Surgical treatment of chronic constipation: a historical review

The term "constipation" (constipation, obstipation, colostasis, colonic stasis) refers to a persistent or intermittent disorder of the bowel movement function. A sign of chronicity is the persistence of constipation in a patient for at least 12 weeks, not necessarily continuously, for six months.

Chronic constipation is a common heterogeneous pathology that occurs in all population groups, the frequency of which increases with age. This is facilitated by a sedentary lifestyle, a wide range of diseases that directly lead to the development of chronic constipation, intercurrent diseases, and 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 Wexner S.D. and Duthie G.D. (2006), US residents spend more than $500 million annually on laxatives, with more than 2.5 million visits to the doctor related to constipation syndrome. In addition, the number of people suffering from chronic constipation in the US exceeds the number of people suffering from chronic diseases such as hypertension, migraine, obesity and diabetes.

Chronic constipation is one of the most pressing problems of modern medicine, which is associated not only with its prevalence. The issues of pathogenesis, diagnostics, conservative and surgical treatment of chronic colostasis have not been fully studied. To date, none of the many proposed methods of conservative and surgical treatment is 100% effective.

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

The 10th volume of the Great Medical Encyclopedia of 1929 provides the following definition of chronic constipation: prolonged retention of feces in the intestines caused by a slowdown in the excretion of feces by the body. The first volume of the Encyclopedic Dictionary of Medical Terms (1982) states that constipation is a slow, difficult or systematically insufficient emptying of the intestines. As we can see, the second definition takes into account not only the slowing of the evacuation of feces, but also difficulty in defecation. According to Fedorov V.D. and Dultsev Yu.V. (1984), constipation is a difficulty emptying the colon for more than 32 hours. The most common in scientific articles of the 80s of the last century is the designation proposed by Drossman in 1982 - "a condition in which defecation occurs with straining, and straining takes 25% of its time, or" if an independent bowel movement occurs less than 2 times a week. However, the rarity of bowel movements alone cannot be a universal and sufficient criterion for the presence of constipation: it is necessary to take into account the presence of incomplete bowel movement, difficulty in defecation with scanty release of stool of a hard consistency, fragmented like "sheep feces".

In order to develop a unified approach to defining chronic constipation, in 1988, 1999 and 2006 a committee of specialists in the field of gastroenterology and proctology developed a special consensus on functional diseases of the gastrointestinal tract (the so-called Rome criteria, respectively, revision I, II, III). According to the Rome criteria of revision III, chronic constipation should be understood as a condition characterized by two or more main signs:

• infrequent evacuation of contents from the intestines (less than 3 bowel movements per week);
• the passage of feces that are dense, dry, fragmented (like “sheep”), traumatizing the anal area (signs are observed in at least 25% of bowel movements);
• lack of a feeling of complete emptying of the intestines after defecation (feeling of incomplete evacuation) in at least 25% of bowel movements;
• the presence of a feeling of blockage of contents in the rectum during straining (anorectal obstruction), in at least 25% of bowel movements;
• the need for strong pushing, despite the presence of soft contents of the rectum and the urge to defecate, sometimes with the need for digital removal of contents from the rectum, support of the pelvic floor with fingers, etc., in at least 25% of bowel movements;
• spontaneous bowel movements rarely occur without the use of laxatives.

In 1968, Z. Marzhatka proposed dividing chronic constipation into two main types: symptomatic and independent constipation. This classification recognizes the possibility of constipation as a primary disorder, which later developed into the term "functional" and later "idiopathic constipation".

Currently, the most common classification of chronic constipation is its division by the characteristics of colonic transit, proposed in the works of A. Koch (1997) and SJ Lahr (1999). It implies division into constipations associated with:

• with slow intestinal transit - colonic,
• with defecation disorders - proctogenic,
• mixed forms.

