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In recent years, advancements have been made in both basic and surgical research of slow-transit constipation (STC). However, compelling references for surgeons in the clinical practice of STC have been lacking, particularly on preoperative evaluation and the choice of surgical procedures. In order to further standardize the diagnosis, assessment and surgical management of STC, Chinese Medical Doctor Association Anorectal Doctor Branch and its Functional Diseases Committee selected relevant experts in the field of STC surgery in China to form the Editorial and Review Committee of the Expert Consensus on Diagnosis, Evaluation and Surgical Management of STC in China. By meticulously reviewing relevant literature from both domestic and international sources and integrating the clinical expertise of the panel of experts, the committee has formulated 20 recommendations. These recommendations aim to establish standardized processes for surgical diagnosis and treatment of STC, ultimately elevating the overall diagnostic and therapeutic standards for STC across China.

Operation is one of the important methods for the treatment of chronic constipation, while the perioperative management is an important part of the operation. This consensus aims to improve the understanding of chronic constipation surgery among Chinese colorectal and anal surgeons and to provide instructions for the perioperative management. This consensus provides detailed recommendations for preoperative assessment, preoperative preparation, the choice of procedures, postoperative management and follow-up. The consensus is intended to reduce complications and improve efficacy.

Objective: To investigate the clinical efficacy of laparoscopic subtotal colonic bypass plus colostomy with antiperistaltic cecoproctostomy (SCBCAC) in the treatment of senile slow transit constipation. Methods: A retrospective cohort study was performed. Clinical data of 30 colonic slow transit constipation patients aged ≥70 years old undergoing laparoscopic SCBCAC from July 2012 to October 2016 (bypass plus colostomy group), and 28 patients undergoing laparoscopic subtotal colonic bypass with antiperistaltic cecoproctostomy (SCBAC) from February 2009 to June 2012 (bypass group) at our institute were collected. Efficacy was compared between the two procedures. Inclusion criteria: (1) meeting the Rome III diagnosis criteria for constipation; (2) confirmed diagnosis of slow transit constipation; (3) age ≥ 70 years old; (4) receiving non-surgical treatment for more than 5 years, and Wexner constipation score > 15; (5) follow-up for more than 2 years. Those with psychiatric symptoms or previous psychiatric history, obvious signs of outlet obstructive constipation, organic diseases of the colon and life-threatening cardiovascular diseases or cancer were excluded. In the bypass plus colostomy group, laparoscopy was performed via five trocars. The ileocecal junction and the ascending colon were mobilized and the ileocecal junction was pulled down to the pelvic inlet. The ascending colon was transected and the appendix was excised. The lateral peritoneum of the sigmoid colon and the rectal mesentery were dissected and the upper rectum was transected. The avil of a circular stapler was placed in the bottom of the cecum. The shaft of the stapler was placed in the rectum via the anal canal to complete end-to-side anastomosis (end rectum to lateral cecum). The end of the rectal-sigmoid colon was used for colostomy via an extraperitoneal approach to complete the operation. The following efficacy indexes were collected before surgery and 3, 6, 12, and 24 months after surgery: the number of daily bowel movements, the Wexner incontinence scale (WIS, 0-20, the lower the better), the Wexner constipation scale (WCS, 0-30, the lower the better), the gastrointestinal quality of life index (GIQLI, 0-144, the higher score, the better), abdominal pain intensity indicated by the numerical rating scale (NRS, 0-10, the lower score, the better), and the abdominal bloating score (ABS, 0-4, the lower score, the better). The complications defined as Clavien-Dindo class II or above were observed and recorded. Results: No significant differences in preoperative WCS, WIS, GIQLI, NRS, and ABS were observed between bypass plus colostomy group and bypass group (all P >0.05). All the patients successfully underwent laparoscopic surgery and no patient in either group experienced postoperative fecal incontinence. WCS and GIQLI were significantly improved (all P <0.001) at 3, 6, 12, and 24 months after surgery in both groups. At 12 months after surgery, the number of bowel movements was significantly less in bypass plus colostomy group than that in bypass group [(2.4±0.7) times vs. (3.4±1.2) times, t =4.048, P <0.001]. At 3, 6, 12 and 24 months after surgery, the improvement of GIQLI in bypass plus colostomy group was significantly better than that in bypass group (all P <0.001). At 24 months after surgery, GIQLI in bypass plus colostomy group and bypass group was 122.3±5.3 and 92.8±16.6, respectively, with a significant difference ( t =9.276, P <0.001). At 12 and 24 months after surgery, NRS in bypass plus colostomy group was significantly better than that in bypass group (both P <0.001). At 24 months after surgery, NRS in bypass plus colostomy group was 0.9±0.7, while that in bypass group was 3.7±2.7. There was a significant difference between two groups ( t= 5.585, P <0.001). At 6, 12 and 24 months after surgery, the improvement of ABS in bypass plus colostomy group was also significantly better than that in bypass group. At 24 months after surgery, ABS in bypass plus colostomy group was 0.6±0.6, while that in bypass group was 2.5±1.0, with a significant difference between two groups ( t= 8.797, P <0.001). At 1 year after surgery, barium enema examination was performed in all the patients of both groups. The barium emptying time was (21.2±3.8) hours and (95.8±86.2) hours in bypass plus colostomy group and bypass group respectively. The former group was significantly better than the latter group ( t= 4.740, P <0.001). Conclusions: Laparoscopic SCBCAC is an effective and safe procedure for the treatment of senile slow transit constipation and can significantly improve prognosis. Its clinical efficacy is better than laparoscopic SCBAC.

