顽固性混合型便秘行金陵术前后直肠肛管压力的前瞻性临床研究
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摘要
慢性便秘（CC）是一常见症候群，我国发病率在3%-17.6%，近年随生活习惯和饮食结构的改变，其发生率逐年升高，并随年龄增大而增高。慢性便秘可分为器质性和功能性两种。功能性便秘（FC）是指排除器质性便秘和心理因素导致的便秘，约占慢性便秘的一半，如不发生并发症，总体上是一种良性病变，可进一步分为结肠慢传输型（STC）、出口梗阻型（OOC）、两者并存的混合型（MC）。慢性便秘最初多单纯表现为结肠慢传输或出口梗阻，因治疗不当、病程迁延，上述两种病理类型互相影响、互为因果、恶性循环，其中约10%发展成为顽固性混合型便秘，内科治疗效果差，往往需求助于手术治疗。顽固性便秘手术目的是缓解症状和提高生活质量，因此对手术效果要求较高。以往的手术方式多单纯针对结肠慢传输或出口梗阻，仅行结肠全切除、次全切除或经会阴行局部手术，效果均差强人意，远期疗效差、复发率高。
南京军区南京总医院普通外科研究所自2000年开始进行顽固性混合型便秘外科治疗的临床研究，创新设计了金陵术（Jinling procedure）——结肠次全切除联合升结肠-直肠侧侧吻合术，可同时纠正结肠慢传输和出口梗阻两种病理生理紊乱。金陵术切除大部结肠、重建盆底，术后短期存在排便次数增多、肛门坠胀、排便不尽等不适症状，但排便感觉受主观因素影响较大，因此我们希望结合客观指标来评估金陵术前后排便功能的变化。
直肠肛管测压（ARM）是排便功能检查的必备指标，是目前临床应用最广泛的直肠肛管疾病检测指标之一，对便秘、排便失禁、巨结肠的诊治及术后直肠肛管功能评估具有重要意义。目前国内广泛应用的为水灌注测压法（WPM），存在诸多不足：需通过检测导管侧孔处注入蒸馏水的压力间接反映肠管内压力，需将测压导管间断拉出，记录相对连续的压力，每次只能检测肠管内同一圆周上一个点的压力，检测时间长，数据分析需要有丰富经验的医师，且注水、牵拉刺激影响直肠肛管压力的准确性。国际上普遍应用固态高分辨率直肠肛管测压系统（HRM-AR）：ManoScan360测压仪，具有较多优点：压力感受器位于测压导管上，直接感受肠管内压力；测压点（144个）密集、均匀，可获得连续高保真的数据；不需拉出导管及注水，数据更加精确、客观；数据转化为“连续等压图”，分析更加简便、直观；与灌注式测压法有较好的相关性，可重复性好。2005年通过CE、FDA标准进入欧美市场，2010年正式进入国内市场，目前在肛肠疾病的应用较少。
本研究论文中，我们利用HRM-AR前瞻性研究顽固性混合型便秘患者行金陵术治疗前后直肠肛管压力的变化，希望能阐明金陵术改善顽固性混合型便秘患者出口梗阻症状的机理、临床表现与压力结果的关系，从而指导、量化术后治疗措施。
目的建立高分辨率直肠肛管测压法（HRM-AR）的标准操作流程，建立本中心正常人高分辨率直肠肛管压力数据库，术前应用HRM-AR对顽固性混合型便秘患者进行检测，评估顽固性混合型便秘患者的直肠肛管功能。
方法2012年10月至12月连续选取50例慢性胆囊炎、胆囊结石或胆囊息肉患者，近1月无急性发作史，排除便秘、腹泻、胃肠道疾病及手术史、代谢性疾病、内分泌疾病、神经精神疾病，签署知情同意书，进行HRM-AR检测，分别记录肛管运动功能：肛管静息压（RP）、肛管最大收缩压（MSP）、肛管括约肌长度（HPZ）、收缩持续时间（DSS）；直肠肛管协调运动功能：直肠排便压（IRP）、肛管舒张压（RAP）、肛管松弛率（ARR）、直肠肛管压力梯度（RAPG）；神经反射功能：直肠肛门抑制反射（RAIR）；直肠感觉功能：直肠初始感觉阈值（Sensation），直肠初始排便阈值（Urge），直肠最大耐受量（Discomfort）等，建立本中心HRM-AR的正常人数据库。对2010年1月至2011年12月210例顽固性混合型便秘患者行金陵术前进行HRM-AR检测，检测方法、检测指标同上，与正常人数据进行对比，分析便秘患者各项检测指标是否存在异常。
