Treatment Of Constipation - Surgical Treatment

1. Patients with slow-transit constipation who fail comprehensive conservative treatment can benefit from surgery (evidence level: C, recommendation strength: strong).

For refractory slow-transit constipation that fails non-surgical treatment, surgery is an effective treatment. However, postoperative diarrhea and chronic abdominal pain will also affect the patient's quality of life, so the surgical indications must be strictly controlled: (1) Meet the Rome IV diagnostic criteria for functional constipation; (2) Intestinal transit test shows delayed colonic transit time; (3) ) The course of disease is generally ≥2 years, and is ineffective after systematic non-surgical treatment; (4) Exclude severe outlet obstruction constipation and megacolon; (5) Exclude organic colorectal diseases; (6) Seriously affect work and life, The patient's willingness for surgery was clear; (7) there were no contraindications to surgery according to the mental and psychological evaluation.

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Surgery-related issues mainly involve the extent of colon resection and the choice of intestinal reconstruction method. Total or subtotal colectomy is currently the most recognized scope of resection. Those with outlet obstruction such as intrarectal prolapse and rectocele accompanied by obvious symptoms of outlet obstruction need to be treated in advance or corresponding treatment at the same time [45]. Partial colectomy should be performed with caution due to the high recurrence rate of constipation.

2. Patients with refractory slow-transit constipation can benefit from total colectomy and ileorectal anastomosis (evidence level: B, recommendation strength: strong).

Total colectomy with ileorectal anastomosis (TC⁃IRA) is currently a commonly used surgical procedure for the treatment of slow transit constipation in the world. Because the patient's entire colon with slow transit is removed, the transit time of intestinal contents is relatively shortened, and the constipation symptoms of patients with slow transit constipation can be significantly improved. The long-term effectiveness is high and the recurrence rate of constipation is low [46-47]. Arabi et al. [46] systematically analyzed 48 documents from 1989 to 2008. A total of 1,046 (72%) of 1,443 patients with chronic constipation underwent TC⁃IRA surgery, and 9 studies reported a satisfaction rate of less than 100%. % and 18 studies reported satisfaction levels ranging from 80% to 96%. In 2017, Knowles et al. [48] systematically analyzed 40 documents from 1988 to 2015 with a total of 2,045 patients. Among them, 1,321 cases (64.6%) in 30 studies underwent TC⁃IRA surgery, and the satisfaction rate was 65%. ~100%[49⁃50]. The frequency of defecation increases significantly after TC⁃IRA, which achieves the purpose of relieving constipation. However, severe diarrhea in the short term and fecal incontinence in individual patients are the main problems and require drug control. The number of patients' defecation can be reduced to an average of 4 to 5 times a day 1 to 2 years after surgery, which is acceptable to most patients [49, 51-52]. The most common short-term complications after surgery are inflammatory intestinal obstruction (6.7%-27.0%), long-term complications are adhesive intestinal obstruction (8%-20%), and others include chronic abdominal pain (13.0%-20.7%). etc. [49, 51, 53]. These are the main reasons that affect the quality of life after surgery, but as time goes by, these complications will have a significant improvement trend and generally will reach a satisfactory state two years after surgery [49]. The results of a retrospective case-control study showed that laparoscopic TC⁃IRA surgery was significantly lower than open surgery in terms of the incidence of postoperative intestinal obstruction, recurrence of constipation, and diarrhea [54].

3. Subtotal colectomy combined with different anastomosis methods is also the surgical treatment of choice for slow transit constipation (evidence level: C, recommendation strength: strong).

