Chronic Constipation
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《新英格兰医药杂志》
To the Editor: We are writing in response to the article by Lembo and Camilleri on chronic constipation (Oct. 2 issue).1 Injection of botulinum toxin into the puborectalis may be effective in the treatment of obstructed constipation.2,3,4,5 Furthermore, we believe that the injection of botulinum toxin is a safe treatment for patients with Parkinson's disease.6 Recent observation in several patients indicates that outlet obstruction is the main cause of anterior rectocele and provides evidence that botulinum toxin may be a remedy.5 Fourteen women with rectocele were treated with botulinum toxin, which was injected into the puborectalis; after two months, improvement in symptoms and defecographic results were noted in nine of them. At the one-year evaluation, none of the patients reported incomplete or digitally assisted rectal voiding. Rectocele was not found at physical examination. In addition, pressure during straining was reduced as compared with base-line values. Defecography showed four recurrent rectoceles, all of which were asymptomatic.
The duration of the efficacy of the injections remains to be measured, and repeated treatments are probably necessary. The optimal dose of botulinum toxin also remains to be determined; a placebo-controlled study with long-term follow-up is warranted.
Giuseppe Brisinda, M.D.
Federica Cadeddu, M.D.
Giorgio Maria, M.D.
University Hospital Agostino Gemelli
00168 Rome, Italy
gbrisin@tin.it
References
Lembo A, Camilleri M. Chronic constipation. N Engl J Med 2003;349:1360-1368.
Joo JS, Agachan F, Wolff B, Nogueras JJ, Wexner SD. Initial North American experience with botulinum toxin type A for treatment of anismus. Dis Colon Rectum 1996;39:1107-1111.
Hallan RI, Williams NS, Melling J, Waldron DJ, Womack NR, Morrison JF. Treatment of anismus in intractable constipation with botulinum A toxin. Lancet 1988;2:714-717.
Shafik A, El-Sibai O. Botulin toxin in the treatment of nonrelaxing puborectalis syndrome. Dig Surg 1998;15:347-351.
Maria G, Brisinda G, Bentivoglio AR, Albanese A, Sganga G, Castagneto M. Anterior rectocele due to obstructed defecation by botulinum toxin. Surgery 2001;129:524-529.
Albanese A, Brisinda G, Bentivoglio AR, Maria G. Treatment of outlet obstruction constipation in Parkinson's disease with botulinum neurotoxin A. Am J Gastroenterol 2003;98:1439-1440.
To the Editor: In Table 3 of their review of chronic constipation, Lembo and Camilleri misclassify a number of laxatives. Polyethylene glycol–based laxatives are polymers belonging to the osmotic laxative class. Similarly, laxatives classified as poorly absorbed sugars exert their effect predominantly through an osmotic action. Like the polyethylene glycol–based laxatives, they are considered osmotic laxatives.1
James Laughton, M.B., B.S.
Schwarz Pharma
Chesham HP5 1DG, United Kingdom
Editor's note: Dr. Laughton reports serving as a medical adviser to a pharmaceutical company that markets a polyethylene glycol (macrogol) laxative and a stool-softener laxative in the United Kingdom.
References
Jafri S, Pasricha PJ. Agents used for diarrhea, constipation, and inflammatory bowel disease: agents used for biliary and pancreatic disease. In: Hardman JG, Limbird LE, eds. Goodman & Gilman's the pharmacological basis of therapeutics. 10th ed. New York: McGraw-Hill, 2001:1037-58.
The authors reply: We agree that polyethylene glycol–based laxatives belong to the class of osmotic laxatives. We acknowledge that Table 3 of our article is unclear, in that the section listing osmotic laxatives should include the section listing poorly absorbed sugars.
Controlled studies are required to determine the role of botulinum toxin injection in the puborectalis muscle for defecatory disorders. The dose, the number of injections, the optimal site of injection, the frequency of reinjection, and the criteria for proper patient selection are not known. Until these points are clarified and the treatment is compared with biofeedback retraining of the pelvic floor, we recommend caution in the use of botulinum toxin injection for this indication.
Anthony Lembo, M.D.
Beth Israel Deaconess Medical Center
Boston, MA 02215
alembo@bidmc.harvard.edu
Michael Camilleri, M.D.
Mayo Clinic
Rochester, MN 55905
The duration of the efficacy of the injections remains to be measured, and repeated treatments are probably necessary. The optimal dose of botulinum toxin also remains to be determined; a placebo-controlled study with long-term follow-up is warranted.
Giuseppe Brisinda, M.D.
Federica Cadeddu, M.D.
Giorgio Maria, M.D.
University Hospital Agostino Gemelli
00168 Rome, Italy
gbrisin@tin.it
References
Lembo A, Camilleri M. Chronic constipation. N Engl J Med 2003;349:1360-1368.
Joo JS, Agachan F, Wolff B, Nogueras JJ, Wexner SD. Initial North American experience with botulinum toxin type A for treatment of anismus. Dis Colon Rectum 1996;39:1107-1111.
Hallan RI, Williams NS, Melling J, Waldron DJ, Womack NR, Morrison JF. Treatment of anismus in intractable constipation with botulinum A toxin. Lancet 1988;2:714-717.
Shafik A, El-Sibai O. Botulin toxin in the treatment of nonrelaxing puborectalis syndrome. Dig Surg 1998;15:347-351.
Maria G, Brisinda G, Bentivoglio AR, Albanese A, Sganga G, Castagneto M. Anterior rectocele due to obstructed defecation by botulinum toxin. Surgery 2001;129:524-529.
Albanese A, Brisinda G, Bentivoglio AR, Maria G. Treatment of outlet obstruction constipation in Parkinson's disease with botulinum neurotoxin A. Am J Gastroenterol 2003;98:1439-1440.
To the Editor: In Table 3 of their review of chronic constipation, Lembo and Camilleri misclassify a number of laxatives. Polyethylene glycol–based laxatives are polymers belonging to the osmotic laxative class. Similarly, laxatives classified as poorly absorbed sugars exert their effect predominantly through an osmotic action. Like the polyethylene glycol–based laxatives, they are considered osmotic laxatives.1
James Laughton, M.B., B.S.
Schwarz Pharma
Chesham HP5 1DG, United Kingdom
Editor's note: Dr. Laughton reports serving as a medical adviser to a pharmaceutical company that markets a polyethylene glycol (macrogol) laxative and a stool-softener laxative in the United Kingdom.
References
Jafri S, Pasricha PJ. Agents used for diarrhea, constipation, and inflammatory bowel disease: agents used for biliary and pancreatic disease. In: Hardman JG, Limbird LE, eds. Goodman & Gilman's the pharmacological basis of therapeutics. 10th ed. New York: McGraw-Hill, 2001:1037-58.
The authors reply: We agree that polyethylene glycol–based laxatives belong to the class of osmotic laxatives. We acknowledge that Table 3 of our article is unclear, in that the section listing osmotic laxatives should include the section listing poorly absorbed sugars.
Controlled studies are required to determine the role of botulinum toxin injection in the puborectalis muscle for defecatory disorders. The dose, the number of injections, the optimal site of injection, the frequency of reinjection, and the criteria for proper patient selection are not known. Until these points are clarified and the treatment is compared with biofeedback retraining of the pelvic floor, we recommend caution in the use of botulinum toxin injection for this indication.
Anthony Lembo, M.D.
Beth Israel Deaconess Medical Center
Boston, MA 02215
alembo@bidmc.harvard.edu
Michael Camilleri, M.D.
Mayo Clinic
Rochester, MN 55905