Objective: To investigate the safety and feasibility of 3D laparoscopic surgery via transrectal extraction of specimens without abdominal incision in the treatment of slow transit constipation (STC)., Methods: From May 2015 to January 2017, 8 STC patients (6 females and 2 males) with informed consent were selected to receive subtotal colectomy with 3D laparoscopy as the no-incision incision group, in which the initial part of ascending colon and rectum were end-to-end anastomosed directly after extraction of the specimen through the rectum. Twelve STC patients (9 females and 3 males) undergoing traditional subtotal colectomy with 3D laparoscopy were selected as the traditional group by case matching method (gender, age, BMI, the difference of receiving operation time less than 12 months, same surgeon team). Perioperative parameters (operation duration, intraoperative blood loss, exhausting time, postoperative hospital stay, complications, postoperative pain score and additional pain management), inflammation index at postoperative day 1 and day 3 (leukocyte, procalcitonin, interleukin 6, C-reactive protein), postoperative peritoneal infection, wound healing, short-term and long-term efficacy, patient satisfaction evaluation (subjective hundred-mark system) at postoperative one year were compared between two groups., Results: There were no significant differences between two groups in operation duration, intraoperative blood loss, exhausting time, postoperative hospital stay and morbidity of complication (all P>0.05). Significantly lower pain scores at postoperative 6-hour (median 3.0 vs. 4.5, U=23.0, P=0.042), lower ratio of additional analgesic at postoperative day 1(1/8 vs. 7/12, P=0.040) were found in the no-incision group. Leukocyte level at postoperative day 1 was significantly lower in the no-incision group [(11.0±3.5)×10 9 /L vs. (14.7±3.6)×10 9 /L, t=-2.281, P=0.035]. C-reactive protein concentration at postoperative day 3 was not significantly different between two groups but with different trend [median 78.1(0.1 to 154.0) mg/L vs. 22.0 (7.0 to 55.9) mg/L,U=33.0, P=0.047]. There were no significant differences of interleukin-6 and procalcitonin between two groups(all P>0.05). All the patients had follow-up for 14-31 months. Subjective effectiveness score was 90±9 in the no-incision group and 94±6 in the traditional group without significant difference(t=-1.099, P=0.286). No long-term complications associated with abdominal infection was observed in the no-incision group., Conclusion: 3D laparoscopic subtotal colectomy via transrectal extraction of specimens without abdominal incision in the treatment of STC has similar short-term and long-term efficacies compared with traditional laparoscopic assisted surgery, and does not increase the probability of abdominal contamination.

Chronic constipation is a polysymptomatic heterogeneous disorder with the incidence rising in many countries, and becomes a common disease affecting the quality of life and financial burden. In China surgical guideline, the primary constipation is divided into 3 types: slow transit constipation, outlet obstructive constipation, mixed constipation. The Rome IIII( criteria is usually referred to diagnosis, considering with clinical features and patient complaints. Through detail interrogation, physical examination and various detections, the secondary causes should be excluded, and etiological treatment is worth to try. Surgery is generally recommended as the second-line therapy, and finally only few patients require operation. There are still several controversies over the choice of surgical procedures and the mode of anastomosis in patients with slow transit constipation. Common surgical procedures include total colectomy with ileorectal anastomosis (TAC-IRA), subtotal colectomy with ileosigmoid anastomosis, ileorectal anastomosis or cecal-rectal anastomosis. Now laparoscopic operations have been widely applied to these patients, and have achieved good efficacy, and the application of robots is also under exploration. With the outlet obstructive constipation complicated pathogeny, the mechanisms currently involved include paradoxical puborectalis contraction, increased perineal descent, rectal intussusception, rectocele and rectal prolapse. In recent years, aiming at the above mechanisms, variety of surgical methods has been explored, including bilateral partial resection of puborectalis (PDPR) for paradoxical puborectalis contraction, rectal mucosa longitudinal plication plus sclerosing agent injection, procedure for prolapse and hemorrhoids (PPH), rectal mucosal resection and muscle plication procedure (Delorme), stapled transanal rectal resection (STARR) and laparoscopic ventral mesh rectopexy (LVR) etc for rectal prolapse. However, there is still no long-term large sample study to prove the advantages and disadvantages of these operations, so operative procedure should be chosen according to the actual situation of the patient. With the integration of the pathogenesis and the diversification of the treatment methods, the constipation still needs the precise treatment combined with multidisciplinary support in the future.

Slow transit constipation (STC) is the most common type of chronic constipation, and surgical treatment is one of the most important means for the treatment of slow transit constipation. With the introduction of the concept of STC and the normalization of STC treatment, development of surgical treatment in slow transit constipation is continuous, and the innovation of the operation method in slow transit constipation is continuous as well from partial colectomy, total colectomy (including ileorectal anastomosis, anorectal anastomosis and ileum bag anal canal anastomosis) to subtotal colectomy (including ileosigmoid colon anastomosis, isoperistaltic cecum rectal anastomosis and antiperistaltic cecum rectal anastomosis). Among these procedures, total colectomy ileorectal anastomosis is the ideal surgical procedure for the treatment of STC. Recent studies revealed that subtotal colectomy cecum rectal anastomosis could also achieve good efficacy. In addition, the other procedures for the treatment of STC include ileostomy, anterograde colonic lavage and colon exclusion, but it is necessary to strictly grasp the indications. With the development of minimally invasive technology, the application of laparoscopic technology in STC has been emphasized gradually. In general, the operation method has experienced from simple to complex and individual choice; from single surgical approach to multiple surgical methods; from abdominal open surgery to laparoscopic minimally invasive surgery. Relieving constipation symptoms and reducing the incidence of complications is the goal of surgical treatment that has always been the pursuit of STC surgery. The surgical method with good efficacy, small trauma, quick recovery and less complications must be designed to meet the individualized needs of patients with different constipations. In this paper, the efficacy and progress of surgical treatment of slow transit constipation from the generation and development are reviewed.

