（英文翻译）便秘的管理

分享一个2021年我科翻译的英文文献。来自ACG的《便秘的管理》。翻译不易，转载请告知。

Management of obstructed defecation

便秘的管理

The management of obstructed defecation syndrome(ODS) is mainly conservative and mainly consists of fiber diet, bulking laxatives, rectal irrigation or hydrocolontherapy, biofeedback, transanal electrostimulation, yoga and psychotherapy.

According to our experience, nearly 20% of the patients need surgical treatment. If we consider ODS an “iceberg syndrome”, with “emerging rocks”, rectocele and rectal internal mucosal prolapse, that may benefit from surgery, at least two out of ten patients also has “underwater rocks” or occult disorders, such as anismus, rectal hyposensation and anxiety/depression, which mostly require conservative treatment.

Rectal prolapse excision or obliterative suture, rectocele and/or enterocele repair, retrograde Malone’s enema and partial myotomy of the puborectalis muscle are effective in selected cases.

Laparoscopic ventral sacral colporectopexy may be an effective surgical option. Stapled transanal rectal resection may lead to severe complications. The Transtar procedure seems to be safer, when dealing with recto-rectal intussusception.A multidisciplinary approach to ODS provides the best results.

Obstructed defecation syndrome (ODS) is a type of constipation characterized by fragmented stools need for straining at defecation, sense of incomplete evacuation, tenesmus, urgency, pelvic heaviness and self-digitation.

Most patients are females. The aim of self-digitation is two-fold: 

（1）by compressing the rectocele pouch through the vagina, the patient makes the anorectum straight and facilitates the evacuation of the stool; 

（2）by pushing on the perineum, the transverse muscles of the perineum are stimulated, and this elicits a reflex rectal contraction aimed at evacuating the feces.

Unfortunately, self-digitation may cause anorectal ulcerations followed by bleeding and discomfort and anal fibrosis leading to a stricture. The diagnosis of ODS is based on a careful evaluation of the patient’s clinical history. The severity of symptoms may be objectively evaluated using a validated score。

Transanal-vaginal ultrasound (US), defecography ,anorectal manometry and the balloon expulsion test, entero defecography, dynamic perineal US and magnetic resonance imaging defecography,pudendal nerve motor latency and psychological evaluation may be useful for the assessment of ODS.

ODS has been also defined an “iceberg syndrome”, as the two most frequent lesions, i.e., rectocele and rectal internal mucosal prolapse, present in more than 90% of patients with ODS, are easily detectable and may be considered “emerging rocks”, whereas the “surgical ship” is likely to “sink” due to the “underwater rocks”, i.e., the occult lesions. At least two occult lesions were present in all patients with ODS in a prospective study conducted by our group.

They are more difficult to diagnose and may be either functional or organic. The former are: anxiety/ depression, anismus or non-relaxing puborectalis muscle on straining, rectal hyposensation, pudendal neuropathy and spastic colon. The latter are: peritoneo- entero- and sigmoidocele, colpocele, cystocele, recto-rectal intussusception and solitary rectal ulcer. Therefore, rectocele and rectal prolapse, which are usually the target of surgery, are more effects than causes of symptoms。

An excessive straining is likely to be the “primum movens”, causing tissue weakness and organ descent, and often is due to long-standing anxiety, muscle tension and consequent non-relaxing puborectalis muscle.

The increased straining causes pudendal nerve stretch which may lead to a pudendal neuropathy which affects rectal sensation. The stool becomes small and hard and more difficult to evacuate, as they are less effective in stimulating the rectal wall, and then eliciting the peristaltic reflex aimed at inhibiting the rectal internal sphincter and facilitating the evacuation of the stool。

It is clear that surgery has a secondary role in correcting the above mentioned defects, as they are mainly psychological and/or muscular and/or neurological. Unfortunately, they would require long and complex treatment, i.e., change of dietary regimen, psychological support, pelvic floor rehabilitation. Instead, both patients and surgeons prefer a faster solution of the problem, i.e., a straightforward operation. This explains why most, if not all surgical procedures tend to fail in the long term.

