Patient Selection
Patients diagnosed and treated for STC in the Department of Colorectal Surgery, Tianjin Union Medical Center, China from July 2015 to July 2021 were included as a part of this study. The choice of surgical method was determined by the patient's personal will. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement 26 was used to conduct the case control study and was approved by the ethics committee of Tianjin Union Medical Center. Helsinki as a statement of ethical principles for our medical study involving human subjects27. All patients provided informed consent.
Inclusion Criteria:
1. Conform to the Roman Ш standard age of diagnosis between 18 and 8528.
2. A digital anal examination revealed normal anal contraction. Three D solid anorectal manometry and balloon expulsion test revealed normal anal function.
3. STC was diagnosed by colon transit and high resolution manometric tests.
4. Recurrent STC after performing partial colectomy or subtotal colon resection.
5. Defecography that diagnosed patients with the length of the segmental colon, and secondary megacolon.
6. Long-term drug conservative treatment was ineffective as it affected the quality of life in patients resulting in need for surgery.
Exclusion Criteria:
1. Contraindications for general anesthesia, and presence of immunodeficiencies, psychological problems, inflammatory bowel disease, and anorectal infectious diseases.
2. Abnormal 3D anorectal manometric results. Colorectal tumors that were diagnosed using electronic colonoscopy.
Surgical Procedure
Members of one surgical teams conducted non-randomized case controlled trials.
IRIA: Laparoscopic total colectomy had finished, A 6-cm incision was made in the middle and lower of the abdomen, and a protective sleeve was used. The distance from the medial rectum to the peritoneal reflex line was 6~8 cm. The blood vessels close to the mesentery of the sigmoid colon were excised. A curved cut closure (US, Johnson, Powered Echelon Flex45) removed the ileum at 10 cm away from the ileocecal region. The specimen was removed and sent for pathological examination.
After disinfecting and cleaning the rectum, a 29-mm-diameter stapling device (US,Johnson,Ethicon Endo-Surgery,CDH29) was inserted through the anus, conducted an EEIRA. An anal drainage tube 1 cm in diameter was inserted through the anus as a support tube for IRIA, a non-absorptive No. 4 thread was sutured to the rectal wall 0.4 cm below the anastomotic site bypassing it. This embedded continuous No. 4 thread was used to suture the ileum between 0.4 cm and 6 ~ 8 cm on the anastomotic site .
The sutures around the rectum and ileum were repeated 6-8 times. The No. 4 thread was tightened, and the ileum with 3~4 cm in length was inserted into the rectum (figure 1). Finally, the anastomosis was embedding sutured with non-absorptive No. 4 threads. The diameter of the IRIA anastomotic site was approximately 12 mm.
Post-operative Treatment
Three days after the surgery, patients with two groups were treated with probiotics, sour milk, and an essential diet. When patients in the EEIRA group had severe diarrhea (more than 10 times a day), they were treated conservatively with octreotide, smecta, and imonotine until they fully recovered. When the volume of the peritoneal drainage was less than 50 ml for 2 consecutive days, pelvic effusion was not detected and the Jackson - Pratt drainage tube was subsequently removed. The indwelling catheter was removed 48 ~72 h after surgery, and the anal vent tube was removed approximately 9 to 12 days after surgery in patients of the IRIA group. Most patients were discharged after their sutures were removed.
Data Collection and Follow-up
The post operative stool frequencies of the patients belonging to the IRIA and EEIRA group were followed up after the clinical data of the pre and post surgery were collected . This frequency was checked 7 days post surgery in the department. This data was communicated by the patients through phone 1, 2, 3, 6, and 12 months after they were discharged.
Safety
Complications of this surgery include urinary tract infection, temporary atelectasis, post-operative benign nausea, vomiting, paroxysmal abdominal pain, incidence of adverse events, and mortality. Surgical site infection requires open or self-drainage. Surgical site infection in the form of mild erythema was not present. Symptoms bleeding, infection, small intestinal obstruction, interventional dilation due to post-operative anastomotic stenosis, deep vein thrombosis, and pulmonary embolism were recorded follow-up at median 3 years (August 2016 to July 2021).
Effectiveness and Quality Of Life
The severity of constipation pre and post operation was quantified by the Wexner constipation scale29. The Fecal Incontinence Quality of Life scale (FIQL) assessed fecal incontinence 30 and Gastrointestinal Quality of Life index (GIQLI) assessed the abdominal pain and bloating of the patients follow-up at median 3 years after surgery31.
Statistics
IBM SPSS 22.0 software was used for statistical analyses. The independent sample t test was performed to measure the continuous variable, Repeated measurement data were analyzed by one-way repeated measures ANOVA, and the chi-square x2test analyzed the categorical data. A P value less than 0.05 was considered as statistically significant.