% of the OR patients experienced constipation (p = 0.09). Constipation was improved in 74% of the LR patients and 54% of the OR patients, and worsened, respectively, in 3% and 17% (p = 0.037). The postoperative incontinence rates were 30% for LR and 33% for OR (p = 0.83). Continence was improved in 48% of the LR patients and 35% of the OR patients, and worsened, respectively, in 9% and 18% (p = 0.22). The mean satisfaction rates for surgery (on a scale of 0 to10) were 7.3 for the LR patients and 8.1 for the OR patients (p = 0.17). Conclusions The hospital stay is shorter for LR than for OR. Both functional results and recurrent full-thickness rectal prolapse were similar for LR and OR during a mean follow-up period of 5 years.     

Dynamic magnetic resonance imaging of the pelvic floor in children and adolescents with vesical and anorectal malformations

Background

Magnetic resonance imaging (MRI) of the pelvic floor allows better assessment of pelvic pathology and has a potential as an adjunct for therapy planning. In complex congenital malformations of the pelvic floor and continence organs, it plays a major role in assessing urinary and fecal incontinence or constipation, especially when performed as a dynamic investigation such as MRI defecography.

Patients and Methods

Twenty-three patients (3-21 years old) with urinary and/or fecal incontinence or constipation attributable to congenital malformations of the pelvic region presented at our institution. The diagnoses were anorectal malformations (18), bladder exstrophy (2), and cloacal exstrophy (3). All patients underwent static and dynamic MRI of the pelvic floor with rest, squeeze, and evacuation in supine position.

Results

Morphology and function of the pelvic floor and pelvic organs could be demonstrated in each case. The reason for urinary incontinence, fecal incontinence, or constipation could be defined, and an individual therapeutic management concept was made based upon the data obtained by the investigation.

Conclusions

The advantages of this method, in comparison to others, are direct visualization of the pelvic floor muscles and continence organs and their anatomical relationship during different functional actions. Pelvic floor dysfunction is often the reason for fecal and urinary incontinence and can be detected by MRI. Especially in children, minimizing radiation exposure is of major concern. Disadvantages are the costs and long investigation time.     

Colonic manometry as predictor of cecostomy success in children with defecation disorders

Purpose

The aim of this study was to define the predictive value of colonic manometry and contrast enema before cecostomy placement in children with defecation disorders.

Methods

Medical records, contrast enema, and colonic manometry studies were reviewed for 32 children with defecation disorders who underwent cecostomy placement between 1999 and 2004. Diagnoses included idiopathic constipation (n = 13), Hirschsprung's disease (n = 2), cerebral palsy (n = 1), imperforate anus (n = 6), spinal abnormality (n = 6), and anal with spinal abnormality (n = 4). Contrast enemas were evaluated for the presence of anatomic abnormalities and the degree of colonic dilatation. Colonic manometry was considered normal when high-amplitude propagating contractions (HAPC) occurred from proximal to distal colon. Clinical success was defined as normal defecation frequency with no or occasional fecal incontinence.

Results

Colonic manometry was done on 32 and contrast enema on 24 patients before cecostomy. At follow-up, 25 patients (78%) fulfilled the success criteria. Absence of HAPC throughout the colon was related to unsuccessful outcome (P = .03). Colonic response with normal HAPC after bisacodyl administration was predictive of success (P = .03). Presence of colonic dilatation was not associated with colonic dysmotility.

Conclusion

Colonic manometry is helpful in predicting the outcome after cecostomy. Patients with generalized colonic dysmotility are less likely to benefit from use of antegrade enemas via cecostomy. Normal colonic response to bisacodyl predicts favorable outcome.     

Left colonic antegrade continence enema: experience gained from 19 cases

Purpose

As problems have developed with the right colonic antegrade continence enema procedure (Malone's procedure/Monti's retubularized ileocolostomy), left colonic antegrade continence enema (LACE) procedure, in which retubularized ileum or sigmoid colon is anastomosed into the sigmoid colon, has gained popularity. The aim of the study was to describe our experience with the LACE procedure.

Methods

We retrospectively reviewed 19 LACE procedures that were performed at the Yonsei University College of Medicine Hospital (Seoul, Korea) from March 2001 to March 2005.

