Surgical treatment of chronic constipation: a historical review

The term "constipation" (obstipation, colostasis, colonic stasis) refers to intermittent or persistent violation of the bowel emptying function. An indication of chronic constipation is to keep the patient for at least 12 weeks, not necessarily continuous, within six months.

Chronic constipation - a common heterogeneous pathology, which is found in all populations, the frequency of which increases with age. This is facilitated by a sedentary lifestyle, a wide range of diseases, directly leading to the development of chronic constipation, intercurrent diseases, abuse of laxatives.

According to Russian authors, in recent years there has been a significant increase in the prevalence of constipation. According to American researchers WexnerS.D. and Duthie G.D. (2006), US citizens annually spend more than $ 500 million on laxatives, though more than 2.5 million visits to the doctor are related to a shut-off syndrome. Moreover, chronic constipation number US exceeds the number suffering from chronic diseases such as hypertension, migraine, obesity and diabetes.

Chronic constipation is one of the most urgent problems of modern medicine, which is due not only to its prevalence. Is not fully understood pathogenesis, diagnosis, conservative and surgical treatment of chronic colostasis. To date, none of the plurality of the proposed methods of conservative and surgical treatment does not have the absolute effectiveness.

In this regard, a review of the scientific literature, reflecting the evolution of views on chronic constipation, in our opinion, may be of interest for researchers and for practitioners.

In the 10th volume of "Great Medical Encyclopedia" in 1929 edition provides the following notation chronic constipation: a long delay of feces in the intestine caused by the delayed release of the body of stool. In the first volume "Encyclopedic Dictionary of Medical Terms" (1982) states that constipation - a slow, labored or systematic lack of bowel movements. As you can see, in the second definition is taken into account not only slowing the evacuation of feces, but also the difficulty in defecation. According to Fedorov VD and Dultseva Y. (1984), constipation is a difficulty in emptying the colon over 32 hours. The most common in scientific articles by 80-ies became a designation proposed Drossman in 1982 - "a condition where defecation takes place with the straining, though attempts to occupy 25% of its time and" if there is an independent chair at least 2 times a week . However, only rare emptying can not be universal and sufficient criterion for the presence of constipation: it is necessary to consider the presence of incomplete bowel movements, difficulty with defecation scanty hard stool consistency, fragmented by the type of "sheep feces."

In order to develop a unified approach to the definition of chronic constipation in 1988, 1999 and 2006. Committee of experts in the field of gastroenterology and coloproctology special consensus on the functional disorders of the gastrointestinal tract has been developed (the so-called Rome criteria, respectively, I, II, III revision). According to the Rome III criteria revision for chronic constipation should be understood condition that is characterized by two or more of the main features:

• rare emptying of the bowel (less than 3 bowel movements per week);
• Department of feces a high density, dry, fragmented (like "sheep") who injures the anus (symptoms are observed in at least 25% of bowel movements);
• Lack of bowel sensation of complete emptying after a bowel movement (a feeling of incomplete evacuation) not less than 25% of bowel movements;
• availability of the contents of the lock feeling in the rectum with vain attempts (anorectal obstruction), not less than 25% of bowel movements;
• the need for strong attempts, despite the presence of the soft contents of the rectum and urge to void, sometimes with the need to delete the contents of the finger from the rectum, pelvic floor support fingers, etc., at least 25% of bowel movements.;
• an independent chair rarely occurs without the use of laxatives.

In 1968, Z. Marzhatka proposed to divide chronic constipation into two main types: self-symptomatic and constipation. This classification recognizes the possibility of constipation as the primary disorder that later found their development in the emergence of the term "functional", and later "idiopathic constipation."

Currently, the most common classification of chronic constipation is a division of his characteristics colonic transit proposed in A. Koch (1997) and S.J. Lahr (1999). It involves the separation of constipation related to:

• a slowdown in transit through the intestines - cologenic,
• a violation of defecation - proctogenic,
• mixed forms.

The problem of chronic constipation excited scientists throughout the development of medical science. In labor healer and scholar of the ancient East Abu Ali ibn Sina (980-1037), "Canon of Medicine" is a separate chapter devoted to this topic - "On the phenomena caused by the detention and emptying." It quite accurately describes the main points of modern understanding of the etiology and pathogenesis of chronic constipation, "is either from weakness expelling force or the power of holding power", "the weakness of the digestive forces, so that the substance for a long time remains in a bin", "due to the narrowness of the passages and clogging them, either because of the density or viscosity of the material "," due to the loss of feeling the need to expel, for emptying and promotes and willpower. " If the above mentioned state of expression to modern medical terms, it is possible to get a full understanding of the pathogenesis of constipation. Delay promote colon contents in certain segments, the weakness of most colon wall muscles and a strong resistance to spasm of the anal sphincter, organic or functional narrowing of the lumen of the colon, compacted fecal lumps, loss of willful urge to defecate - all of these links in the pathogenesis of constipation outlined Avicenna, and nowadays it seems to be most important.