The problem of chronic constipation has concerned scientists throughout the development of medical science. In the work of the physician and scholar of the ancient East Abu Ali ibn Sina (980-1037) "The Canon of Medicine" there is a separate chapter devoted to this topic - "On the phenomena caused by retention and emptying". It quite accurately sets out the main points of the modern understanding of the etiology and pathogenesis of chronic constipation: "it occurs either from the weakness of the expelling force, or from the strength of the retaining force", "from the weakness of the digestive force, as a result of which the substance remains in the receptacle for a long time", "due to the narrowness of the passages and their blockage, or because of the density or viscosity of the substance", "due to the loss of the feeling of the need to expel, because emptying is also facilitated by willpower." If we express the above expressions in modern medical language, we can get a complete picture of the pathogenesis of constipation. Delay in the movement of the contents of the colon in certain segments, weakness of the muscles of the walls of the intestine itself and powerful resistance of the spasmodic anal sphincter, organic or functional narrowing of the lumen of the colon, compacted fecal lumps, loss of the volitional urge to defecate - all these links in the pathogenesis of constipation, described by Avicenna, are still considered the most important in our time.

This work also indicates that constipation can occur from drinking poor quality "stagnant" water, from weak digestive capacity of the intestines, which also does not contradict the ideas of modern scientists. According to the author, a violation of the expulsion of intestinal contents leads to various diseases (for example, "indigestion... tumors... acne"). As for the treatment of constipation, the author points out the need to take cabbage juice, safflower core with barley water, use special "wet" and oil enemas, etc.

The famous ancient scientist Galen, who lived in the 2nd century AD, devoted a separate chapter of his work "On the Purpose of the Parts of the Human Body" to the peculiarities of the functioning of the large intestine: "the large intestines were created so that the excrement would not be excreted too quickly." The author points out that "animals of a higher order and complete structure... do not get rid of excrement continuously" due to the "width of the large intestine." Then the process of the act of defecation is considered in sufficient detail, with a description of the work of the muscles involved in it.

Beginning in the mid-19th century, doctors began paying special attention to constipation syndrome, and the first articles devoted to this problem appeared in scientific medical periodicals. Most of them are descriptive: cases from personal clinical practice are cited, the results of pathological autopsies are described, much attention is paid to the clinical picture, and the use of cleansing enemas and the use of various herbal medicines are mainly proposed as treatment.

In 1841, the French anatomist, pathologist, military surgeon, and president of the French Academy of Medicine J. Cruveilhier gave a detailed description of the transverse colon, which was located in the abdominal cavity in a zigzag position and descended into the pelvic cavity. He suggested that this occurred as a result of wearing tight corsets that displaced the liver downwards, which in turn led to a change in the position of the intestines and affected the functioning of the entire gastrointestinal tract.

H. Collet in 1851 emphasized that the problem of treating chronic constipation is very acute, since it is very often ineffective. He believed that the first step is to establish the absence of an organic cause of constipation and only then begin treatment, and the intake of drugs should be under the supervision of a doctor. The author paid much attention to diet and lifestyle. The author mainly associated the violation of defecation with the diet of his contemporaries, which leads to a decrease in the volume of intestinal contents, which in turn entails insufficient stretching of the intestine and a violation of its evacuation function.

Between 1885 and 1899, the French clinician CMF Glenard developed a theory of prolapse of internal organs (enteroptosis, splanchnoptosis), which he believed to occur as a result of upright walking. He wrote about 30 scientific papers on the topic. In his early works, Glenard wrote that upright walking causes stagnation of the contents of the colon, which leads to a downward displacement of its sections with the possible subsequent development of chronic constipation. In his later works, he suggested that prolapse of the intestines may be a consequence of liver dysfunction, leading to deterioration of intrahepatic blood circulation and a decrease in intestinal tone.