Results

Male-to-female ratio was 11:8, with median age of 10 years (range, 3-34 years). Most common diagnosis was meningomyelocele (78.9%, 15/19). The median total follow-up period was 23 months (range, 3-37 months); median antegrade continence enema volume used was 600 mL (range, 250-1500 mL); and median transit time was 30 minutes (range, 15-60 minutes). Patients performed antegrade continence enema with an average of once every 2 days (range, 0.3-3 days). Social continence was achieved in 14 patients (73.7%). Regurgitation of fecal material through stoma was not reported at all in 17 patients (89.5%).

Conclusions

We recommend LACE as the procedure of choice for children with congenital malformations or any other condition predisposing to fecal incontinence or constipation intractable to conventional treatment.     

Pelvic Organ Support Study (POSST) and bowel symptoms: straining at stool is associated with perineal and anterior vaginal descent in a general gynecologic population

OBJECTIVE: The purpose of this study was to evaluate the association of constipation symptoms and anal incontinence with vaginal wall and pelvic organ descent in a general gynecologic population. STUDY DESIGN: In this multicenter, cross-sectional study, 1004 women attending routine gynecologic healthcare underwent pelvic organ prolapse quantification (POPQ) measurements, and were surveyed regarding anal incontinence, digitation, < 2 bowel movements (BMs)/week, and > 25% frequency of: straining, hard/lumpy stools, and incomplete emptying. Constipation scores reflected the sum of positive responses. Associations between POPQ measurements (Ba, C, Bp, gh+pb), constipation scores, and anal incontinence were evaluated using multivariable regression. RESULTS: Of 119 women with Bp > or = -1.00, 47% reported no constipation symptoms. Hard/lumpy stools (26%), incomplete emptying (24%), and straining (24%) were more prevalent; fewer women reported < 2 BMs/week (15%) or digitation (7%). Constipation scores were weakly correlated with Bp, gh+pb (both r < .1, P < .02). Women reporting > or = 2 symptoms had greater gh+pb measurements than women reporting 0 or 1 symptom (P = .03). Women with anal incontinence had greater gh+pb and gh values than women without anal incontinence (P < .01). POPQ measurements were regressed separately onto (1) total constipation scores, (2) dichotomized scores, and (3) individual symptoms, with BMI, age, number of vaginal deliveries (NVD), weight of largest vaginal delivery (WLVD), race, hysterectomy, study site, and income included as covariates. Total constipation scores and dichotomized scores were nonsignificant in all models. With regard to individual symptoms, straining at stool was significant in the models for Ba and gh+pb, with greater Ba and gh+pb measurements among strainers relative to nonstrainers. CONCLUSION: Most associations between bowel symptoms and vaginal or pelvic organ descent were weak. After controlling for important covariates, straining at stool remained associated with anterior vaginal wall and perineal descent.     

胆囊切除术与保胆术治疗胆囊结石的比较

目的分析胆囊切除术与内镜微创保胆取石术治疗胆囊结石的疗效和术后并发症和不良反应的发生情况。方法对2009年10月—2010年6月期间,11所医院对因胆石症行胆囊切除术与内镜微创保胆取石术的患者进行了随访,对术后各种并发症和不良反应的发生情况进行了调查。结果调查实际随访病例数10449例,其中胆囊切除术6750例,内镜微创保胆取石术3699例。保胆手术组除有9.76%胆囊结石复发外,其余并发症和不良反发应(胆道功能障碍、肝外胆管损伤、胆汁漏、术后肠梗阻、肝外胆管结石、结肠癌、术后腹泻、返流性胃炎、返流性食道炎)发生率均显著低于胆囊切除术组(分别为0.84%vs.11.5%,0vs.0.61%,0.03%vs.1.90%,0.27%vs.2.01%,1.65%vs.5.67%,0.16%vs.0.84%,1.95%vs.12.19%,2.14%vs.5.72%,1.03%vs.3.84%)(均P<0.01)。结论内镜微创保胆取石术后不良反应发生率及复发率低,是一种安全、有效的治疗方法;腹泻为胆囊切除术后最主要的不良反应,但可能为治疗功能性便秘提供思路。     

成人结肠脾曲综合征102例的诊断与外科治疗

目的 总结成人结肠脾曲综合征(syndrome of splenic flexure of colon,SSFC)的诊断与外科治疗经验.方法 对1989年7月至2010年10月收治的102例SSFC病人的临床资料进行回顾性分析.结果 本组病人以反复发作性腹痛、腹胀及便秘并顽固性不全结肠梗阻为主要临床表现.98例X线钡剂...     

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。