The Chinese Society of Coloproctology (CSCP) released the updated "guidelines for the diagnosis and treatment of constipation surgery" in 2017. The major amendments include the following aspects: (1) According to defecation reflex involving parts of the classification, the cause of constipation is divided into three parts, including colorectal factors, internal and external colorectal factors. The new division is more rational, easy to make clear the location and the possible pathogenesis. (2) Constipation is divided into slow transit constipation, outlet obstructive constipation and mixed constipation. The main consideration of this division is the name of the surgery for the outlet obstructive constipation, such as the rectal prolapse and the rectocele. (3) The 6-hour observation time point is added in the colonic transit test and to make clear whether the stomach and the small intestine has slow transit. (4) Micro ecological preparations, promoting dynamic drugs and promoting secretion drugs as well as psychological treatment and acupuncture treatment are added in non-surgical treatment of constipation (5) The antegrade colonic enema is removed from surgical treatment of slow transit constipation; in the surgical treatment of internal rectal prolapse, STARR surgery is added and Delorme surgery is deleted; transrectal and transperineal approach are added in the surgical treatment of rectocele. In this paper, we compare the domestic and international constipation-related guidelines, and summarize the main revisions in the 2017 edition of "guidelines for the diagnosis and treatment of constipation surgery".

Surgery, as one of the methods for the treatment of chronic constipation, is the final choice after the failure of non-surgical treatment with its specific particularity. The history of surgical treatment of chronic constipation is complex and tortuous. How to select operation among many kinds of surgery, and control risk is difficult for clinician. The choice of surgical procedure depends mainly on the patient's conditions, the objective examination basis and the experience of physician teams. Based on the previous reports and the team's experience, this paper discusses the choice of surgical treatment for the following types of chronic constipation: (1) Slow transit constipation: subtotal colorectal resection plus ileorectal anastomosis or ascending colon rectum anastomosis is widely used at present in the domestic, and its efficacy is quite good. (2) Outlet obstructive constipation: surgical treatment needs to be cautious with no consensus, and surgeons must follow the advice of "minimally invasive first" principle. (3) Mixed constipation: there is no clear and unified surgical treatment, while Jinling surgery is a promising way of operation. (4) Adult Hirschsprung's disease: surgery is the only treatment, and removing the stenosis segment, transitional segment and obvious expansion segment is the basic principle, and preventive ileostomy at the same time is also recommended. (5) Adult idiopathic megacolon: subtotal colectomy with ileorectal anastomosis or ascending colon rectum anastomosis is highly recommended. (6) Hypoganglionosis: it is rare, and no consensus has been reached in surgical treatment. How to select the proper timing and mode of operation, and how to control the operation risk are the contents that clinicians must master. With the development of laparoscopic surgical technology, minimally invasive surgery is becoming the main direction of constipation treatment.

Objective: To evaluate the long-term efficacy of stapled transanal rectal resection (STARR) in treating obstructed defecation syndrome(ODS)., Methods: Clinical data of 95 female patients with ODS undergoing STARR at Department of Colorectal Surgery, Rocket Army General Hospital from February 2010 to August 2012 were analyzed retrospectively. The Cleveland constipation scoring system (CSS), Longo ODS scoring system and severe symptoms score(SSS) were used to evaluate the degree and intensity of clinical symptoms. Patient satisfaction was assessed by visual analogue scale (VAS). Clinical symptoms at postoperative 12-month were defined as short-term efficacy, and at the end of follow up (≥48 months) were defined as long-term efficacy., Results: The mean age was 54.5 (29 to 79) years and the median follow-up was 65 (48 to 78) months. Eighty (84.2%) and 44 (46.3%) patients completed the short-term and long-term efficacy evaluation respectively. At the end of follow up, compared with the baseline levels before operation, the CSS score (14.69 vs. 6.02), ODS score (16.51 vs. 5.73) and SSS score (14.64 vs. 5.14) were significantly decreased (all P<0.01), but the VAS score (3.96 vs. 7.20, P<0.01) was significantly increased. A total of 10 patients (22.7%) developed symptomatic recurrence. The self-reported definitive satisfaction was excellent in 10 (22.7%) patients, fairly good in 17(38.6%), good in 9(20.5%), and poor in 8(18.2%). The total effective rate was 81.8%(36/44)., Conclusion: Long-term efficacy of STARR in the treatment of ODS is good, but the rate of symptomatic recurrence is relatively high.

