Novel surgery for refractory mixed constipation: Jinling procedure – technical notes and early outcome

Abstract

IntroductionThe treatment of slow-transit constipation combined with outlet obstruction is controversial. This study introduced a new surgical strategy, subtotal colectomy combined with a modified Duhamel procedure (Jinling procedure), of which the safety and satisfactory rate were examined.Material and methodsNinety patients with refractory slow-transit constipation associated with outlet obstruction were consecutively included between Jan 2010 and Dec 2010. All underwent the laparoscopic-assisted Jinling procedure, which added a new side-to-side anastomosis to the colorectal posterior anastomosis after subtotal colectomy. The pre- and post-operative data were collected.ResultsThere was no surgery-related death. A total of 39 complications and adverse events were reported in 22 patients (morbidity rate of 24.4%). Most complications were managed conservatively without significant events. The satisfactory rate was 93.1% at 6-month follow-up.ConclusionsThe Jinling procedure is safe for refractory slow-transit constipation associated with outlet obstruction, with minimal major complications and a high satisfaction rate. However, this procedure requires rigorous preoperative examination, exquisite surgical and laparoscopic techniques and excellent perioperative management. The pelvic floor, especially the presacral space, is damaged, and therefore it may be unsalvageable if severe complications, such as anastomosis leakage or ischemia, occur.

Searching for a definition for pharmacologically refractory constipation: A systematic review

“…Surgery for constipation would normally be carried out on patients with the most refractory symptoms. In this review, 48 studies involving surgical treatment of constipation were included: 32 of which were surgical series, 6,[14][15][16]21,[26][27][28][29][30][32][33][34][35]37,39,41,43,45,46,48,49,[51][52][53][54]56,[58][59][60]63 while 16 were studies on colonic tissue obtained at colectomy. [8][9][10][11][17][18][19][20]22,23,25,31,36,44,62,66 Seven of the pathological series came from one center 10,11,…”

“…[8][9][10][11][17][18][19][20]22,23,25,31,36,44,62,66 Seven of the pathological series came from one center 10,11,19,20,22,25,44 and three from another group. 23,31,36 The duration of constipation prior to inclusion ranged from at least 6 weeks 51 to 6 years 53,56,63 or a mean duration of 14.6 years 17 or 19 years. 18 A number of studies used Rome II 20,26,35,37,52,62 or Rome III 45,53,56 criteria for defining functional constipation, implying minimum symptom duration as 12 or 6 months, respectively.…”

“…23,31,36 The duration of constipation prior to inclusion ranged from at least 6 weeks 51 to 6 years 53,56,63 or a mean duration of 14.6 years 17 or 19 years. 18 A number of studies used Rome II 20,26,35,37,52,62 or Rome III 45,53,56 criteria for defining functional constipation, implying minimum symptom duration as 12 or 6 months, respectively. Sixteen studies 6,8,14,21,27,[32][33][34]39,41,43,48,49,54,58,60 did not specify the duration of constipation in their patients although one author described it as "a long time" 43 and another "longstanding".…”

“…Sixteen studies 6,8,14,21,27,[32][33][34]39,41,43,48,49,54,58,60 did not specify the duration of constipation in their patients although one author described it as "a long time" 43 and another "longstanding". 8 The constipation was said to be severe in 11 studies, 18,20,21,27,33,39,41,43,49,53,56 intractable in 9 studies, [8][9][10]16,28,35,45,48,60 severely intractable in 5 studies, 11,19,22,25,44 and refractory in 7 studies. 15,29,37,59,63,65,66 The severity of the constipation was not qualified in 16 ...…”

“…14,15,37,41 Of these four studies, two performed anorectal manometry with balloon expulsion test, 14,41 one with balloon expulsion test and defecography, 37 and another with only defecography. 15 There were five studies on surgery for combined slow transit constipation with obstructive defecation, 53,54,56,63,65 and all five performed colonic transit studies and defecography. All except one 63 performed anorectal manometry.…”