Subtotal colectomy is also a common surgical procedure for the surgical treatment of slow-transit constipation and is widely used in China. It mainly includes two categories: (1) subtotal colectomy and cecal-rectal or ascending colorectal anastomosis with preservation of the ileocecal valve; (2) subtotal colectomy and ileosigmoid anastomosis with preservation of the distal sigmoid colon. Both surgical methods can effectively improve the symptoms of reduced defecation frequency in patients with slow transit constipation, but there are significant differences in the results reported by different studies, with the total effective rate and patient satisfaction rate ranging from 39% to 100% [49]. The former can alleviate intractable postoperative diarrhea to a certain extent because it preserves the ileocecal valve; the latter preserves part of the sigmoid colon, which is helpful in alleviating postoperative diarrhea, but both are likely to increase the recurrence of postoperative constipation [55]. Subtotal colectomy with preservation of the ileocecal valve includes ascending colorectal side-to-side anastomosis (Jinling operation) [56], end-to-side anastomosis of the cecum with 90-degree rotation and the rectum [57], and retroperistaltic anastomosis of the end of the cecum and the rectum [58]. Some studies believe that Jinling surgery can correct anatomical abnormalities and functional disorders of the rectum and anal canal at the same time, and is suitable for patients with mainly slow colonic transit and concurrent outlet obstruction [56]. However, ultra-low ascending colorectal anastomosis increases the difficulty of the operation and the risk of anastomotic leakage; some people believe that not performing pelvic separation can avoid the impact on urinary function and sexual function [59].

4. Antegrade colon lavage, colon or ileostomy, and colon exclusion surgery can be considered when the elderly are frail or unable to tolerate other surgeries, and are also options in extreme cases after other surgeries fail (level of evidence: C, recommendation strength: weak).

Antegrade lavage of the colon generally uses an appendicostomy or cecal tube. Reports on the use of antegrade colonic lavage, colon or ileostomy, and colon exclusion surgery for patients with refractory constipation in a specific population are mostly observational studies with small samples. They have recent effects on relieving constipation, but there are few Long-term follow-up data[60]. This type of surgery has the advantages of simple operation, short operation time, and minimal trauma. However, there are many postoperative complications, such as blind loop syndrome after exclusion, which can easily lead to abdominal distension and abdominal pain; antegrade lavage can easily lead to tube blockage or stenosis, The lavage fluid backflows; enterostomy-related complications occur [61-62]. It is generally believed that for patients who are extremely weak and unable to tolerate colectomy, or who have severe symptoms of intestinal obstruction due to constipation and are unconditionally required to undergo colectomy, or who have had constipation recurrence after previous surgery failed and cannot bear greater risk of surgery, etc., you can consider selecting applications.

5. For moderate to severe intrarectal prolapse associated with outlet obstruction symptoms, surgery may be considered when conservative treatment fails (evidence level: B, recommendation strength: strong).

For patients with severe outlet obstruction symptoms who are confirmed to have moderate to severe intrarectal prolapse by imaging examination, surgery may be considered when conservative treatment is ineffective. Surgical methods can be divided into two categories: transabdominal and transperineal: transabdominal surgery includes various types of rectal suspension or fixation; transperineal surgery includes Delorme surgery, stapled transanal rectal resection (STARR) )wait. Each of these procedures has advantages and disadvantages, and the clinical selection is controversial.

The laparoscopic minimally invasive approach is recommended for the transabdominal approach. Various suture rectopexy is a classic surgical procedure for the treatment of rectal prolapse. There are many surgical procedures reported in the literature. The main differences lie in whether a patch is used and the location where the patch is fixed. The constipation relief rate is 40% to 90% [63-64]. Among them, the representative surgical procedure, laparoscopic ventral mesh rectopexy (LVMR), has been highly praised in recent years and is the preferred surgical procedure for the treatment of intrarectal prolapse by European colorectal surgeons [65-66]. The constipation relief rate after LVMR is over 90%, new constipation is rare, and the recurrence rate is about 6% [67-68]. Postoperative complications of LVMR include mesh erosion, infection, and displacement, and the incidence rate of mesh erosion is 2% to 3% [69-70]. Some studies believe that biological patches can reduce the incidence of erosion [70]. In addition, LVMR surgery may cause problems such as pelvic pain and sexual dysfunction [71]. The efficacy of robot-assisted ventral patch rectopexy is equivalent to that of LVMR [72]. Resection rectopexy is a sigmoidectomy performed based on rectopexy [73]. Some studies believe that this surgery can improve the improvement rate of constipation symptoms [63]; it will not increase the incidence of postoperative complications [74]. However, caution should be considered when using patch fixation to avoid intraoperative contamination.