Objective: To investigate the clinical efficacy and safety of modified stapled transanal rectal resection (STARR) combined with perioperative pelvic floor biofeedback therapy (POPFBFT) in treating obstructed defecation syndrome (ODS)., Methods: Thirty female ODS patients underwent modified STARR (resection and suture was performed in rectocele with one staple) combined with POPFBFT in Department of Colorectal and Anal Surgery, The First Hospital of Jilin university from October 2013 to March 2015. Before the modified STARR, patients received a course of POPFBFT (20 min/time, 2 times/d, 10 times as a course), and another 2 courses were carried out in clinic after discharge. Efficacy evaluation included general conditions of patients, morbidity of postoperative complication, overall subjective satisfaction (excellent: without any symptoms; good: 1 to 2 times of laxatives per month and without the need of any other auxiliary defecation; fairly good: more than 3 times of laxatives per month ; poor: with no improvement; excellent, good, fairly good are defined as effective), Longo ODS score (range 0 to 40 points, the higher the score, the more severe the symptoms), gastrointestinal quality of life index(GIQLI)(range 0 to 144 points, the lower the score, the more severe the symptoms), anorectal manometry and defecography examination. The follow-up lasted 12 months after operation (ended at April 2016)., Results: Average age of 30 patients was 57(46 to 72) years and Longo ODS score of every patient was ≥9 before operation. The modified STARR was completed successfully in all the 30 patients with average operation time of 25 (18 to 34) min and average hospital stay of 6(4 to 9) d. Postoperative complications included pain(20%, 6/30), urinary retention (16.7%, 5/30), anorectal heaviness (6.7%, 2/30), and fecal urgency(26.7%, 8/30). Anaorectal heaviness and fecal urgency disappeared within 3 months. No severe complications, such as postoperative bleeding, infection, rectovaginal fistula, anastomotic dehiscence and anal incontinence were observed. The effective rate of overall subjective satisfaction was 93.3%(28/30) during the follow-up of 12 months. There was no significant difference in Longo ODS score between pre- POPFBFT and pre-operation (pre- POPFBFT: 32.95±3.22, pre-operation: 32.85±3.62, t=1.472, P=0.163). Compared with pre-POPFBFT, Longo ODS score at 1 week after operation decreased (t=4.306, P=0.000), moreover, score at 1 month after operation was lower than that at 1 week (13.05±7.49 vs. 15.00±7.17, t=7.322, P=0.000), while no significant differences were found among 1, 3, 6, 12 months after operation (F=2.111, P=0.107). Likewise, there was no significant difference in GIQLI score between pre-POPFBFT and pre-operation (pre-POPFBFT: 79.39±17.14, pre-operation: 76.65±17.56, t=1.735, P=0.096). Compared with the pre-POPFBFT, GIQLI score at 1 week after operation increased (t=4.714, P=0.000), moreover, GIQLI score at 1 month after operation was higher than that at 1 week (102.26±19.24 vs 91.31±21.35, t=5.628, P=0.000), while no significant differences were found among 1, 3, 6, 12 months after operation(F=1.211, P=0.313). In comparison with pre- POPFBFT, parameters of defecography examination at 12 months after operation showed obvious improvement: the rectocele decreased from (34.1±0.4) mm to (3.1±0.3) mm (t=6.847, P=0.000), anorectal angle during defecation increased from (123.8±6.7)degree to (134.7±8.5)degree, enlargement of anorectal angle during defecation increased from (29.1±3.5)degree to (37.1±5.3)degree, while no significant differences in descend of perineum, anorectal angles at rest as well as parameters of anorectal manometry were found (all P>0.05)., Conclusion: Modified STARR combined with POPFBFT is safe and effective for ODS patients.

Objective: To explore the efficacy of partial resection of puborectalis combined with mutilation of internal anal sphincter(IAS) in the treatment of puborectalis syndrome with high anal pressure., Methods: Twenty-five cases of puborectalis syndrome with high anal resting pressure in the preoperative examination received the operation of partial resection of puborectalis combined with mutilation of IAS in Zhongnan Hospital of Wuhan University between January 2013 and May 2015. The position of puborectalis was confirmed by touching with the exposure under the transfixion device, and a transverse incision was made by electrotome between 3 and 5 o'clock direction of puborectalis, then partial puborectalis was lifted by vessel clamp at 5 o'clock direction, and about 0.5 cm of muscular tissue was resected. Between 8 to 10 o'clock direction of anal tube, about 1 cm length of transverse incision was made by electrotome, then partial IAS was lifted by vessel clamp and cut off. Preoperative and postoperative 3-month anorectal manometry and defecography were carried out. Wexner constipation score and Cleveland Clinic incontinence score were implemented before surgery and 3, 6, 12 months after operation. This study was registered in the Chinese Clinical Trial Registry (registration number: ChiCTR-ORB-16007695)., Results: Of the 25 cases, 18 were male and 7 were female, the average age was 55 years old and the average course of disease was 9 years. Compared with pre-operation, the postoperative 3-month anal resting pressure and maximal squeeze pressure were significantly decreased [(53.56±9.05) mmHg vs. (92.44±7.06) mmHg, (142.80±20.35) mmHg vs. (210.88±20.56) mmHg, respectively, both P=0.000]; anorectal angulation at resting state and forced defecation state increased significantly [(102.32±4.96)degree vs. (95.88±4.01)degree, (117.88±5.95)degree vs. (89.52±3.25)degree, respectively, both P=0.000]. Wexner constipation score of postoperative 3-month, 6-month, 12-month (8.28±3.91, 7.40±3.64 and 8.04±4.74) was significantly lower than the preoperative score (16.00±3.69, all P<0.05), while the score was not significantly different among 3 time points after operation (P>0.05). Cleveland Clinic incontinence score was 0 at postoperative 6 and 12 months, and revealed 20 cases were effective among all the surgical patients(80%)., Conclusion: Partial resection of puborectalis combined with mutilation of internal anal sphincter can effectively reduce anal pressure and improve symptoms of outlet obstruction, which is an effective method in the treatment of puborectalis syndrome with high anal pressure.