Fiber diet, plenty of water and bulking laxatives are the most used frequently conservative treatments of ODS.

Chocolate and other foods which increase stool viscosity thus making more difficult stool expulsion “in one shot” should be avoided。

Hydrocolontherapy or lavage has a positive role in the treatment of ODS and there is no risk of side effects。Several authors are in favour of rectal irrigation, which is reported to be effective in nearly half of the patients with intestinal dysfunction。

Nevertheless it is well known that the abuse of self- administered enemas may cause anorectal fibrosis and stricture, due to repeated microtrauma.

Anismus may be also cured with yoga exercises and botulinum toxin A, (50 units injected into the puborectalis muscle), with a short-term cure rate of about 50% and minor or rare side effects, such as transient anal incontinence and hypotension。

Transanal electrostimulation, which may be carried out as a home procedure using small probe inserted into the anus and connected with a portable electrostimulator, may be effective in both pudendal neuropathy and rectal hyposensation。

SURGICAI TREATMENT: MANUAL TECHNIQUES

1.The options at disposal of the surgeon who deals with ODS are as follows: (1) to perform a kind of “surgical” irrigation; (2) to perform either a resection or a plication or a pexy in case of internal mucosal prolapse; (3) to reinforce the rectovaginal septum and/or, again, resect the redundant mucosa, in case of significant rectocele; and (4) to perform miotomy in case ODS is due to a muscular disorder.

2、An alternative minimally invasive procedure, which is indicated when dealing with smaller prolapse and rectocele, consists of an over-running suture on the anterior midline starting from the dentate line up to the apex of the rectocele and then reversal, going back to the dentate line. The consequent plication of the rectal layers forms a kind of barrier and reinforces the weakened recto- vaginal septum obliterating both the prolapse and the rectocele。

3.Resection rectopexy, the internal Delorme procedure or circumferential rectal mucosectomy with rectal muscle plication, sacral rectopexy and ventral laparoscopic rectopexy have been used with satisfactory short-term outcomes when dealing with ODS due to recto-rectal intussusception, but the long- term outcomes are less encouraging, as nearly half of the patients have a recurrence of ODS symptoms at 4 years。

4.Instead, nearly 90% of the patients are cured at 4 years after a combined transanal-transperineal and abdominal approach, i.e., positioning of mesh at the pelvic outlet, for rectocele-internal rectal prolapse and enterocele. The reason for the high success rate is that the other occult concomitant functional diseases, such as anismus, are cured with psycho-echo-biofeedback.while the patient strains and is encouraged to carefully watch the contraction-relaxation of the puborectalis muscle on the screen of the transanal or, better yet, the transvaginal US machine。

5.It consists of a transperineal bilateral partial myotomy of the puborectalis muscle, aimed at favouring its relaxation on straining. According to its inventor, the operation is more effective than biofeedback conditioning and botulinum toxin A injection。

SURGICAL TREATMENT : STAPING TECHNIGUES

1.The first stapled procedure for rectal mucosal prolapse causing ODS was reported by Pescatori et al, using a circular stapler in a small series with good short-term results and no relevant complications. 

2.The first study on STARR, was published by Boccasanta et al, who reported good results in around 90% patients in the short term, but painful defecation at one year in 20%. Post-STARR chronic proctalgia, which may be severe and affect patients’ quality of life, is likely to be due to the fibrosis around retained staples, which triggers the nerve spindles on the levator ani and puborectalis muscles。

3.Complications have been reported following STARR, such as severe rectal bleeding, fecal urgency and anal incontinence, recto-vaginal fistulae, retrorectal hematoma, pelvic sepsis , and deaths. Fecal urgency and anal incontinence after STARR are most likely to be due to the reduced size of the rectal reservoir。