结果熟练掌握高分辨率胃肠动力检测系统——ManoScan360HRM；制定本中心HRM-AR检测的标准操作流程；正常人的高分辨率直肠肛管压力数据与国外文献报道相似，在直肠最大耐受量指标上有较大差异（均值分别为146ml、96ml）。便秘患者较正常人存在RP、MSP、ARR及RAIR阳性率降低，直肠初始感觉阈值及初始排便感觉阈值增高，P值均小于0.05。
结论HRM-AR系统操作简单，灵敏度高，被检者耐受性较好，可以获得连续高保真数据；正常人的HRM-AR结果与传统WPM结果有差异，但相关性较好，与国外正常人的HRM-AR结果相比一致性较好；顽固性混合型便秘患者肛管的张力、收缩及舒张功能减退，局部神经反射功能减退，直肠感觉阈值升高。
目的为发现顽固性混合型便秘患者行金陵术（结肠次全切除联合升结肠-直肠侧侧吻合）后不适，及时处理，进一步证实金陵术的安全性及可靠性；金陵术对盆底进行重建，测压导管放置位置较术前有改变，探讨导管放置位置对压力检测结果的影响；对行金陵术治疗的顽固性便秘患者术后进行HRM-AR检测随访，观察直肠肛管压力改变的客观依据，证实金陵术可改善顽固混合型便秘患者的直肠肛管功能。
方法2010年1月至2011年12月共194例顽固性混合型便秘患者行金陵，术后1月、3月、6月、12月来院门诊随访，随访率分别为96.9%（188）、95.4%（185）、93.8%（182）、90.2%（175）应用问卷方式对顽固性混合型便秘患者术后排便情况、胃肠生活质量情况、手术满意程度进行量化，包括：Wexner便秘严重度评分、Longo′s出口梗阻评分、胃肠生存质量指数（GIQLI）、Wexner肛门失禁评分、排便满意度；2010年1月至3月选取连续10例金陵术后随访患者，进行HRM-AR检测，先将测压导管尖端经升结肠-直肠侧侧吻合口置于升结肠内，此为A组，后将测压导管退至直肠残端内，进行HRM-AR检测，此为B组，分析测压导管位置不同对检测结果的影响，决定术后HRM-AR检测导管放置位置；对2010年2月至2013年1月随访的患者如无检查禁忌进行HRM-AR检测，共进行650人次检测（术后1月162例、术后3月164例、术后6月165例、术后12月159例）。应用SPSS17.0软件进行统计分析，计量资料以均数±标准误（x±SE）表示，两组均数比较用t检验，计数资料用Pearson卡方检验或Fisher精确概率法检验，检验水准定为P<0.05。
结果金陵术后粪便干结、排便困难症状消失，排便顺畅无需用力及药物、灌肠辅助排便，Wexner便秘评分由20.28±4.37降至4.29±1.85，Longo’s出口梗阻评分由17.50±5.87降至1.91±1.21，均有显著性差异；术后早期腹泻、排便次数增多，吻合口炎症、水肿所致里急后重感觉明显，患者对术后症状及排便习惯改变存在生理及心理上的不适，GIQLI评分由术前62.30±12.19降至术后1月的46.60±8.39，显著降低，排便满意度不高，随着手术创伤愈合、排便次数减少、里急后重感觉消失，对手术效果的疑虑解除，GIQLI评分升至98.27±9.02，排便满意度由术后1月的41.0%升至术后12月的93.7%，均有显著提高；Wexner排便失禁评分由术前的1.20±1.07升至术后1月的7.10±3.17，显著升高，术后12月降至1.21±0.98，与术前无显著差异。