Objective: To investigate the application value of colonic transit test (CTT) combined with anorectal manometry (ARM), barium enema (BE) and defecography (DFG) in accurately evaluating colonic lesions of slow transit constipation complicated with adult megacolon., Methods: Clinical data of 47 above patients admitted between October 2007 and February 2015 in the People's Hospital of Hunan Province were analyzed retrospectively. All the patients were examined with≥2 times of CTT combined with ARM and BE, and 42 cases received additional DFG at the same time, to evaluate colonic lesions before operation. Operative biopsy pathology was used as the standard. The sensitivity, specificity, positive predictive value(PPV) and negative predictive value(NPV) of positioning in the ascending colon and caecum, transverse colon and descending colon were calculated, and the consistency was represented by Kappa test(Kappa value≥0.75 indicates good consistency, meanwhile higher Kappa value indicates better consistency). The Heikkinen score was used to evaluate defecation function at postoperative 6 months., Results: The age of 47 patients was from 18 to 56 years old. Compared with intraoperative findings and biopsy pathology, the diagnostic coincidence rate was 89.4% by CTT combined with BE and DFG positioning, which suggested pathology-changed colonic segment locating in the ascending colon and cecum (n=12), transverse colon (n=26) and descending colon (n=9), while intraoperative findings and biopsy pathology suggested pathology-changed colonic segment locating in the ascending colon and cecum (n=11), transverse colon (n=23) and descending colon (n=13). The sensitivity was 88.3%, specificity 93.5%, PPV 92.1%, NPV 94.9% and Kappa value was 0.827(P<0.001). Procedures performed included segmental colectomy (n=8), subtotal colectomy (n=29), total colectomy (n=10). There was no serious complication during and after operation. Defecatory function was excellent in 24 cases (60.0%), good in 10 (25.0%), and moderate in 6 (15.0%) evaluated by Heikkinen score at postoperative 6 months. A total of 40 patients were followed up from 1 to 7 years (median 3 years) and there was no long-term diarrhea and recurrence of constipation or giant colon after operation., Conclusion: Preoperative detection of CTT combined with ARM, BE and DFG in patients with slow transit constipation complicated with adult megacolon can make a more precise assessment of the extent of colonic lesions in advance, which has a good clinical predictive value.

Objective: To investigate the feasibility and efficacy of laparoscopic subtotal colectomy and modified Duhamel procedure combined with transanal endoscopic microsurgery (TEM) in the treatment of severe functional constipation(SFC)., Methods: The clinical data of 10 patients with SFC treated by laparoscopic surgery combined with TEM between May 2010 and October 2012 in Ruijin Hospital of Shanghai Jiaotong University School of Medicine were retrospectively analyzed. The gastrointestinal quality of life index(GIQLI), Wexner constipation scale and daily frequency of defecation postoperatively during follow-up were collected., Results: All the 10 operations were successfully accomplished laparoscopic subtotal colectomy combined with TEM without abdominal incision. There was no conversion to open procedure. One case had preventive terminal ileum stoma. The mean operative time was (256 ± 58) min. The mean blood loss was (178 ± 67) ml. The mean time to first flatus was (40 ± 11) h. There were no ureteric injury, anastomotic leak, pelvic sepsis and other complications postoperatively. There was one case of insufficient small bowel obstruction which was released by conservative treatments. The patients were discharged from the hospital in (9.0 ± 1.5) d postoperatively. The GIQLI in one year postoperatively was (112 ± 10) points, which indicated good results compared to (75 ± 12) points preoperatively (P=0.000). The Wexner constipation scale was 20.8 ± 2.2 preoperatively and decreased to 5.2 ± 1.8 at one year follow-up(P=0.000)., Conclusion: Laparoscopic subtotal colectomy and modified Duhamel procedure combined with TEM provides SFC patients a safe and feasible minimally invasive surgery.

Objective: To investigate the clinical application of laparoscopy-assisted subtotal colectomy with transanal specimen extraction for slow transit constipation(STC)., Methods: Retrospective analysis was performed on the clinical data of 8 cases with STC undergoing the procedure mentioned above from February to November 2013. Pre-and post-operative constipation was assessed using Wexner Constipation and Incontinence Scales, and quality of life was assessed using Gastrointestinal Quality of Life Index., Results: All the operations were completely successful without postoperative complications, such as intestinal fistula, pelvic infection, anastomotic stricture, intestinal obstruction. The Operative time was (287.6 ± 21.5) min, blood loss was (109.7 ± 41.1) ml, time to first flatus was (2.5 ± 0.9) d. The proportion of postoperative constipation symptom index improvement was(77.6 ± 8.3)%. Postoperative quality of life score was 97.3 ± 15.7, significantly higher than that before operation(P<0.05). Postoperative Wexner constipation score was 8.8 ± 3.7, significantly lower than that before operation., Conclusion: Laparoscopy-assisted subtotal colectomy with transanal specimen extraction in the treatment of STC has good short-term efficacy with obvious improvement in quality of life.

Objective: To study the feasibility of subtotal colectomy with cecorectal end-side anastomosis for slow transit constipation., Methods: Retrospective analysis was performed on 23 patients with colon slow transit constipation treated by subtotal colectomy with cecorectal end-side anastomosis in our department from March 2006 to April 2013. The main measure outcome was the curative effect on constipation by this type of surgery., Results: Twenty-three patients were successfully treated. Anastomotic leakage occurred in one case, and urinary retention in 1 case, while no anastomotic stricture, abdominal bleeding, abdominal hernia, incontinence and other complications occurred. During follow-up of 2 months to 7 years, defecation frequency was 1-4 times a day with no need of antidiarrheal agents. Each time of defecation was less than 5 min. All the patients had no recurrence of constipation., Conclusion: Subtotal colectomy with cecorectal end-side anastomosis can be used to treat colon slow transit constipation, while accurate preoperative evaluation and strict indications for the surgery is the key to success.

