Improved Outcomes in Colon and Rectal Surgery part 24 pot

 improved outcomes in colon and rectal surgery wound closure reported less infectious complications(13% vs. 30%) and recurrences(5% vs. 10%) with the open technique, but more overall wound complications. Slightly more patients in the open group were not satisfied with the outcome of treatment(8% vs. 5%). However, a larger series of 493 patients (25) treated with midline excision and primary closure via an oblique elliptical inci- sion which crossed the midline showed recurrence rate of 5.6% at 18 months, with very low incidence of wound infection(1.2%), hematoma(0.4%), or wound dehiscence (1%) postoperatively. The benefit of faster healing time and smaller final scar slightly outweighs the possible increase in infection or wound dehiscence. Recurrence is related more to inadequate excision of diseased tissue rather than to closure technique. Excision or Unroofing with Marsupialization Another option to leave a smaller wound is marsupialization. The excision of tissue is carried out as described above. Then the skin edges are tacked down to the base of the wound using absorb- able suture. This leaves a smaller and more shallow wound which is easier to pack.(Figures 21.4a–d) By not completely closing the wound, there is a theoretical decrease in wound complications, and the duration of healing is less than for a fully open wound. Simply unroofing the wound versus excision also results in a smaller wound. A study of 26 patients who underwent wide local excision and 42 who had unroofing and marsupialization reported sig- nificantly longer healing times (21 vs. 6 weeks) and wound com- plications requiring reoperation (35% vs. 2%) in the wide local excision group.(26) Simple unroofing without marsupialization has become the preferred initial operation for pilonidal disease and the editors’ institution. A more recent series of 380 patients (27) who underwent exci- sion with either primary closure or wound left open reported similar length of stay, wound infection rate, and recurrence rate among the two groups. However, the length of time off from work Figure 21.4 Marsupialization. (A) The diseased tissue is excised with electocautery. (B) The cavity is debrided. (C) The edges of the wound are then sutured down to the base of the wound using absorbable suture. (D) Resulting in a small open wound. (A) (B) (C)(D)  surgery for pilonidal disease and hidradenitis suppurativa and healing time were significantly shorter in the group that had the wound closed primarily. Limited Excision In an attempt to minimize the morbidity of this disease, some surgeons have advocated a more limited excision of the sinuses rather than removing all the surrounding tissue. This technique is recommended for patients with limited disease, defined as four or less pits and no concurrent abscess or active infection. The technique as described by Oncel et al. (28) requires excising each individual pit along with a funnel-shaped cone of tissue around the track. Methylene blue may be injected into the pits to aid in identifying the tracks, though some authors believe that this leads to excision of more tissue than is necessary. Additionally, if two pits are found to be connected, the fistula overlying them should be unroofed. The goal is to remove all pits along with their underlying tracks and granulation tissue. The wounds are then left open to heal by secondary intention. The same group reported their medium-term follow-up of 62 patients treated with this technique.(29) They found that the patients were able to return to work in 2 days and healed completely in 43 days. They reported one recurrence after 1 year of follow-up. Mohamed et al. (30) reported a prospective randomized trial of 83 patients assigned to wide excision with primary closure, wide excision with wound left open, or limited excision of fistula tracks. They found that the limited excision group had shorter operative time, shorter length of stay and less postoperative pain, while the wide excision with open wound group had the longest time to complete healing. There was no difference in recurrence among the three groups and therefore recommended a limited excision approach when possible. Bascom Operation Bascom described a different operation (10) based on his theory that treatment of pilonidal disease should center around remov- ing the midline follicles or pits rather than excising large amounts of tissue. The goal of this operation is to excise the midline pits, drain the underlying abscess, and elevate the gluteal cleft. A verti- cal incision is made overlying the chronic abscess approximately 1 cm away from the gluteal cleft. The abscess cavity is then deb- rided, and any communicating fistula tracts are identified and undermined so that they connect to the open wound. The midline pits are excised via small incisions encompassing each one indi- vidually. These wounds are closed with nonabsorbable suture. The lateral wound is left open to heal by secondary intention and hair in the area is shaved until the wound is completely healed. (Figure 21.5) Bascom reported his experience with 149 patients (7) with 3.5 year follow-up after follicle-excision surgery and found that 16% had recurring problems, but that these were all minor and did not cause added morbidity. All his patients were able to return to work within 1 day of surgery and took approximately 3 weeks to heal the lateral wound. In a series of 218 patients (31) who underwent Bascom’s operation, 