CONCLOUSION

The outcome of surgery alone for ODS may be good in the short term, but it worsens over time, probably due to the fact that both the diagnosis and the management of the “occult” lesion(s) causing symptoms are neglected. The psychosomatic component of ODS should be recognized and managed as it affects two-thirds of the patients. Several conservative treatments are available and should be attempted prior to surgical management of ODS. The holistic approach is important, i.e., psyche and soma should be considered a unique entity. The key to successful treatment of ODS appears to be a multidisciplinary approach。

排便困难综合征的主要的保守治疗包括饮食膳食纤维、口服容积性泻药、灌肠、结肠水疗、生物反馈治疗、经肛门电刺激治疗、瑜伽和心理治疗。

根据我们的经验，将近20%的病人需要外科手术治疗。如果我们把ODS比作为隐匿性疾病的“冰山现象”，如能够受益于外科手术治疗的直肠前突和直肠粘膜内脱垂疾病，至少十分之二的患者还具有患有隐匿性疾病，如肛门痉挛、直肠感觉减退和焦虑/抑郁，这些疾病大多需要保守治疗。

直肠脱垂切除或闭合缝合、直肠前突和或经肠腔内修补、逆行马龙氏灌肠和部分耻骨直肠肌切开术对部分病例有效。

腹腔镜下骶骨结肠固定术可能是一种有效的手术方法。经肛门吻合器直肠切除术可能导致严重的并发症。当处理直肠直肠套叠时，TST术式似乎更安全。通过ODS的多学科方法提供最好的结果。

梗阻性排便综合征(ODS)是一种便秘类型，其特征是需要用力排出干硬便、排便不尽感、里急后重、急便感、骨盆沉重感、自我用手指促进排便。

大多数病人是女性患者。自我用手指促进排便有两个目的：

⑴通过阴道挤压直肠前突储袋，使肛直角变直，促进粪便排出；

⑵通过推动会阴，会阴的横文肌受到刺激，导致直肠收缩反射，有利于排便。

 不幸地是自我用手指促进排便可能导致肛肠溃疡，引起出血、不适、肛门纤维化导致肛门狭窄。ODS的诊断基于对患者临床病史的仔细评估。症状的严重程度可以用一个有效的评分来客观地评估。

经阴道超声(US)、排粪造影、肛门直肠测压及气球逼出试验、肠内排粪造影、动态会阴超声及磁共振排粪造影、阴部神经动态监测及心理评价对ODS评价有一定的参考价值。

ODS被看作为“冰山现象”，也就是有两种常见原因，比如目前有超过90%伴有ODS的患者,很容易被检查到患有直肠前突和直肠粘膜内脱垂,被视为“隐匿性疾病”,然而这种隐匿的病变会导致外科手术的失败。目前在我们的前瞻性研究中，至少有两个隐匿的病变存在在所有ODS患者。

这种隐匿性病变很难诊断，也许是功能性的或是器质性病变。功能性病变包括：焦虑或抑郁、肛门痉挛性痛或用力排便时耻骨直肠肌不松弛、直肠感觉减退、阴部神经病变、结肠痉挛。器官病变包括：腹腔脏器脱垂、肠内脱垂、乙状结肠脱垂、阴道壁脱垂、膀胱脱垂、直肠-直肠套叠、顽固性直肠溃疡。因此，直肠前突和直肠粘膜脱垂通常采取手术治疗，能够很好的控制其症状。

过度用力排便可能是导致盆底肌松弛、器官下垂的始动因素，也会导致长期焦虑、肌紧张和耻骨直肠肌持续紧张。

这种过度用力排便会导致阴部神经拉长从而导致阴部神经病变影响直肠排便感觉。大便变得小而硬而且很难排出，由于它们不能有效刺激直肠壁诱发肠蠕动反射，进而抑制了直肠内括约肌而不利于排出大便。

因为ODS主要是心理和/或肌肉和/或神经系统方面的疾病导致的，所以很明显手术治疗在治疗上述提到的病变只是扮演次要的角色。不幸的是,ODS需要长期和复杂的治疗过程。即改变饮食习惯、心理支持治疗、盆底功能的锻炼。相反,病人和外科医生喜欢更快的方式解决问题,例如,一个简单的手术。这就解释了为什么大多数手术时间长了还是失败了。

