| Part ? Study on the relationship between clinical charcteristics anddiagnosis of the subtype of obstructed defaecation syndromeBACKGROUNDChronic constipation is a common global disease with a prevalence of about 2.4 to 22.4%.Constipation has become an important benign disease affecting living quality,which may be caused by organic reasons or functional diseases.In conclusion,chronic constipation can be divided into primary constipation and secondary constipation according to the etiology.The latter is caused by medicine and organic diseases,while the former is caused by other factors,which is also known as Functional Constipation(FC).Clinical characteristics such as sex,age and so on has been reported to have correlationship with the final diagnos of subtype of obstructed defaecation syndrome,but the results was not consistent.Moreover,there is no systematic study on the general data characteristics,clinical manifestations of the patients with various types of obstructed defaecation syndrome,nor the complications of different etiologies of constipation.Only when the patient's symptoms meet the diagnostic criteria for constipation,are the positive auxiliary examination results of follow-up s meaningful.Therefore,how to refine the medical history and clinical manifestations of various outlet obstruction constipation more comprehensively and accurately has become the first priority of improving the clinical diagnosis and treatment level.OBJECTIVESBecause obstructed defaecation syndrome is a benign disease that is associated with multiple functional abnormalities,invasive examinations are often difficult to perform in clinical studies.By studying the correlation between the clinical characteristics(sex,age,BMI,delivery,sympotoms,et al)of constipation patients and specific subtypes of obstructed defaecation syndrome,this study attempts to explore the possibility of more accurate diagnosis of constipation types based on general clinical data of patients and corresponding constipation symptoms.METHODSFour types of patients with obstructed defaecation syndrome were selected as the research objects,namely:rectal prolapse,perineal descending syndrome,pelvic floor muscle spasm syndrome and rectal intramucosal prolapse.Inclusion and exclusion criteria were first developed to collect enrolled cases.The general data of the patients were collected and analyzed thereafter,the incidence of various clinical symptoms of the patients were counted,and assisted examinations such as anorectal pressure measurement,colonic transport test,balloon forced test and defecography were performed to confirm the diagnosis.Binary Logistic analysis was used to study the correlationship between the clinical characteristics and subtype of obstructed defaecation syndrome including rectal prolapse,descending perineal syndrome,pelvic floor muscle spasm syndrome and rectal mucosal prolapse.RESULTS1.The overall incidence of obstructed constipation is closely related to the following factors:elder age(OR=1.983,95%CI 1.964-2.982,P<0.05),female(OR=1.415,95%CI 1.018-2.817,P<0.05),high frequency of delivery(OR=1.266,95%CI 1.229-1.939,P<0.05),BMI>30kg/m2(OR=1.133,95%CI 1.060-3.559,P<0.05),more than 25%of the defecation has anal obstruction(OR=2.157,95%CI 1.417-4.826,P<0.05),more than 25%of the defecation has incomplete defecation(OR=1.608,95%CI 1.365-1.764,P<0.05),high 72h marker residue in sigmoid colon and rectum(OR=2.008,95%CI 1.860-2.182,P<0.05),high average Ti index after 72h(OR=3.213,95%CI 3.033-3.522,P<0.05)?As for the patients with obstructed defaecation syndrome,patients with characters of more than 25%of the patients with incomplete defecation(OR=3.569,95%CI 1.350-9.434,P<0.05)?high 72h marker residue in sigmoid colon and rectum(OR=1.247,95%CI 1.021-1.522,P<0.05)tend to choose biofeedback therapy;the patients with BMI>30kg/m2(OR=3.800,95%CI 1.147-12.590,P<0.05)?more than 25%of the defaecation cannot evacuate the enema(OR=1.416,95%CI 1.186-1.927,P<0.05)?low defecation times every week(OR=0.069,95%CI 0.018-0.204,P<0.05)?high 72h marker residue in sigmoid colon and rectum(OR=1,827,95%CI 1.698-1.979,P<0.05)?high average Ti index after 72h(OR=1.040,95%CI 1.010-1.071,P<0.05)finally tend to choose surgical treatment?2.The incidence of rectocele is closely related to the following factors:old age(OR=1.991,95%CI 1.967-2.989,P<0.05),high BMI(OR=1.914,95%CI 1.771-1.984,P<0.05),long history of defecation tolerance(OR=1.404,95%CI 1.185-2.883,P<0.05),high frequency of delivery(OR=1.876,95%CI 1.222-1.905,P<0.05),BMI>30kg/m2(OR=1.912,95%CI 1.226-2.977,P<0.05),more than 25%of defecation needs manual assistance(OR=1.581,95%CI 