In this work there is an indication to the fact that constipation can occur from taking bad in quality, "standing" water from the weakness of the digestive capacity of the intestine, which is also not contrary to notions of modern scientists. Violation of the expulsion of intestinal contents leads, according to the author, to various diseases (for example, "indigestion ... ... acne tumors"). As for the treatment of constipation, the author points to the need for acceptance of cabbage juice, safflower core with barley water, the use of special "wet" and oil enemas and others.

A renowned scholar of antiquity, Galen, who lived in the II century BC, dedicated a chapter of his work "On the appointment of a human body parts" peculiarities of functioning of the colon, "the large intestine were created in order to elimination of excrement did not pass too quickly." The author points out that "higher order animals and completed buildings ... not exempt from feces continuously" due to the "width of the colon." Further considered in some detail the process of defecation with a description of the work involved in its muscles.

Since the middle of the XIX century, doctors pay close attention to the shut-off syndrome, the first article appeared in the scientific medical periodicals devoted to this issue. Most of them are descriptive: are cases of private clinical practice, describes the results of autopsy, much attention is paid to the clinical picture as well as the treatment offered in the main use of cleansing enemas, and receive a variety of herbal remedies.

In 1841, a French anatomist, pathologist, a military surgeon, president of the French Academy of Medicine J. Cruveilhier gave a detailed description of the transverse colon, is located in the abdominal cavity in a zigzag position and lowered into the pelvic cavity. He suggested that this occurs as a result of wearing tight corsets, which moves down the liver, which in turn leads to a change in bowel situation and reflected on the work of the gastrointestinal tract.

H. Collet in 1851 stressed that the problem of the treatment of chronic constipation is very acute, as it very often ineffective. He believed that the first step is to establish the absence of organic causes of constipation, and only then proceed to the treatment, the administration of drugs should be under medical supervision. Much attention is paid to compliance with diet and lifestyle. Violation of defecation author mainly linked with the power of his contemporaries, which leads to a decrease in volume of intestinal contents, which in turn entails a lack of bowel distension and violation of his evacuation function.

Between 1885 and 1899 the French clinician C.M.F. Glenard developed the doctrine of the deletion of the internal organs (visceroptosis), which, he believed, is the result of human bipedalism. In total he has written about 30 scientific papers on the topic. In the first studies Glenard wrote that the upright posture as a result of colonic contents congestion occurs, leading to a shift down its divisions to the possible development in the future of chronic constipation. In later works he expressed the idea that intestinal prolapse may be due to liver function abnormalities, leading to deterioration of intrahepatic blood circulation and reduce intestinal tone.

Isolated form visceroptosis described and proposed a method for its elimination in 1905, German surgeon, professor of the University Surgical Clinic in Walde Grayfs Erwin Payr. It was a characteristic symptom, occurring in stenosis of the colon due to its excess in the area splenic curvature. Clinically he manifested paroxysmal pain due to stagnation of gas or stool in the splenic flexure, a feeling of pressure or fullness in the upper left quadrant of the abdomen, pressure or burning pain in the heart, palpitation, dyspnea, retrosternal or precordial pain with a sense of fear, one or bilateral shoulder pain radiating to the arm, pain between the shoulder blades. This anatomical anomaly different authors evaluated differently. Some believe it malformation associated with prenatal violation of attachment of the mesentery of the colon, while others relate to manifestations of general visceroptosis. Subsequently, this pathological condition has been called - Payra syndrome.

Sir William Arbuthnot Lane - famous Scottish physician and scientist beginning of XX century, first described refractory chronic constipation in women, and pay attention to its typical clinical picture and the first who offered to treat them surgically. In tribute to the scientist, this kind of constipation abroad called «Lane's disease». In 1905, he analyzed the possible causes of constipation syndrome, described the typical clinical symptoms. Lane singled out the following links in the pathogenesis of chronic constipation: the expansion and relocation of the cecum in the pelvis due to the presence of adhesions in the abdominal cavity, the presence of highly placed hepatic and splenic flexure of the colon, the presence of elongated transverse colon and sigmoid colon. The omission of the colon results in a total visceroptosis, resulting in impaired functioning of the digestive tract and urogenital system. Also important he considered the development of "auto-intoxication" as a result of entering the bloodstream products colonic microflora ability to live in chronic constipation. He noted that the majority of women suffering from chronic constipation, older than 35 years, slim build, they strapped and inelastic skin, frequent mastitis (resulting in an increased risk of breast cancer), kidney, abnormal mobility, impaired peripheral microcirculation, poorly developed secondary sexual characteristics, and increased the number of ovarian cysts, they suffer from infertility and amenorrhea. And W. Lane believed that joining the symptoms violations stool abdominal pain indicates a high degree of "auto-intoxication".