ODS的保守治疗方法包括：纤维饮食,大量饮水和口服容积性泻药。

避免食用可以增加粪便粘度，很难排出的食物，如巧克力类的食物。

结肠水疗或灌肠有助于治疗ODS，并且没有危险的副作用。一些专家也是很支持灌肠，据报道近一半肠道功能失调的患者灌肠有效。

然而众所周知的是病人自己滥用泻药可造成不断微损伤从而导致肛门的狭窄和纤维化。

肛门痉挛可以通过练习瑜伽和注射肉毒杆菌A治疗（50个单位注射到耻骨直肠肌中），短期的治愈率可达50%，并且副作用少见，常见的副作用是暂时的大便失禁和低血压。

经肛门电刺激治疗对阴部神经病变和直肠感觉减退有效，该治疗可以在家通过插入肛门的小电极连接便携式电刺激治疗仪进行。

1、外科医生一般选择以下方法治疗ODS：1）采取一种外科式的灌肠。2）采用切除或者折叠术或者对脱垂直肠粘膜悬吊。3）加强直肠阴道膈或者切除直肠前突者多余的粘膜。4）括约肌功能紊乱者行括约肌切开。

2、一种可选择的创伤很小的有创手术方法可以治疗较轻的直肠粘膜脱垂和直肠前突。即：反复的缝合直肠前壁中线，从齿状线开始到达直肠前突的顶端然后折返再缝到齿状线位置。这种术式使直肠粘膜层形成了一种屏障作用并且加强了直肠阴道膈同时消除了直肠粘膜内脱垂和直肠前突。

3、直肠切除固定术、Delorme术式、环形直肠粘膜切除加折叠术、骶直肠固定术、腹腔镜下直肠固定术在治疗直肠-直肠套叠引起的ODS短期效果满意。但长期效果不能令人满意，近一半的患者术后4年再次发作ODS症状。

相反，4年后近90%复发的患者通过联合经阴经肛联和经腹的方法可以治愈，比如对于直肠粘膜内脱垂和直肠前突的患者在骨盆出口放置补片。之所以这么高的成功率是因为一些伴随的隐匿的并发症，比如肛门痉挛通过心理-生物学反馈治愈。这种治疗是病人的排便反射经肛门或经阴道的B超机器通过观看屏幕上的耻骨直肠肌的收缩和舒张反馈来实现。

通过经会阴部分切开两侧的耻骨直肠肌目的是减轻耻骨直肠肌的紧张性。据该术式的发明者介绍，该术式（治疗盆底肌失迟缓）比生物反馈治疗和肉毒杆菌A注射治疗有效。

1、首次使用吻合器治疗直肠粘膜脱垂引起的ODS是Pescatori等报道的，在小样本中使用圆形吻合器治疗的短期疗效很好并没有相关并发症。

2、Boccasanta 首先发表了有关STARR的研究，并报告约90%的病人术后短期效果很好，但1年后有20%的病人有肛门疼痛的症状。这种严重影响了病人的生活质量的症状可能是由于纤维组织在吻合钉的周围增生，触发了肛提肌和耻骨直肠肌的神经反射轴。

3、STARR的并发症包括严重直肠出血、排便急促感、肛门失禁、直肠阴道漏、直肠后血肿、盆腔脓肿和死亡。STARR术后排便急迫感和便失禁很有可能是由于直肠储袋的大小减少。

单独的手术治疗ODS疾病在短期效果可能很好,但随着时间的推移变得恶化,可能是由于在诊断和治疗过程中被忽视的隐匿方面导致症状被忽视。ODS的心身因素应该被识别和管理,因为它影响了三分之二的病人。一些保守的治疗方法可供选择，在手术治疗ODS前应尝试。整体的观念是很重要的,例如,心理和身体应被视为一个整体。成功治疗ODS的关键看来在于多学科合作的方法。