An isolated form of splanchnoptosis was described and a method for its elimination was proposed in 1905 by the German surgeon, professor of the University Surgical Clinic in Greifswalde Erwin Payr. It was a characteristic symptom complex arising from stenosis of the colon, caused by its kink in the area of the splenic curvature. Clinically, it was manifested by paroxysmal pain due to stagnation of gases or feces in the area of the splenic flexure, a feeling of pressure or fullness in the left upper quadrant of the abdomen, pressure or burning pain in the heart area, palpitations, shortness of breath, retrosternal or precordial pain with a feeling of fear, unilateral or bilateral pain in the shoulder radiating to the arm, pain between the shoulder blades. Different authors evaluate this anatomical anomaly differently. Some consider it a developmental defect associated with intrauterine disruption of the mesentery of the colon, others attribute it to manifestations of general splanchnoptosis. Subsequently, this pathological condition was named Payr's syndrome.

Sir William Arbuthnot Lane is a famous Scottish physician and scientist of the early 20th century, who was the first to describe refractory chronic constipation in women and draw attention to its characteristic clinical picture, and was also the first to suggest treating them surgically. In tribute to the scientist, this type of constipation is called "Lane's disease" abroad. In 1905, he analyzed the possible causes of constipation syndrome and described the characteristic clinical symptoms. Lane identified the following links in the pathogenesis of chronic constipation: expansion and displacement of the cecum into the small pelvis due to the presence of adhesions in the abdominal cavity, the presence of highly located hepatic and splenic flexures of the colon, the presence of an elongated transverse colon and sigmoid colon. Prolapse of the colon entails general visceroptosis, resulting in disruption of the functioning of the gastrointestinal tract and genitourinary system. He also considered the development of "autointoxication" as a result of the entry of waste products of the colonic microflora into the bloodstream during chronic constipation to be of no small importance. He noted that most women suffering from chronic constipation are over 35 years old, thin, have tight and inelastic skin, often suffer from mastitis (which increases the risk of breast cancer), have abnormally mobile kidneys, impaired peripheral microcirculation, poorly developed secondary sexual characteristics and an increased number of ovarian cysts, suffer from infertility and amenorrhea. Moreover, W. Lane believed that the addition of abdominal pain to the symptoms of bowel disorders indicates a high degree of "autointoxication".

In 1986, DM Preston and JE Lennard-Jones, studying patients with constipation, also drew attention to the characteristic clinical picture of refractory chronic constipation in women. They proposed a new term to designate this group of patients: idiopathic slow-transit constipation. These patients have a significant prolongation of colonic transit time in the absence of organic causes of obstruction of passage, an increase in the caliber of the intestine, dysfunction of the pelvic floor muscles, and other causes of the development of constipation syndrome.

In 1987, the Russian scientist P.A. Romanov published a monograph, “Clinical Anatomy of Variants and Anomalies of the Colon,” which remains the only one in this area to this day. This work summarizes numerous data published in the literature, as well as the results of the author’s own research. He proposed an original topographic-anatomical classification of colon variants.

When speaking about chronic constipation, one cannot ignore the congenital form of megacolon. In the 17th century, the famous Dutch anatomist F. Ruycsh made the first description of this pathology, having discovered the expansion of the colon during the autopsy of a five-year-old child. Subsequently, isolated reports of the same kind periodically appeared in the literature about individual observations, which were regarded as casuistry. The priority of describing megacolon in adults belongs to the Italian doctor C. Fawalli. In the journal "Gazetta medica di Milano" for 1846, he published an observation of hypertrophy and expansion of the colon in an adult man.

In 1886, the Danish pediatrician Hirschsprung presented a report at a meeting of the Berlin Society of Pediatricians, and later published an article entitled "Constipation in Newborns Due to Dilation and Hypertrophy of the Colon," where he summarized 57 cases described by that time and 2 of his own observations of megacolon. He was the first to identify it as an independent nosological entity. In Russian literature, the first report of Hirschsprung's disease was made in 1903 by V.P. Zhukovsky.

A qualitative breakthrough in understanding the essence of suffering occurred with the appearance of the works of F. R. Whitehouse, O. Swenson, I. Kernohan (1948). The authors studied in detail the autonomic innervation of the colon in patients of different ages, including newborns with symptoms of "congenital megacolon", and established that in Hirschsprung's disease, the zone of complete aganglionosis gradually passes into a zone with a normal structure of the parasympathetic plexus (proximal parts of the colon).