测压导管放置A、B组比较发现：两者在直肠感觉、直肠运动及神经反射功能上没有显著性差异；在肛管运动、直肠肛管协调运动功能上差异明显。金陵术后短期肛管括约肌功能明显减退（RP、HPZ、MSP、DSS较术前降低，P值均小于0.01，提示收缩无力），远期其运动功能逐渐恢复。术后短期RP、RAP降低，ARR同步降低，P值均小于0.05，提示括约肌松弛障碍；远期RAP进一步降低，ARR升高，P值均小于0.01，提示排便改善后，括约肌舒张功能亦改善。IRP术后短期较术前稍降低，P=0.10；远期恢复，提示金陵术虽然切断部分腹直肌，并未影响其功能；RAPG为IRP与RAP的差值，术后逐渐增大，虽然仍为负值，已高于正常人，且肛管矛盾收缩的比例明显降低；金陵术后短期RAIR阳性率明显降低（术后1月P=0.014），但仍有高达75%的患者表现为阳性，且部分全直肠切除患者仍可引出RAIR，考虑该反射感受器除位于直肠壁内，还可能位于直肠周围的盆底肌肉内。术后12月RAIR阳性率逐渐恢复至术前水平，接近于健康人，并没有完全恢复正常。
结论术后Wexner便秘严重度评分、Longo’s出口梗阻评分均显著下降，排便满意度逐渐增高，金陵术可明显明显改善顽固性混合型便秘症状；术后远期GIQLI明显增加，金陵术可显著提高便秘患者胃肠生活质量； Wexner肛门失禁评分术后短期显著升高，远期降至术前水平，金陵术并没有增加排便失禁的风险，未损伤括约肌功能。A组虽将测压导管尖端放过吻合口，置入升结肠，测压导管的直肠压力感受器多位于侧侧吻合口的顶端，球囊的膨胀可刺激直肠残端，可以检测术后新直肠（升结肠-直肠贮袋）的感觉、运动及最大容积，同时可以完整的检测肛管的运动功能，更好的评估金陵术后直肠肛管功能。金陵术后短期肛管运动功能有所减退，表现为收缩无力、舒张障碍，远期其收缩及舒张功能逐渐改善；肛管的矛盾收缩较前明显改善，腹部、盆底、括约肌的协调功能改善；RAIR的感受器可能还存在于盆底肌肉内，随感觉功能的改善，神经反射的引出率较前稍提高，但由于神经变性导致的反射消失无法恢复；直肠的感觉功能明显改善，升结肠-直肠的贮袋完全代偿原直肠的贮便功能。
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.
南京军区南京总医院普通外科研究所自2000年开始进行顽固性混合型便秘外科治疗的临床研究，创新设计了金陵术（Jinling procedure）——结肠次全切除联合升结肠-直肠侧侧吻合术，可同时纠正结肠慢传输和出口梗阻两种病理生理紊乱。金陵术切除大部结肠、重建盆底，术后短期存在排便次数增多、肛门坠胀、排便不尽等不适症状，但排便感觉受主观因素影响较大，因此我们希望结合客观指标来评估金陵术前后排便功能的变化。
直肠肛管测压（ARM）是排便功能检查的必备指标，是目前临床应用最广泛的直肠肛管疾病检测指标之一，对便秘、排便失禁、巨结肠的诊治及术后直肠肛管功能评估具有重要意义。目前国内广泛应用的为水灌注测压法（WPM），存在诸多不足：需通过检测导管侧孔处注入蒸馏水的压力间接反映肠管内压力，需将测压导管间断拉出，记录相对连续的压力，每次只能检测肠管内同一圆周上一个点的压力，检测时间长，数据分析需要有丰富经验的医师，且注水、牵拉刺激影响直肠肛管压力的准确性。国际上普遍应用固态高分辨率直肠肛管测压系统（HRM-AR）：ManoScan360测压仪，具有较多优点：压力感受器位于测压导管上，直接感受肠管内压力；测压点（144个）密集、均匀，可获得连续高保真的数据；不需拉出导管及注水，数据更加精确、客观；数据转化为“连续等压图”，分析更加简便、直观；与灌注式测压法有较好的相关性，可重复性好。2005年通过CE、FDA标准进入欧美市场，2010年正式进入国内市场，目前在肛肠疾病的应用较少。