Objective: To explore the efficacy of different procedures for refractory constipation complicated with megacolon., Methods: Clinical data of 112 patients of refractory constipation complicated with megacolon undergoing surgery in our institute from June 2007 to January 2013 were retrospectively analyzed. Of these 112 patients, the duration of constipation ranged from 4 to 22 years. Seventy-four patients had previous abdominal operations. Surgical procedures: (1)Jinling procedure (subtotal colectomy plus ascending colorectal posterior wall side-to-side anastomosis, n=81), including 24 laparoscopy-assisted procedures, 18 terminal ileostomies. (2)total colectomy plus ileorectal side-to-side anastomosis(n=18). (3)total colectomy plus end ileostomy, and ileorectal posterior wall side-to-side anastomosis 6 months later(n=13). The end ileostomy was reversed 6 months after operation., Results: The successful rate was 100%, and no surgery-related deaths were found. Postoperative complications included early diarrhea (90 cases, 80.4%), anal pain and incomplete evacuation (22 cases, 19.6%), urinary retention within 24-48 h after catheter removal (16 cases, 14.2%), anastomosis bleeding (9 cases, 8.0%), anastomosis leakage (6 cases, 5.4%), and intestinal obstruction (15 cases, 13.4%). Six patients with intestinal obstruction underwent adhesiolysis, and others were managed by conservative therapy. At the postoperative follow-up at 6 months, the Wexner constipation score was significantly reduced (5.8-8.3 vs. 21.4-28.7, P<0.01), and malnutrition improved as well., Conclusion: Surgical intervention results in good efficacy for refractory constipation complicated with megacolon.

Objective: To evaluate the feasibility and safety of total colonic exclusion plus side to side antiperistaltic ileorectal anastomosis in the treatment for elderly patients with slow transit constipation (STC)., Methods: Clinical data of 13 patients with severe idiopathic STC undergoing the above novel procedure in Zhongnan Hospital of Wuhan University between May 2009 and September 2012 were retrospectively analyzed. The Wexner constipation score and gastrointestinal quality of life index (GIQLI) before and 6 months after operation were compared., Results: There were 8 female and 5 male patients, with a mean age of 74 years (range 63-82 years). No procedure-related deaths or any serious complication occurred. The length of follow-up ranged from 6 to 29 months (median,12 months). The duration of surgery was (55±4) min. Blood loss was (30±2) ml. The postoperative hospital stay ranged 10 to 16 days (mean 11.4 days). The first bowel movement occurred in the 4th day (range 2nd-8th day) after operation. There was no intestinal occlusion and anastomotic leakage that required surgery in all the patients. No fecal incontinence or constipation recurrence was found. One patient developed blind loop syndrome 14 months after operation. Postoperative complications included incision fat liquefaction in 2 cases, anorectal bearing-down while bowel movement in 2 cases, and minor defecate difficulty needed glycerin enema in 1 case. Wexner scores was significantly improved from 22.8±3.3 before operation to 5.4±2.1 six months after operation (P<0.05). GQLI was significantly increased from 93.6±20.5 before operation to 120.8±13.0 six months after operation (P<0.05). At 6 months after operation, the outcome was excellent in 11 patients and good in 2 patients., Conclusion: Total colonic exclusion plus side to side antiperistaltic ileorectal anastomosis is easy, safe and effective in the treatment for selected elderly patients with STC.

The treatment of constipation is to alleviate the symptoms and improve quality of life. If complications occur after surgery, it will bring more pain to the patients.The requirement of constipation surgery is higher than that of malignant tumor. The efficacy of constipation surgery depends on accurate diagnosis and reasonable operation method.Laparoscopic technique is preferred with small trauma, quick recovery and satisfactory cosmetic outcomes.

Objective: To evaluate the anatomy and functional changes of pelvis before and after Jinling procedure (subtotal colectomy and side-to-side colorectal anastomosis) using defecography., Methods: Fifty patients with refractory mixed constipation received Jinling procedure in the Jinling Hospital between March 2009 and December 2010 and were included in this prospective study. The defecography was performed at one week before surgery and 6 months after Jinling procedure. Longo outlet obstructed score, Wexner constipation score and Wexner incontinence score were also recorded before and after the procedure., Results: After 6 months follow-up, defecography showed that anterior rectocele, prolapse, intussusception, and descending perineum were significantly improved (P<0.01). Anterior rectoceles were significantly reduced in depth from 22.0±1.8 mm to 2.4±0.4 mm (P<0.01). Intussusception decreased from 1.9±0.4 cm to 0.4±0.5 cm (P<0.01). Compared with preoperative score, Longo score and Wexner constipation score were significantly improved from 17.6±3.8 to 5.3±2.0 and from 19.5±4.8 to 5.5±2.4, respectively (P<0.01)., Conclusions: Jinling procedure can correct the anatomy and functional pelvic disorders in mixed constipation. Clinical improvement of obstructed defecation syndrome after Jinling procedure correlates well with morphologic correction of the rectal redundancy.

