| Background: Obstructive defecation syndrome(ODS)is a common type of chronic constipation(CC).Its incidence rate is high,and the clinical treatment effect is often not satisfactory,which seriously affecting people's quality of life.The tr eatment measures of patients with ODS mainly include drug treatment,auxiliary enema,biofeedback and surgical treatment.When patients can not tolerate laxative or enema treatment,non-surgical treatment is ineffective,and the quality of life of patients is seriously affected,surgical treatment options should be considered.Up to now,there are more than one hundred of surgical methods for ODS reported in the literature,which are mainly divided into two categories: transperitoneal approaches and transperineal approaches.Both of them have their own indications,advantages and disadvantages.At present,no one surgical method has become the gold standard in the world.There are still many controversies about the choice between the transabdominal approaches and the transperineal approaches.In 2017,the American Society of colon and Rectal Surgeons(ASCRS)issued a clinical practice guide for rectal prolapse,which recommended that the choice of surgical methods should depend on the experience of surgoen,surgical habits and patient factors,such as the severity and classification of the disease,as well as the comprehensive consideration of gender,age and patient willingness.Therefore,it is of great significance to analyze and compare the therapeutic effects of different surgical methods on patients with ODS,and to select the most suitable surgical method for patients through individual selection and comprehensive systematic analysis and evaluation.As a multifactorial and symptomatic disease,the pathophysiological mechanism of defecation dysfunction in patients with ODS is not completely clear,which may be related to anatomical abnormalities of pelvic floor and pelvic organ relaxation and prolapse,neuromuscular abnormal regulation,mental and psychological factors.The complete anorectal sensory function is very important to the defecation process.The clinical manifestations of frequent defecation,anorectal distension pain and difficult defecation in ODS patients may be related to the abnormal changes of nerve receptors and rectal sensitivity.However,so far,studies on the rectal mucosa nerve receptor expression and sensitive changes in patients with ODS have not been researched.Transient receptor potentia1 vanilloid 1(TRPV1),also known as the capsaicin receptor,and transient receptor potential channel subtypes A1(TRPA1)are widely distributed in the sensory neurons,mucosa,submucosa and muscular layer of the gut.They are involved in the regulation of visceral pain sensation,movement and secretion,and play an important physiological role in intestinal sensory and motor dysfunction.TRPV1 is coexpressed with TRPA1 in many nerve and non nerve cells,and has synergistic effect on function.Our previous studies have found that the abnormal expression of TRPV1 / TRPA1 in slow transit constipation may be related to low sensitivity of colon.However,the expression of TRPV1 and TRPA1 in the rectum of patients with ODS has not been reported.Objective: To analyze the clinical data and follow-up results of ODS patients and adult megacolon in our hospital,and to compare the curative effect of different surgical methods on patients,and to explore the individualized procedures.At the same time,the expression of TRPV1,TRPA1,5-HT3 R and 5-HT4 R in rectal mucosa of patients with ODS were detected,and their role in the pathogenesis of ODS patients were discussed.Method:1.The clinical data and follow-up results of 183 patients with ODS and 22 patients with adult megacolon in our hospital from January 2000 to December 2018 were retrospectively analyzed,and the postoperative efficacy of different surgical procedures were compared,and the selection principle of individualized procedure was analyzed.2.Consecutive patients who underwent abdominal ventral mesh rectopexy(AVMR)with colectomy for ODS were identified prospectively in our department between January2016 and December 2018.The research objectives were to evaluate the efficacy and safety of AVMR with colectomy in the selected patients of mixed constipation with ODS as the main characteristics.3.The expressions of TRPV1,TRPA1,5-HT3 R and 5-HT4 R in the rectum of patients with ODS were detected by immunohistochemistry and Western Blot,and the role of TRPV1 and TRPA1 in the pathogenesis of ODS patients were discussed.Result:1.There were significant differences in operation time,blood loss,postoperative hospital stay and hospitalization expenses between transabdominal and transperineal groups(p<0.001).No significant difference was shown in the early postoperative complications between the two groups(p>0.05),but there was statistical difference in the late postoperative complications(p=0.012).There was a significant difference in the recurrence rate between the two groups(p=0.033)?The postoperative Wexner constipation score of the transabdominal group was better than that of the transperineal group(p<0.001).There was no significant difference in postoperative subjective effectiveness and satisfaction evaluation between the two groups(p>0.05).There were significant differences in operation time,blood loss,postoperative hospital stay and hospitalization expenses between abdominal rectopexy and abdominal rectopexy with sigmoidectomy(p<0.05);No significant difference was shown in the early and late postoperative complications between the two groups(p>0.05).There was no significant difference in the recurrence rate between the two groups(p>0.05).No significant difference was shown in postoperative Wexner constipation score between the two groups(p>0.05).There was no significant difference in postoperative subjective effectiveness and satisfaction evaluation between the two groups(p>0.05).Laparoscopic colectomy and Duhamel anastomosis is a safe and effective method for adult megacolon.Emergency patients underwent one-stage enterostomy and two-stage colectomy is feasible.2.Abdominal ventral mesh rectopexy combined with left colon resection is a safe procedure,which can significantly improve the long-term follow-up function of patients with severe mixed constipation dominated by ODS.3.Immunohistochemical staining showed that the expression of TRPV1,TRPA1,5-HT3 and 5-HT4 receptors in rectal mucosa of patients with ODS was higher than that of the control group(p<0.001).Western blot showed that the expression of TRPV1,TRPA1 and 5-HT3,5-HT4 receptors in rectal mucosa of patients with ODS was higher than that of the control group(p<0.001).Conclusion1.Both transabdominal and transperineal surgeries can achieve good results in the surgical treatment of ODS.The improvement rate of constipation score after transabdominal surgery was better than that of transperineal surgery,and the recurrence rate of transabdominal surgery was significantly lower than that of transperineal surgery.Additional sigmoidectomy did not result in better improvement of constipation in the abdominal rectopexy.The choice of surgical procedure should be individualized for each patient.Laparoscopic colectomy and Duhamel anastomosis is a safe and effective method for adult megacolon.It is necessary to make individualized analysis on whether one-stage definite operation or staged operation should be adopted for adult patients with megacolon,and the scope of intestinal resection should be individualized.Early diagnosis and early operation should be carried out to avoid emergency operation and reduce the possibility of enterostomy.2.AVMR combined with left colon resection is a safe procedure.It has satisfactory effect on patients with severe mixed constipation,which can be used as an option of individualized operation.3.The choice of procedures in patients with ODS needs to be considered by the patient's complaints and demands,patient's examination results and t he general situation,and the surgeon's personal experience,habits individually.At the same time,it needs to be supported by long-term multidisciplinary comprehensive treatment measures.4.The expression of TRPV1,TRPA1 and 5-HT3,5-HT4 receptors in rectal mucosa of patients with ODS were higher,suggesting that TRPV1 and TRPA1 may play an important role in the regulation of rectal fecal sensory and motor mechanisms in ODS patients through the signal transduction pathway of 5-HT3 and 5-HT4 receptors. |
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