In our country, information about the first fundamental pathomorphological study of Hirschsprung's disease was published in the book by Yu. F. Isakov "Megacolon in Children" (1965). And in 1986, the book by V. D. Fedorov and G. I. Vorobyov "Megacolon in Adults" was published in the USSR, where clinical symptoms in 62 patients with aganglionosis and hypoganglionosis of the colon were described in detail, and a detailed analysis of various methods of surgical treatment of the disease and correction of postoperative complications was given.

Despite the century-long history of surgery for resistant forms of colostasis, indications for surgical treatment, its scope, timing of conservative treatment and criteria for assessing its effectiveness have not yet been clearly defined.

The pioneer in the surgery of chronic colostasis was the above-mentioned W. A. Lane. In 1905, he wrote that some patients with severe pain syndrome often undergo appendectomy without a positive clinical result. In 1908, he reported on his own experience of surgical treatment of 39 patients with chronic colostasis. He justified the need for surgery in resistant forms of constipation by the development of "autointoxication". Lane noted that surgical treatment should be resorted to only in the case of failure of conservative therapy. As for the choice of the scope of surgical intervention, the author emphasized that it is determined by the degree of constipation, its duration and the severity of morphological changes in the intestine. In some cases, it is sufficient to separate adhesions or mobilize the site of intestinal kinking, in others - to impose a bypass anastomosis between the terminal ileum and the sigmoid or rectum with preservation of the entire colon, in others - it is necessary to perform extensive resections of the colon up to colectomy. Moreover, in men, the author considered the first option of the operation sufficient and more preferable.
Lane drew attention to the simplicity of this surgical intervention, its excellent results, and all sorts of associated risks, in the author's opinion, are justified by the benefit of eliminating the symptoms of "autointoxication". Lane noted that performing limited resections of the colon in the future is fraught with a relapse of constipation syndrome, therefore, in the case of severe chronic constipation, he considered colectomy to be more preferable. He also drew attention to the fact that patients should be warned about possible complications during surgery and in the postoperative period.

In 1905, E. Payr proposed an original method of treating the prolapse of the colon that he described: he sutured the transverse colon along its entire length to the greater curvature of the stomach.

Colopexy - fixation of the right flank of the colon to the abdominal wall - was first described in 1908 by M. Wilms, and the Soviet surgeon I.E. Gagen-Torn was the first to suggest performing mesosigmoplication in case of volvulus of the elongated sigmoid colon in 1928.

In 1977, N.K. Streuli reported on 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 should be performed after excluding all possible causes of chronic constipation and after careful selection of patients.

In 1984, KP Gilbert et al., based on their own experience, recommended subtotal colectomy as the operation of choice for chronic constipation. If constipation is caused by dolichosigmoid, they considered it possible to limit themselves to its resection, pointing out, however, that a repeat operation may be necessary in the future due to recurrence of constipation.

In 1988, S.A. Vasilevsky et al., based on the analysis of the treatment results of 52 patients, concluded that subtotal colectomy for slow-transient chronic constipation is an adequate intervention in terms of volume. Christiansen was one of the first in 1989 to propose total colproctectomy with the formation of a small intestinal reservoir for chronic constipation caused by slow transit of intestinal contents and an inert rectum.

A. Glia A. et al. (1999) report good long-term functional results in patients with constipation after total colectomy with ileorectal anastomosis. However, they point out that in rare cases, constipation may recur, but new symptoms such as diarrhea and incontinence appear more often. In 2008, Frattini et al. point out colectomy with ileorectal anastomosis as the operation of choice for constipation. In their opinion, this technique is associated with the lowest number of recurrences, and the operation itself is best performed laparoscopically.