Objective: To propose a novel surgical procedure for refractory constipation, namely Jinling procedure, and to explore its safety and efficacy through long-term follow-up., Methods: A total of 614 patients with refractory constipation were admitted to the Department of General Surgery between February 2000 and June 2011. Five hundred and fifty-four patients received Jinling procedure and were included in this study. The general clinical data, complications after Jinling procedure, gastrointestinal quality of life index (GIQLI), Wexner constipation scale and satisfaction rate during follow-up were collected., Results: No operation-associated death occurred. Increased bowel movement frequency was observed during the perioperative period. Temporary difficulty in urination occurred in 24.5% of the patients. Other complications included small bowel obstruction (9.6%), anastomotic bleeding (8.1%), anastomotic leakage (3.1%), sexual dysfunction (3.1%), and wound infection (3.1%). Most postoperative complications were managed conservatively. The most recent follow-up was on August 2011, and the follow-up rate was 100%, 88.8%, 75.1%, 56.3% at 3, 6, 12, and 24 months after surgery. GIQLI temporarily increased from 78.1±9.4 preoperatively to 92.0±9.5 at 3 months follow-up, but continued to decrease during the follow-up at the 6 months (48.4±14.1), 12 months (21.0±4.3), and 24 months (20.0±3.4). Wexner constipation scale decreased from 19.9±4.3 preoperatively to 8.4±2.1 at 3 months follow-up (P<0.01). The low Wexner scale sustained until 24 months after operation. The satisfaction rate at the 3, 6,12 and 24 months follow-up was 78.1%, 91.1%, 94.2% and 94.6%, respectively., Conclusion: Jinling procedure provides refractory constipation patients with a novel, safe and effective surgical option.

Objective: To summarize the experience in the management of slow transit constipation complicated with adult megacolon., Methods: The clinical data of 32 above patients admitted between October 2007 and June 2011 were retrospectively studied., Results: Thirty-two patients were diagnosed as slow transit constipation according to the Roman III criteria. There were 15 males and 17 females aging from 18 to 56 years old. Sitz marker study showed prolonged colon transit time. Barium enema and defecography suggested bowel stricture locating in the transverse colon (n=3), descending colon (n=4), rectum (n=20), and concurrent transverse colon or descending colon and rectum (n=5). Anal manometry showed that anorectal inhibitory reflex was absent in 23 patients, while the other 9 patients were normal. Procedures performed included segmental colectomy and side-to-side anastomosis (n=1), subtotal colectomy and modified Duhamel anastomosis (n=16), total colectomy and ileal J-pouch Duhamel anastomosis (n=9). There were no postoperative complications. During the follow-up ranging from 3 to 47 months, defacatory function was excellent in 18, good in 9, and moderate in 5 patients., Conclusions: Adult megacolon should be considered differential diagnosis of slow transit constipation. Detailed history taking and thorough evaluation of testing is the key to obviate misdiagnosis. Extent of resection should include the diseased dilated colon and slow transit colon.

Objective: To explore the clinical significance of multiple radiography of the pelvis in the evaluation of surgical outcomes for patients with slow transit constipation complicated with outlet obstruction., Methods: Patients with slow transit constipation complicated with outlet obstruction were diagnosed by multiple radiography of the pelvis after screening using colon transit study. Surgery was performed according to the cause of the obstruction. Anorectal angle and the locations of perineum, pelvic peritoneum, and bladder were assessed by multiple radiography of the pelvis one month after surgery. The changes in locations of pelvic organs were assessed and the imaging appearance after the release of obstruction was observed., Results: A total of 48 patients were included. Rectocele repair, partial mucosectomy with rectopexy, and hysteropexy were performed. All the patients were followed up with a mean length of 19(6-58) months. Excluding 2 patients who had no symptomatic improvement, the mean bowel movements was 1.9 times per day in the remaining 46 patients(95.8%). Preoperative anorectal angle at the squeezing phase was(128.09±13.82) degree and the difference between squeezing and resting phase was (11.14±12.58) degree, while the postoperative angle was (180.26±9.98) degree and the difference(20.01±13.11) degree(P<0.05). Preoperative location of the perineum at the squeezing phase was(-2.05±0.83) cm and the difference was(2.23±0.78) cm, while postoperative location was (-0.50±1.13) cm and the difference was (2.18±1.04) cm(P<0.05). Preoperative location of the pelvic peritoneum at the squeezing phase was(4.91±1.32) cm and the difference was (1.32±0.89) cm, while postoperative location was (2.62±2.53) cm and the difference was (3.28±0.68) cm (P<0.05). Preoperative bladder location at the squeezing phase in patients with urological symptoms was (3.92±2.51) cm and the difference was(1.39±1.27) cm, while postoperative location was (2.15±1.55) cm and the difference was (1.98±1.54) cm(P<0.05)., Conclusion: Multiple imaging of the pelvis provides objective evidence in the evaluation of surgical outcomes for patients with chronic slow transit constipation complicated with outlet obstruction.