D.M. Preston and J.E. Lennard-Jones in 1986, studying patients with constipation, also drew attention to the characteristic clinical picture of refractory chronic constipation in women. They proposed a new term for this group of patients: idiopathic slow-transient constipation ( «idiopathic slow transit constipation»). In these patients there was a significant prolongation of time colonic transit with no organic cause obstruction of passage, increased bowel caliber, dysfunction of the pelvic floor muscles, and other causes of the shut-off syndrome.

In 1987, Russian scientist monograph PA Romanov "Clinical anatomy and variants of colon abnormalities", to this day remains the only one in this area. This paper summarizes the numerous data published in the literature and the results of author's own research. He offered an original classification of colon topographic anatomy options.

Talking about chronic constipation, can not ignore the innate form of megacolon. In the XVII century the famous Dutch anatomist F. Ruycsh made the first description of this disease is to find the expansion of the colon at necropsy five children. Later periodically appeared in the literature are few reports of the same kind of individual observations, which were regarded as casuistry. megacolon description Priority adults belongs to the Italian doctor S. Fawalli. The magazine «Gazetta medica di Milano» for 1846 he published observation hypertrophy and expansion of an adult male colon.

In 1886, a Danish pediatrician Hirschsprung spoke at a meeting of the Berlin Society of Pediatricians with the report, and later published an article "Constipation in newborns due to enlargement and hypertrophy of the colon," where he has compiled 57 described by the time cases and 2 own observations megacolon. He first identified it as a separate disease entities. In Russian literature the first report of the disease Hirshsprungs was made in 1903 VP Zhukovsky.

The qualitative change in the understanding of the nature of suffering has occurred with the appearance of works F.R. Whitehouse, O. Swenson, I. Kernohan (1948). The authors studied in detail the autonomic innervation of the colon in patients of all ages, including newborns had symptoms of "congenital megacolon ', and found that the disease Hirshsprungs area full agangliosis gradually passes into the zone with the normal structure of the parasympathetic plexus (proximal colon) .

In our country, information about the first fundamental Pathology at Hirshsprungs disease published in the book YF Isakov "Megacolon children" (1965). And in 1986, the book was published in the Soviet Union VD Fedorov and GI Vorobiev 'Megacolon adults ", where detailed clinical symptoms in 62 patients with agangliosis gipogangliosis and colon, as well as a detailed analysis of different methods of surgical treatment of disease and correction of postoperative complications.

Despite a century of surgery resistant forms colostasis still not clearly defined indications for surgical treatment, its scope, the timing of medical treatment and the criteria for assessing its effectiveness.

The pioneer in surgery has become chronic colostasis above mentioned W.A. Lane. In 1905 he wrote that the proportion of patients with severe pain are often performed appendectomy without a positive clinical outcome. In 1908, he reported on the experience of surgical treatment of 39 patients with chronic colostasis. The need for surgery for resistant forms of constipation, he justified the development of "auto-intoxication". Lane noted that resorting to surgery should be only in case of failure of conservative therapy. Regarding the choice of volume of operative intervention, the authors emphasize that it is due to the severity of constipation, its duration and the severity of morphological changes in the intestine. In some cases it is sufficient separation of adhesions or bowel mobilization places inflection in the other - imposing bypass anastomosis between the terminal ileum and sigmoid or straight while retaining all of the colon, in the third - the need for extensive resection of the colon until colectomy. Moreover, men sufficient and preferable to the author considered the first version of the operation.

Lane drew attention to the ease of implementation of this surgery and its excellent results, and the various associated risks, in my opinion, justified by the benefit from the elimination of "autointoxication" symptoms. Lane noted that the implementation of limited resection of the colon in the future is fraught with the closure relapse syndrome, so in the case of severe chronic constipation preferred considered satisfied colectomy. He also drew attention to the fact that it is necessary to warn patients about possible complications during surgery and in the postoperative period.

In 1905 E. Payr proposed an original method of treatment of prolapse of the colon described them, the transverse colon, he stitched throughout to the greater curvature of the stomach.

For the first time colopexy - fixation to the abdominal wall of the right side of the colon described in 1908 by M. Wilms, a Soviet surgeon IE Hagen-Thorn in 1928 first proposed to produce mesosigmaplication with elongated sigmoid volvulus.

NK Streuli said in 1977 about the experience of treating 28 patients with resistant forms of chronic constipation, recommending subtotal colectomy with anastomosis between the ileum and sigmoid colon. According to him, the operation must be performed after eliminating all the possible causes of chronic constipation, and after a careful selection of patients.