As for Hirschsprung's disease, numerous attempts to use conservative treatment methods in both children and adults have proven ineffective. The need for surgery for this disease is currently beyond anyone's doubt. There is a unanimous opinion among pediatric surgeons that radical surgery should involve the removal of all or almost all of the aganglionic zone and decompensated, significantly dilated sections of the colon.

In 1954, O. Swenson proposed a technique of abdominoperineal rectosigmoidectomy, which subsequently became the prototype of all subsequent operations. Soon, in 1958 and 1965, this intervention was significantly improved by RB Hiatt and Yu.F. Isakov. In 1956, Duhamel proposed an operation consisting of retrorectal lowering of the colon. In further modifications (Bairov G.A., 1968; Grob M., 1959, etc.), the existing shortcomings of this technique were largely eliminated. In 1963, F. Soave proposed mobilizing the affected area of the rectum and sigmoid colon, removing it from the perineum through a canal formed by peeling off the mucous membrane of the rectum, and then resecting the removed part without imposing a primary anastomosis.

There are no special surgical methods for the treatment of Hirschsprung's disease in adults. The experience of the State Scientific Center of Proctology of the Ministry of Health of the Russian Federation shows that the use of classical surgical techniques used in pediatric proctology in adult patients is difficult due to anatomical features, in particular, the pronounced cicatricial process in the intestinal wall in older patients, which is fraught with the likelihood of developing a large number of postoperative complications. Within the walls of this institution, a modification of the radical operation according to Duhamel has been developed, performed by two teams with a two-stage formation of colorectal anastomosis.

The rapid development of laparoscopic surgery in the early 90s of the twentieth century led to the introduction of surgical interventions on the colon into clinical practice. DL Fowler was the first in the history of proctology who performed a laparoscopic resection of the sigmoid colon in 1991. He believed that the next stage in the development of endoscopic abdominal surgery after cholecystectomy should be intestinal surgery. The removed sections of the colon were extracted through a mini-laparotomy incision, and the anastomosis was applied using an end-to-end hardware method.

In 1997, an article by YH Ho et al. was published, which compared open and laparoscopic colectomies for constipation. The authors came to the conclusion that the long-term results of both methods were similar, but the laparoscopic technique, although more complex, had a better cosmetic result, as well as a shorter hospital stay for the patient.

In 2002, Y. Inoue et al. reported the world's first total colectomy with ileorectal anastomosis for chronic constipation, performed entirely laparoscopically. The resected colon was evacuated transanally, and the ileorectal anastomosis was performed end-to-end with a circular stapler. According to the authors, this approach shortens the duration of the operation and reduces the risk of wound infection. In 2012, H. Kawahara et al. reported the first experience of performing total colectomy with ileorectal anastomosis via single-port access (SILS) for chronic constipation in 2009.

Thus, the history of studying chronic constipation began in the depths of centuries - even then, scientists correctly identified the main links in the development of this disease, giving them accurate descriptions, but the basic idea of chronic constipation remained unchanged for a long time, supplemented by new details in accordance with the level of development of medical knowledge. In subsequent works of medical scientists, previously unknown mechanisms were revealed, their assessment was given, and classifications were developed based on the data obtained. Work on the study of the pathogenesis of chronic constipation continues to this day. Approaches to the treatment of resistant forms of colostasis have remained unchanged for many years: surgical intervention is a method of despair, it is resorted to only when the possibilities of conservative management have already been exhausted. From the very beginning of the history of surgery for chronic constipation, surgeons justified the need for it by the development of intoxication of the body with severe colostasis, which is consonant with modern concepts. And although surgery for constipation syndrome has been around for over a hundred years, and more than one surgical technique has been developed, the problems of choosing the scope of intervention and the optimal technique for performing it remain not fully resolved and are certainly subject to further discussion.

Postgraduate student of the Department of Surgical Diseases with courses in oncology, anesthesiology and resuscitation Shakurov Aidar Faritovich. Surgical treatment of chronic constipation: a historical review // Practical Medicine. 8 (64) December 2012 / Volume 1

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