Objective: To summarize the clinical experience and to evaluate the safety and technical characters of laparoscopy-assisted total/subtotal colectomy(LAC)., Methods: From June 2005 to May 2008, a total of 150 cases underwent LAC in Jinling Hospital. There were 126 cases of severe functional constipation (SFC) treated by LAC combined with modified Duhamel procedure. There were 11 cases of familial adenomatous polyposis, 8 cases of ulcer colitis and 5 cases of multiple colorectal tumors treated with LAC combined with ileum-rectum anastomosis., Results: Of the 150 cases, LAC was successfully performed in 147 cases. The mean operation time of LAC was (76.0+/-23.5) min. The estimated operative blood loss was (35.4+/-10.9) ml. The length of assisted incision was (5.2+/-1.1) cm. The time to resume intestinal function was (42.5+/-12.6) h. There was no postoperative wound infection, anastomotic stoma and other complications. Within 1 week after operation, severe diarrhea occurred in 2 cases and incomplete small bowl obstruction in 2 cases, who were relieved by conservative treatment. The mean postoperative hospital stay in patients without complication was(7.2+/-1.5) d. One year later, the score of gastrointestinal index quality of life in 116 patients was (110.3+/-20.7), which was significantly elevated as compared with the pre-operation score (90.1+/-23.8) and was not significantly different with the healthy score. The constipation symptoms were released in all the 105 SFC patients with different degree diarrhea in 7 cases and recurrence of mild constipation in 4 cases. There was no sign of recurrence and metastasis in 3 cases of multiple colorectal tumors., Conclusions: LAC embodies the advantages of less invasiveness of laparoscopy. It is a reasonable choice of operation method in treating various diseases related to total colon.

Objective: To compare the efficacy between subtotal colectomy with antiperistaltic cecoproctostomy and total colectomy with ileorectal anastomosis (TAC-IRA) for patients with severe refractory slow transit constipation(STC)., Methods: During 1999 to 2002, TAC-IRA was the preferred procedure for 20 STC patients in our department. From 2003 to 2005, 17 STC patients underwent subtotal colectomy plus antiperistaltic cecoproctostomy. Clinical data of the two groups were collected and compared retrospectively., Results: There were no significant differences in basic preoperative clinical data between the two groups. During the follow-up period, the time of daily defecation in the antiperistaltic cecoproctostomy group was less than that of TAC-IRA group (2.4+/-0.9 vs 3.4+/-0.8, P=0.0014), meanwhile the Wexner continence score was significantly lower in the antiperistaltic cecoproctostomy group (4.3+/-1.8 vs 5.8+/-1.9, P=0.0223). Barium enema after subtotal colectomy showed that residual ascending colon and cecum presented a sign of "reservoir"., Conclusion: Subtotal colectomy with antiperistaltic cecoproctostomy is a better method for appropriately selected patients with STC than TAC-IRA.

Objective: To explore the satisfactory surgical procedure for severe functional constipation (SFC)., Methods: The data of 50 SFC patients, undergone subtotal colectomy and modified Duhamel procedure from Sep. 2000 to Apr. 2005, were analyzed retrospectively. Gastrointestinal quality of life (GIQOL) of these patients were also evaluated., Results: All the 50 patients failed to respond to conservative treatment and accepted subtotal colectomy and modified Duhamel procedure after finding pathological changes by the examination of colonoscopy, colon transit time (CTT) and dynamic proctography (DPG). Twenty-seven out of 50 cases (54%) showed colonic muscular atrophy and 29 out of 50 cases (58%) showed decreased ganglion cells in myenteric plexuses of colon. The mean follow-up time after surgical treatment was (2.4+/-1.2) years. GIQOL and constipation index improved dramatically after operations. Forty-four out of 50 patients (88%) were satisfied with their postoperative evacuation. Nine patients complained minor abdominal pain,3 patients diarrhea and 2 patients recurrence of constipation, who were healed by the use of bulk-forming laxatives and GI-mobility drugs., Conclusion: The combination of modified Duhamel procedure and subtotal colectomy is an effective surgical procedure for the treatment of SFC.

Objective: To explore the diagnosis and treatment methods of pediatric anismus., Methods: Twenty-nine patients with idiopathic chronic constipation, diagnosed with anismus by colon barium contrast and anorectal manometry from Nov. 2001 to Nov. 2004 in our hospital, were investigated retrospectively., Results: This group consisted of 13 men and 16 women whose mean age was (6.7+/-4.0) years. Hirschsprung diseases were excluded from the patients by colon barium contrast and rectoanal inhibitory reflex (RAIR) examination. Normal RAIR (5-10 ml elicited) was showed on 21 cases while weakened RAIR (15-30 ml elicited) was showed on 8 cases. After the diagnosis, the patients were treated by toilet training, diet regulation and laxative for 1-2 months. 4 cases were recovered, 5 cases were improved and 20 cases were relied on glycerin suppository. Four cases, relied on glycerin suppository, underwent Lynn procedure and had good results after 5-24 months follow-up. Two cases were re-examined by anorectal manometry 3 and 6 months after surgery, the resting pressure and the high pressure zone (HPZ) decreased, but the simulation defecation reflex was still abnormal., Conclusions: The diagnosis of pediatric anismus relies on history of constipation, combined with anorectal manometry and colon barium contrast. Lynn procedure could be chosen for the patients unsatisfied in toilet training and other non-operative treatment.

Objective: To summarize the causes and treatment experiences of postoperative constipation recurrences of Hirschsprung disease., Methods: Clinical data of 37 cases receiving operation again for postoperative constipation recurrences of Hirschsprung disease were collected. The recurrent causes, reoperation procedures and therapeutic efficacy were analyzed., Results: Among 37 cases, the recurrent causes included insufficient resection of the intestine in 14 cases, co-existent intestinal neural hypogenesis in 6, gate syndrome in 5, and others in 12 cases. There was no postoperative death. Thirty-one cases (83.8%) were followed-up from 6 months to 11 years. The defecation frequency was 1-2 times per day in 15 cases, one times per two days in 7, one times per three days in 6 cases. Two cases could defecate with the help of laxative purgatives. Nobody had incontinence., Conclusion: The main cause of postoperative constipation recurrences of Hirschsprung disease is insufficient resection of the intestine,and reoperation can get better results.