In 1984 K.P. Gilbert et al. based on their own experience recommended subtotal colectomy as a selection operation for chronic constipation. If constipation is caused dolichosigma, they considered it possible to confine its resection, indicating, however, that in the future may require reoperation for recurrent constipation.

In 1988, SA Vasilevsky et al. based on the analysis of results of treatment 52 patients concluded that the conduct of subtotal colectomy for slow-transient nature of chronic constipation is adequate in terms of intervention. Christiansen was among the first in 1989, it offers a total holding colproctectomy with enteral reservoir formation in chronic constipation caused by slow transit of intestinal contents and inert rectum.

A. Glia A. et al. (1999) report good long-term functional outcome in patients with constipation when the total colectomy with anastomosis ileorectal. However, indicate that in rare cases, it is still possible relapse of constipation, but often there are new symptoms such as diarrhea and incontinence. In 2008, Frattini et al. as the operation of choice in constipation indicate colectomy with ileorectalanastomosis. According to them, after this procedure is observed the smallest number of relapses, and the operation itself is best done laparoscopically.

As the disease Hirshsprungs, numerous attempts to apply conservative methods of treatment in both children and adults were inconclusive. The need for surgery in this disease is currently no one in doubt. Among pediatric surgeons there was unanimous agreement that radical surgery should be the removal of all or almost all agangliosis zone and decompensated greatly expanded the large intestine.

In 1954, O. Swenson proposed methodology abdominoperineal proctosigmoidectomy, which later was the prototype of all subsequent operations. Soon, in 1958 and 1965., This intervention was significantly improved R.B. Hiatt and YF Isakov. In 1956, Duhamel proposed operation consisting in retrorectal downgrade colon. In further modifications (Bairov GA 1968;. Grob M., 1959, etc.) the shortcomings of this method have been eliminated in many ways. In 1963, F. Soave proposed to make the mobilization of the affected area rectum and sigmoid colon, withdraw it from the perineum through the channel formed by the peeling of the mucous membrane of the rectum, and then resect derived part without primary anastomosis.

Special methods of surgical treatment Hirshsprungs disease in adults has not been developed. Experience SSC Coloproctology Russian Ministry of Health shows that the use of classical methods of treatment used in children's Coloproctology, in adult patients is difficult because of anatomical features, particularly pronounced cicatricial process in the wall of the colon in patients older age group, which is fraught with the likelihood of a large number of post-operative complications . Within the walls of this institution developed a radical modification operations Duhamel performed two teams a two-step formation of colorectal anastomosis.

The rapid development of laparoscopic surgery in the early 90s of the twentieth century led to the introduction into clinical practice of surgery of the colon. D.L. Fowler was the first in the history of Coloproctology, who in 1991 performed the laparoscopic resection of the sigmoid colon. He believed that the next step in the development of endoscopic surgery of the abdomen after cholecystectomy should be intestinal surgery. Removable parts of the colon are removed through a mini-laparotomy incision and anastomosis imposed by hardware, "end-to-end."

In 1997 he published an article Y.H. Ho et al., In which a comparison made of open and laparoscopic colectomy about constipation. The authors conclude that long-term results of both methods are similar, but the laparoscopic technique though is more complex, but it has better cosmetic results and shorter duration of the patient's hospital stay.

In 2002 Y. Inoue et al. reported on the world's first total colectomy with ileorectal anastomosis for chronic constipation, performed entirely laparoscopically. Resected colon was evacuated Transanal and ileorectal anastomosis was imposed "end-to-end" circular stapler apparatus. This approach, according to the authors, reduces the duration of surgery and reduces the risk of wound infection. In 2012, H. Kawahara et al. reported the first experience in conducting in 2009 a total colectomy with ileorectal anastomosis single-port access (SILS) for chronic constipation.

Thus, the history of the study of chronic constipation began in the mists of time - even then scientists have correctly identified the main links of this suffering, giving them accurate descriptions, but a basic understanding of chronic constipation for a long time remained unchanged, complemented by new items in accordance with the level of medical knowledge. In subsequent studies, medical scientists have uncovered previously unknown mechanisms, given their assessment on the basis of the data developed classification. Work on the study of the pathogenesis of chronic constipation continues today. Approaches to the treatment of drug-resistant forms of colostasis remain unchanged over the years: surgery is the treatment of desperation, resort to it only when already exhausted the possibility of conservative management. From the very beginning of the history of surgery of chronic constipation need to justify the development of her surgeons intoxication in severe colostasis that is consonant with modern ideas. Although surgery constipation syndrome for over a hundred years, though not developed one operative technique, the problem of choosing the scope of intervention and the optimal technique of its implementation are still not fully resolved and, of course, subject to further discussion.

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10]