本研究论文中，我们利用HRM-AR前瞻性研究顽固性混合型便秘患者行金陵术治疗前后直肠肛管压力的变化，希望能阐明金陵术改善顽固性混合型便秘患者出口梗阻症状的机理、临床表现与压力结果的关系，从而指导、量化术后治疗措施。
目的建立高分辨率直肠肛管测压法（HRM-AR）的标准操作流程，建立本中心正常人高分辨率直肠肛管压力数据库，术前应用HRM-AR对顽固性混合型便秘患者进行检测，评估顽固性混合型便秘患者的直肠肛管功能。
方法2012年10月至12月连续选取50例慢性胆囊炎、胆囊结石或胆囊息肉患者，近1月无急性发作史，排除便秘、腹泻、胃肠道疾病及手术史、代谢性疾病、内分泌疾病、神经精神疾病，签署知情同意书，进行HRM-AR检测，分别记录肛管运动功能：肛管静息压（RP）、肛管最大收缩压（MSP）、肛管括约肌长度（HPZ）、收缩持续时间（DSS）；直肠肛管协调运动功能：直肠排便压（IRP）、肛管舒张压（RAP）、肛管松弛率（ARR）、直肠肛管压力梯度（RAPG）；神经反射功能：直肠肛门抑制反射（RAIR）；直肠感觉功能：直肠初始感觉阈值（Sensation），直肠初始排便阈值（Urge），直肠最大耐受量（Discomfort）等，建立本中心HRM-AR的正常人数据库。对2010年1月至2011年12月210例顽固性混合型便秘患者行金陵术前进行HRM-AR检测，检测方法、检测指标同上，与正常人数据进行对比，分析便秘患者各项检测指标是否存在异常。
结果熟练掌握高分辨率胃肠动力检测系统——ManoScan360HRM；制定本中心HRM-AR检测的标准操作流程；正常人的高分辨率直肠肛管压力数据与国外文献报道相似，在直肠最大耐受量指标上有较大差异（均值分别为146ml、96ml）。便秘患者较正常人存在RP、MSP、ARR及RAIR阳性率降低，直肠初始感觉阈值及初始排便感觉阈值增高，P值均小于0.05。
结论HRM-AR系统操作简单，灵敏度高，被检者耐受性较好，可以获得连续高保真数据；正常人的HRM-AR结果与传统WPM结果有差异，但相关性较好，与国外正常人的HRM-AR结果相比一致性较好；顽固性混合型便秘患者肛管的张力、收缩及舒张功能减退，局部神经反射功能减退，直肠感觉阈值升高。
目的为发现顽固性混合型便秘患者行金陵术（结肠次全切除联合升结肠-直肠侧侧吻合）后不适，及时处理，进一步证实金陵术的安全性及可靠性；金陵术对盆底进行重建，测压导管放置位置较术前有改变，探讨导管放置位置对压力检测结果的影响；对行金陵术治疗的顽固性便秘患者术后进行HRM-AR检测随访，观察直肠肛管压力改变的客观依据，证实金陵术可改善顽固混合型便秘患者的直肠肛管功能。
方法2010年1月至2011年12月共194例顽固性混合型便秘患者行金陵，术后1月、3月、6月、12月来院门诊随访，随访率分别为96.9%（188）、95.4%（185）、93.8%（182）、90.2%（175）应用问卷方式对顽固性混合型便秘患者术后排便情况、胃肠生活质量情况、手术满意程度进行量化，包括：Wexner便秘严重度评分、Longo′s出口梗阻评分、胃肠生存质量指数（GIQLI）、Wexner肛门失禁评分、排便满意度；2010年1月至3月选取连续10例金陵术后随访患者，进行HRM-AR检测，先将测压导管尖端经升结肠-直肠侧侧吻合口置于升结肠内，此为A组，后将测压导管退至直肠残端内，进行HRM-AR检测，此为B组，分析测压导管位置不同对检测结果的影响，决定术后HRM-AR检测导管放置位置；对2010年2月至2013年1月随访的患者如无检查禁忌进行HRM-AR检测，共进行650人次检测（术后1月162例、术后3月164例、术后6月165例、术后12月159例）。应用SPSS17.0软件进行统计分析，计量资料以均数±标准误（x±SE）表示，两组均数比较用t检验，计数资料用Pearson卡方检验或Fisher精确概率法检验，检验水准定为P<0.05。