1.176-2.382,P<0.05),more than 25%of defecation has defecation posture change(OR=3.003,95%CI 2.782-8.527,P<0.05),high anal angle at displacement(OR=1.292,95%CI 1.074-1.990,P<0.05),high anal resting pressure(OR=1.021,95%CI 1.003-1.039,P<0.05),high anal maximum systolic pressure(OR=1.022,95%CI 1.002-1.043,P<0.05),high 72h marker residue in sigmoid colon and rectum(OR=1.913,95%CI 1.121-2.377,P<0.05),high 72 h average Ti index(OR=1.727,95%CI 1.002-2.439,P<0.05)?Patients with characteristics of high frequency of delivery(OR=2.133,95%CI 1.197-6.764,P<0.05)more than 25%of the defecation need manual assistance(OR=6.006,95%CI 0.821-8.949,P<0.05),more than 25%of the defecation need posture changes(OR=2.980,95%CI 0.535-7.622,P<0.05)?high depth of rectocele(OR=3.620,95%CI 1.829-4.350,P<0.05)eventually tend to choose surgical treatment?3.The incidence of rectal mucosal prolapse is closely related to the following factors::old age(OR=1.983,95%CI 1.964-1.992,P<0.05),high delivery times(OR=2.006,95%CI 1.289-3.439,P<0.05),more than 25%of defecation with anal obstruction(OR=1.953,95%CI 1.658-2.884,P<0.05),more than 25%of defecation with incomplete defecation(OR=1.524,95%CI 1.235-2.910,P<0.05),more than 25%of defecation with defecation posture changes(OR=1.529,95%CI 1.316-1.885,P<0.05),low anal resting pressure(OR=0.942,95%CI 0.928-0.969,P<0.05),low maximum systolic pressure(OR=0.992,95%CI 0.978-0.996,P<0.05),high initial sensory threshold(OR=2.000,95%CI 1.953-2.049,P<0.05)?Patients with characteristics of old age(OR=1.060,95%CI 1.006-1.118,P<0.05),high BMI index(OR=7.827,95%CI 1.530-40.041,P<0.05),BMI>30kg/m2(OR=1.003,95%CI 1.000-1.095,P<0.05),low anal resting pressure(OR=0.241,95%CI 0.099-0.401,P<0.05)tend to choose biofeedback treatment;Patients with old age(OR=1.962,95%CI 1.929-2.997,P<0.05),history of defaecation tolorance(OR=1.182,95%CI 1.040-1.837,P<0.05),high frequency of delivery(OR=6.314,95%CI 1.308-30.468,P<0.05),more than 25%of defecation with incomplete evacuation(OR=1.197,95%CI 1.025-1.545,P<0.05),more than 25%of defecation cannot evacuate enema(OR=1.197,95%CI 1.056-1.698,P<0.05)?low anal resting pressure(OR=0.921,95%CI 0.854-0.993,P<0.05),low maximum systolic pressure(OR=0.830,95%CI 0.717-0.960,P<0.05),high defecation feeling threshold(OR=1.959,95%CI 1.924-1.996,P<0.05),high average Ti index after 72 hours(OR=1.000,95%CI 1.000-1.012,P<0.05)finally tend to choose surgical treatment.4.The incidence of descending perineum syndrome is closely related to the following factors:old age(OR=3.627,95%CI 1.391-7.571,P<0.05),female(OR=2.348,95%CI 2.257-2.895,P<0.05),long-term history of defecation tolerance(OR=1.944,95%CI 1.908-1.962,P<0.05),high frequency of delivery(OR=2.294,95%CI 1.690-2.426,P<0.05),BMI>30kg/m2(OR=1.732,95%CI 1.083-2.489,P<0.05),low anal resting pressure(OR=0.901,95%CI 0.857-0.948,P<0.05),low maximum systolic pressure(OR=0.930,95%CI 0.905-0.956,P<0.05),low threshold of initial sensation(OR=0.801,95%CI 0.732-0.876,P<0.05),low threshold of defecation sensation(OR=0.925,95%CI 0.868-0.984,P<0.05),high markers residual in sigmoid colon and rectum(OR=1.985,95%CI 1.734-2.320,P<0.05),high average Ti index after 72h(OR=1.972,95%CI 1.003-2.628,P<0.05).Patients with characteristics of old age(OR=1.227,95%CI 1.186-1.770,P<0.05),low delivery times(OR=0.644,95%CI 0.623-0.698,P<0.05)tend to choose biofeedback treatment;Patients with characteristics of female(OR=3.764,95%CI 1.096-6.059,P<0.05),high delivery times(OR=3.124,95%CI 3.097-3.208,P<0.05),more than 25%of the defecation with incomplete evacuation(OR=2.609,95%CI 2.435-2.614,P<0.05),high anal distance(OR=1.628,95%CI 1.602-1.656,P<0.05)tend to choose surgical treatment.5.Incidence of pelvic floor spasm syndrome is closely related to the following factors::high BMI index(OR=1.586,95%CI 1.056-2.380,P<0.05),BMI>30kg/m2(OR=2.415,95%CI 2.353-2.723,P<0.05),more than 25%defecation with pain(OR=1.110,95%CI 1.014-1.343,P<0.05),high anal resting pressure(OR=1.978,95%CI 1.049-2.126,P<0.05),high maximum systolic pressure(OR=1.980,95%CI 1.946-2.014,P<0.05),high defecation feeling threshold(OR=2.044,95%CI 1.983-2.108,P<0.05),high average Ti index after 72 hours(OR=1.785,95%CI 1.079-2.402,P<0.05).CONCLUSIONStatistical characteristics of general demographic factors can be used as a useful supplement for the diagnosis of symptoms of outlet obstruction constipation,which is helpful for the diagnostic accuracy of specific typesPart ? Khubchandani's procedure combined with stapled posterior rectal wall resection for rectocele-a perspective studyBACKGROUNDObstructed defecation syndrome(ODS)is a widespread disease in the world.Rectocele is the