There are many transperineal surgeries, including Delorme surgery and STARR surgery. These two surgeries have similar therapeutic effects on rectal prolapse, and the long-term recurrence rate is >10% [75]. A randomized controlled study proved that LVMR surgery has better long-term efficacy than STARR surgery in the elderly [75]. However, a retrospective study of 450 cases concluded that the overall constipation improvement of the two surgical methods was similar [76]. It is generally believed that the transabdominal approach has a low recurrence rate and a high symptom improvement rate, but a slightly higher complication rate; while the transperineal approach has a lower complication rate, but a higher recurrence rate. With the popularity of laparoscopic and robotic minimally invasive surgeries, the transabdominal surgical approach is increasingly recommended internationally. However, there are contraindications for transabdominal approach surgery, those who cannot tolerate general anesthesia, and young and middle-aged men who are wary of the potential impact of surgery on reproductive function. When affected, transperineal surgery is also a reasonable option. Clinically, individual selection should be made based on the condition, the doctor's experience and habits, and the patient's demands.

6. When rectocele can explain the clinical symptoms of outlet obstruction and constipation, surgery may be considered (evidence level: B, recommendation strength: strong).

If the symptoms of outlet obstruction and constipation are obvious, rectocele may be considered in clinical and imaging diagnosis. If conservative treatment is ineffective, surgery may be considered. It is generally believed that when the depth of rectocele shown by defecography is >3 cm, and some studies suggest that it is >2 cm when the symptoms are severe, it can also be considered [77]; the protruding bag has a contrast agent residue and requires manual pressure on the vagina or hands. Assisting defecation is also an important basis for increasing surgical considerations [13, 78]. Currently reported surgical approaches for rectocele include transanal, transvaginal, transperineal, and transabdominal approaches [13,78-83].

Transanal rectocele repair includes traditional transanal rectocele repair, STARR surgery, and other transanal incision and stapler rectocele repairs [13, 79-83]. Patients at risk of anal incontinence should use transanal surgery with caution [13]. According to literature reports, the overall effectiveness of traditional transanal rectocele repair is about 70% [84]; the overall postoperative satisfaction rate after STARR is 68% to 99% [80, 85]. The postoperative constipation score was significantly lower than that before surgery [80]. Common complications include urgency of defecation, anastomotic bleeding, and rectal pain. As the follow-up time increases, the recurrence rate of constipation increases [76, 85-86].

Transvaginal rectocele surgery is a commonly used surgical approach. It has the advantages of better exposing the pelvic fascia and levator ani muscles, maintaining the integrity of the rectal wall, and reducing complications such as infection and rectovaginal fistula formation. The overall effective rate is >80 %, and the recurrence rate is low [85]. The incidence rate of dyspareunia complications reported in the literature is 0 to 36% [87].

The transperineal approach to rectocele repair is often combined with patch placement or levator angioplasty, which is especially suitable for patients with rectocele accompanied by sphincter defect or risk of fecal incontinence. The improvement rate of outlet obstruction symptoms is 70% to 91%. [88⁃89]. Common complications include wound infection, bleeding or hematoma, dyspareunia, rectovaginal fistula, and patch erosion [89-90]. A recent RCT study concluded that the transvaginal approach has a better constipation improvement rate and sexual life quality [88].

For patients with rectocele accompanied by anatomic abnormalities such as rectal prolapse, pelvic floor peritoneal hernia, or utero-vesical prolapse, LVMR surgery is recommended [13, 78, 85, 91-92]. Some studies believe that compared with transvaginal and transanal rectocele repair, patients in the LVMR group achieved better postoperative quality of life scores, anatomical correction, and lower recurrence rates [91-92].

7. Biofeedback treatment should be the first choice for spastic constipation of pelvic floor muscles. Type A carnitine injection closure can also be chosen. The effect of surgery on spastic constipation of pelvic floor muscles is uncertain and careful selection is required (Evidence quality: C, Recommendation strength: Strong ).

Typical dyssynergic defecation disorders (DD) that are common clinically include pelvic floor spasm syndrome and puborectalis syndrome. The clinical manifestations of the two are similar and it is difficult to distinguish them with imaging. The main manifestation is that the internal and external anal sphincter, puborectalis, and other pelvic floor muscles cannot relax or relax insufficiently during defecation, or even contract abnormally [93]. The success rate of biofeedback treatment is between 33% and 80% [94-95]. It can be used as the first choice treatment method and has been tried many times.