结果金陵术后粪便干结、排便困难症状消失，排便顺畅无需用力及药物、灌肠辅助排便，Wexner便秘评分由20.28±4.37降至4.29±1.85，Longo’s出口梗阻评分由17.50±5.87降至1.91±1.21，均有显著性差异；术后早期腹泻、排便次数增多，吻合口炎症、水肿所致里急后重感觉明显，患者对术后症状及排便习惯改变存在生理及心理上的不适，GIQLI评分由术前62.30±12.19降至术后1月的46.60±8.39，显著降低，排便满意度不高，随着手术创伤愈合、排便次数减少、里急后重感觉消失，对手术效果的疑虑解除，GIQLI评分升至98.27±9.02，排便满意度由术后1月的41.0%升至术后12月的93.7%，均有显著提高；Wexner排便失禁评分由术前的1.20±1.07升至术后1月的7.10±3.17，显著升高，术后12月降至1.21±0.98，与术前无显著差异。测压导管放置A、B组比较发现：两者在直肠感觉、直肠运动及神经反射功能上没有显著性差异；在肛管运动、直肠肛管协调运动功能上差异明显。金陵术后短期肛管括约肌功能明显减退（RP、HPZ、MSP、DSS较术前降低，P值均小于0.01，提示收缩无力），远期其运动功能逐渐恢复。术后短期RP、RAP降低，ARR同步降低，P值均小于0.05，提示括约肌松弛障碍；远期RAP进一步降低，ARR升高，P值均小于0.01，提示排便改善后，括约肌舒张功能亦改善。IRP术后短期较术前稍降低，P=0.10；远期恢复，提示金陵术虽然切断部分腹直肌，并未影响其功能；RAPG为IRP与RAP的差值，术后逐渐增大，虽然仍为负值，已高于正常人，且肛管矛盾收缩的比例明显降低；金陵术后短期RAIR阳性率明显降低（术后1月P=0.014），但仍有高达75%的患者表现为阳性，且部分全直肠切除患者仍可引出RAIR，考虑该反射感受器除位于直肠壁内，还可能位于直肠周围的盆底肌肉内。术后12月RAIR阳性率逐渐恢复至术前水平，接近于健康人，并没有完全恢复正常。
结论术后Wexner便秘严重度评分、Longo’s出口梗阻评分均显著下降，排便满意度逐渐增高，金陵术可明显明显改善顽固性混合型便秘症状；术后远期GIQLI明显增加，金陵术可显著提高便秘患者胃肠生活质量； Wexner肛门失禁评分术后短期显著升高，远期降至术前水平，金陵术并没有增加排便失禁的风险，未损伤括约肌功能。A组虽将测压导管尖端放过吻合口，置入升结肠，测压导管的直肠压力感受器多位于侧侧吻合口的顶端，球囊的膨胀可刺激直肠残端，可以检测术后新直肠（升结肠-直肠贮袋）的感觉、运动及最大容积，同时可以完整的检测肛管的运动功能，更好的评估金陵术后直肠肛管功能。金陵术后短期肛管运动功能有所减退，表现为收缩无力、舒张障碍，远期其收缩及舒张功能逐渐改善；肛管的矛盾收缩较前明显改善，腹部、盆底、括约肌的协调功能改善；RAIR的感受器可能还存在于盆底肌肉内，随感觉功能的改善，神经反射的引出率较前稍提高，但由于神经变性导致的反射消失无法恢复；直肠的感觉功能明显改善，升结肠-直肠的贮袋完全代偿原直肠的贮便功能。
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.
引文
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