most common cause of ODS in females.Multiple procedures have been performed to treat rectocele and no procedure has been accepted as the gold-standard procedure.Stapled transanal rectal resection(STARR)has been widely used.However,there are still some disadvantages in this procedure and its effectiveness in anterior wall repair is doubtful.Therefore,new procedures are expected to further improve the treatment of rectoceleOBJECTIVESTo evaluate the efficacy and safety of a novel rectocele repair combining Khubchandani's procedure with stapled posterior rectal wall resection.METHODSA cohort of 93 patients were recruited in our randomized clinical trial and were divided into two different groups in a randomized manner.Forty-two(group A)patients underwent Khubchandani's procedure with stapled posterior rectal wall resection and 51 patients(group B)underwent the STARR procedure.Follow-up was performed at 1,3,6,and 12 month after the operation.Preoperative and postoperative ODS scores and depth of rectocele,postoperative complications,blood loss,and hospital stay of each patient were documented.All data were analyzed statistically to evaluate the efficiency and safety of our procedureRESULTSIn group A,42 patients underwent Khubchandani's procedure with stapled posterior rectal wall resection and 34 were followed until the final analysis.In group B,51 patients underwent the STARR procedure and 37 were followed until the final analysis.Mean operative duration was 41.47±6.43 min(group A)vs 39.24 ± 6.53 min(group B).Mean hospital stay was 3.15±0.70 d(group A)vs 3.14±0.54 d(group B).Mean blood loss was 10.91 ± 2.52 mL(group A)vs 10.14±1.86 mL(group B).Mean ODS score in group A declined from 16.50±2.06 before operation to 5.06±1.07 one year after the operation,whereas in group B it was 17.11±2.57 before operation and 6.03±2.63 one year after the operation.The mean depth of rectocele decreased from 4.32±0.96 cm(group A)vs 4.18±0.95 cm(group B)preoperatively to 1.19±0.43 cm(group A)vs 1.54±0.82 cm(group B)one year after operation.No other serious complications,such as rectovaginal fistula,perianal sepsis,or deaths,were recorded.After 12 mo of follow-up,30 patients'(30/34,88.2%)final outcomes were judged as effective and 4(4/34,11.8%)as moderate in group A,whereas in group B,30(30/37,81.1%)patients' outcomes were judged as effective,5(5/37,13.5%)as moderate,and 2(2/37,5.4%)as poor.CONCLUSIONKhubchandani's procedure combined with stapled posterior rectal wall resection is an effective,feasible,and safe procedure with minor trauma to rectocelePart ? A prospective study of surgery of pelvic floor elevation andrectal suspension combined with biofeedback therapy in thetreatment of descending perineum syndromeBACKGROUNDDescending perineum syndrome refers to a series of clinical symptoms,such as dysfunctional pelvic floor muscles,dyslaxity of pelvic floor muscles,difficult defecation,anal distention and incomplete defecation.Long term forced defecation,multiple childbearing history,old age,obesity and other factors may be the cause of the descent of perineum syndrome.The diagnosis of descent of the perineum syndrome mainly depends on the combination of defecography and symptoms.At present,there is no clear and effective standard for the treatment of the descent of the perineum syndrome.Most of the patients first receive conservative treatment,including diet therapy,pelvic floor exercise therapy,etc.when the conservative treatment fails,the patients turn to biofeedback therapy.Howevere,the long-term effect of biofeedback treatment remains disappointing.Surgery,though still in controversial,has become more and more important in treating descending perineum syndrome.However,none of the existing research has not been widely accepted Moreover,there was no systemetic treatment for descending perineum syndromeOBJECTIVESTo evaluate the efficacy and safety of a novel surgical treatment combined with biofeedback treatment for descending perineum syndromeMETHODSA cohort of 50 patients with descending perineum syndrome were recruited in clinical trial.All of them were given conservative therapy including diet therapy,pelvic floor exercise,enema and laxtives,but the effect was poor.The patients went through biofeedback therapy at first stage and a one-year follow-up which include ODS score the the depth of the decline of perineum was taken after the therapy finished.Patients who had good treatment effect and those who had bad treatment effect but refused to undergo surgery took another one-year follow-up.Patients who had poor biofeedback effect and agreed to undergo surgery will receive a one-year follow-up