For patients who are ineffective in biofeedback treatment, perianal injection of type A carnitine can be considered for closed treatment. Usually, under the guidance of digital anal examination at 3 o'clock and 9 o'clock, the puborectalis muscle and/or external anal sphincter are injected, and the symptoms are improved. The rate is 29.2%~100%, with great heterogeneity [96]. When various conservative treatments are ineffective, partial puborectal muscle amputation can be attempted, but there are few relevant reports, the efficacy is uncertain, and there is a certain risk of incontinence, and the indications for surgery need to be strictly controlled [95].

8. Adult Hirschsprung disease is a special type of constipation with unique pathogenesis and different surgical methods. The presence of this disease must be clarified during the preoperative evaluation of chronic constipation (Evidence level: B, Recommendation strength: Strong)

Adult megacolon includes adult Hirschsprungdisease (HD) and adult idiopathic megacolon (IMC). Due to their different pathogenesis, the surgical procedures are different [97-98].

HD is caused by a lack of ganglion cells in the distal colon, rectal submucosal plexus, and myenteric plexus. Surgery is an effective method to cure the disease. The basic principle of surgery is to remove the stenotic segment, transitional segment and obviously dilated segment of the intestine. During the operation, the tissue was quickly frozen and sectioned to observe the distribution of ganglion cells in the intestinal wall muscle layer. Ganglion cells should be clearly seen at both the far and near resection edges before intestinal reconstruction can be performed [99].

IMC has many similarities with HD, but IMC does not have an obviously narrow intestinal segment. Its dilated intestinal segment is the diseased intestinal segment. The number of ganglia in this intestinal segment is reduced and degenerated, the smooth muscle layer of the intestinal wall is thin, and intestinal peristalsis is weak. The principles of surgical treatment of IMC are also different from HD. In the former, the dilated intestinal segment should be resected. Subtotal colectomy plus ileorectal anastomosis or ascending colorectal anastomosis should be selected. The latter retains the function of the ileocecal valve and can reduce postoperative diarrhea. Symptoms[100].

Since the causes of adult megacolon are different, surgical treatment strategies are also different. Only by doing as comprehensive and detailed a preoperative evaluation as possible can we obtain satisfactory treatment results.

Natural Herbal Medicine For Relieving Constipation-Cistanche 

Cistanche is a genus of parasitic plants that belongs to the family Orobanchaceae. These plants are known for their medicinal properties and have been used in Traditional Chinese Medicine (TCM) for centuries. Cistanche species are predominantly found in arid and desert regions of China, Mongolia, and other parts of Central Asia. Cistanche plants are characterized by their fleshy, yellowish stems and are highly valued for their potential health benefits. In TCM, Cistanche is believed to have tonic properties and is commonly used to nourish the kidney, enhance vitality, and support sexual function. It is also used to address issues related to aging, fatigue, and overall well-being. While Cistanche has a long history of use in traditional medicine, scientific research on its efficacy and safety is ongoing and limited. However, it is known to contain various bioactive compounds such as phenylethanoid glycosides, iridoids, lignans, and polysaccharides, which may contribute to its medicinal effects.

Wecistanche's cistanche powder, cistanche tablets, cistanche capsules, and other products are developed using desert cistanche as raw materials, all of which have a good effect on relieving constipation. The specific mechanism is as follows: Cistanche is believed to have potential benefits for relieving constipation based on its traditional use and certain compounds it contains. While scientific research specifically on Cistanche's effect on constipation is limited, it is thought to have multiple mechanisms that may contribute to its potential to relieve constipation. Laxative Effect: Cistanche has long been used in Traditional Chinese Medicine as a remedy for constipation. It is believed to have a mild laxative effect, which can help promote bowel movements and induce constipation. This effect may be attributed to various compounds found in Cistanche, such as phenylethanoid glycosides and polysaccharides. Moistening the Intestines: Based on traditional use, Cistanche is considered to have moisturizing properties, specifically targeting the Intestines. Promoting hydration and lubrication of the Intestines may help soften tools and facilitate easier passage, thereby relieving constipation. Anti-inflammatory Effect: Constipation can sometimes be associated with inflammation in the digestive tract. Cistanche contains certain compounds, including phenylethanoid glycosides and lignans, that are believed to have anti-inflammatory properties. By reducing inflammation in the intestines, it may help improve bowel movement regularity and relieve constipation.