which include information as operation complications(such as postoperative bleeding,incontinence,persistent pain,etc.),the depth of perineum and the change of ODS score.These follow-up was performed at 3,6,and 12 month to evaluate the effect of the treatmentRESULTS1.Stage 1Finally,43 patients were followed up for at least 12 months and included in the final statistics,with an average age of 55.49±11.52 years and a disease cycle of 4.30 ±0.82 years.The main symptoms of the patients were more than 25%incomplete defaecation,more than 25%defaecation hardness,more than 25%defaecation longer than 10min.The ODS score before treatment was 15.85±2.84,and the ODS score 1 week,6month and 12month after treatment was 7.54±3.89,8.52±4.42 and 9.98±5.72 respectively.The depth of perineum before treatment was 4.13±0.63cm,and the depth of perineum was 2.71±0.86 cm,2.98±0.88 cm and 3.03±0.80cm at 1week,6month and 12month after treatment respectively.After 12 months of follow-up,the effect of 22 cases were evaluated as good,21 cases as poor.2.Stage 22.1 Operation Group:Finally,11 patients were followed up for at least 12 months and included in the final statistics,with an average age of 44.09±4.10 years and a disease cycle of 3.87±0.89 years.There were 9 women and 2 men in the group.The main symptoms of the patients were defaecation hardness,incomplete defaecation,obstructed defaecation.The average operation time,estimated intraoperative bleeding and hospitalization time were 42.27±6.25 points,14.09±2.87 ml,5.27±0.75 days.The preoperative ODS score was 16.55±2.93,and the postoperative ODS score was 5.45±1.92,5.82±1.80,4.91±1.73 in the third month,the sixth month and one year respectively.The preoperative depth of perineum was 3.67±0.48cm.The degree of decline of perineum was 1.53±0.25cm,1.50±0.23cm,1.47±0.22cm respectively at the 3rd,6th month and one year after operation.Four patients had vaginal discomfort within one week after operation.Postoperative urinary retention occurred in 3 cases The other complications in the first week were nausea,incomplete defecation,urgency of defecation,and persistent pain.The urgency of defecation was found in 2 patients one year after operation,with normal ODS score and depth of perineum After 12 months of follow-up,the effect of 9 cases were evaluated as good,2 cases as average2.2 Non-operation Group:Finally,3 patients were followed up for at least 12 months and included in the final statistics,with an average age of 54.67±2.87 years and a disease cycle of 2.42±0.41 years.They were all females.The beginning ODS score at Stage Two was 11.67±0.47,and the ODS score was 12.33±0.47,13.33±1.25,14.67±1.25 in the third month,the sixth month and one year respectively.The beginning depth of perineum at Stage Two was 3.87±0.26cm.The degree of depth of perineum was3.93±0.25cm,3.87±0.29cm,3.90±0.22cm respectively at the 3rd,6th month and one year.2.3 Observation Group:Finally,14 patients were followed up for at least 12 months and included in the final statistics,with an average age of 45.00±4.60years and a disease cycle of 3.40±1.31 years.There were 5 females and 9 males.The ODS score at the beginning of Stage Two of the experiment was 5.64±2.19,and the ODS score was 6.67±1.93,7.25±2.42,7.92±2.84 in the third month,the sixth month and one year of the follow-up respectively.The beginning depth of perineum at Stage Two was 2.11±0.25cm.The degree of depth of perineum was2.29±0.22cm,2.44±0.19cm,2.71±0.32cm respectively at the 3rd,6th month and one year.3.Correlation between clinical characteristics and effect of biofeedback therapyFemale,high deliveries times,and the high anal distance before treatment were positively correlated with the degree of perineum decline greater than 3 cm and ODS score greater than 10 after biofeedback treatmentCONCLUSION1.Biofeedback therapy is a safe,noninvasive and effective conservative therapy for the descending perineum syndrom patients which not respond to general treatment.However,biofeedback therapy alone can not effectively treat all descending perineum syndrom patients.Among them,female,high delivery times,high anal distance before treatment are closely related to the poor therapeutic effect of biofeedback therapy.2.Pelvic floor elevation combined with rectal suspension is an effective and safe surgical method for the descending perineum syndrom patients which not respond to biofeedback treatment.3.Biofeedback therapy combined with sequential surgery is an effective and safe treatment strategy for the descending perineum syndrom patients which not respond to general treatment. |
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