84% were performed under local anesthesia and all patients were discharged home the same day. 6% had infectious complications and 10% recurred, with com- plete healing in all but 1 patient, who required further surgery. Surgery for Complicated Pilonidal Disease and Nonhealing Wounds While most patients who undergo surgery for pilonidal disease heal without complication, a few return with chronic nonhealing wounds. Many of these patients are those who underwent wide exci- sion and were left with an open wound to close secondarily or those Figure 21.5 Bascom operation. (A) A vertical incision is made overlying the cyst, 1 cm away from the gluteal cleft. The cyst cavity any communicating fistula tracts are debrided. The midline pits are excised, with the wounds communicating to the cavity. (B) The midline wounds are closed primarily with absorbable suture and the vertical wound is packed lightly and left to heal by secondary intention. (A) (B)  improved outcomes in colon and rectal surgery whose incisions broke down. Those patients who have recurrence after initial surgery or have unacceptable scars also are included in this group. Several methods have been described to excise tissue in the gluteal cleft and close the resulting defect with a flap technique. (Table 21.2) These methods may be used as the initial treatment approach, and also for complicated recurrent disease. In 1973, Karydakis (32) described an asymmetric advancement flap technique which results in excision of the disease, a primarily closed wound, and a flatter gluteal cleft. An elliptical incision is made vertically and centered off midline to the most affected side. The incision should encompass all midline pits and skin sinuses. The incision is carried down to the sacrococcygeal fascia, remov- ing the affected tissue. A skin flap is raised under the medial edge of the wound and across the midline.When the buttocks are released and approximated, the edges of the wound should come together easily. The incision is closed primarily off the midline, and a flatter gluteal cleft is created. (Figure 21.6) This is believed to aid in healing and lessen recurrence. External drainage is useful to prevent fluid collections under the flap, though one study found no effect on wound infections or recurrence.(33) In his series of 6,545 patients treated with this technique (6), Karydakis reported less than 1% recurrence rate. While this excellent result has not been replicated, many smaller series have reported accept- able results. Kitchen reported a series of 141 patients treated by this technique.(34) He found a recurrence rate of 4%. 23% of his patients had recurred after previous operations for pilonidal disease, and all of them were cured after this procedure. More recent series have reported recurrence rates ranging from 0 to 4%, with 5% to 8% wound complications.(35–38) Similar results have been obtained in obese patients.(39) A modification of this technique was described by Bascom in 2002, known as the “cleft lift” or “Bascom II” procedure.(40) An important key to this operation is preoperative skin marking of the patient. With the patient standing up, the buttocks are pushed together so the line of contact between the two may be marked with a pen. When the buttocks are taped apart with the patient lying prone, the area between the pen markings delineates the limits of the flap dissection. An asymmetric ellipse is drawn off midline to include the midline pits. This ellipse is then excised, with the inci- sion reaching to the sacrococcygeal fascia. The flap, consisting of Figure 21.6 Karydakis flap. (A) Schematic of the operative field depicting a pilonidal cyst slightly to the left of midline with two midline pits. (B) An elliptical incision is made encompassing the cyst and pits. The excision is carried down to the sacrococcygeal fascia. (C) The medial edge of the wound is raised as a flap crossing the midline. (D) The tape retracting the buttocks is released so that the wound edges are able to be approximated without tension. (E) Final result showing a vertical incision closed primarily away from the midline, resulting in a flattened gluteal cleft. (A) (B) (C) (D) (E) Table 21.2 Advanced procedures for pilonidal disease. Technique Study Year Number of Patients Hospital time (days) Healing time (days) Infection (%) Recurrence (%) Follow-up (months) Karydakis flap Kitchen et al. 34 (1996) 141 (–) (–) (–) 4 18 Karydakis flap Akinci et al. 46 (2000) 112 2.6 13.2 1.8 0.9 28 Karydakis flap Keshava et al. 35 (2007) 70 (–) 80 (–) 4.2 36 Rhomboid flap Bozkurt et al. 47 (1998) 24 4.1 17.5 0 0 27 Rhomboid flap Milito et al. 48 (1998) 67 5.3 14 0 0 74.4 Rhomboid flap Arumugam et al. 42 (2003) 53 4 14 13 7 24 Rhomboid flap Topgul et al. 43 (2003) 200 3.1 12.8 1.5 2.5 60 Rhomboid flap Katsoulis et al. 49 (2006) 25 4 (–) (–) 4 20 Bascom operation Senapati et al. 31 (2000) 218 Outpatient 28 6 10 12 V-Y flap Dylek et al. 50 (1998) 23 10 21 4 0 18 Z-plasty Fazeli et al. 45 (2006 72 2.86 15.4 9.7 4.2 22 (-) not described.  surgery for pilonidal disease and hidradenitis suppurativa skin and subcutaneous fat, is then mobilized towards the affected side, breaking up the scar tissue in the subcutaneous fat. The flap should be mobilized until the plane of dissection reaches the pen mark on the contralateral buttock. When the tapes are released, the edges of the flap should come together. A drain is placed under the flap and the incision is closed, resulting in a scar off the mid- line and a flattened gluteal cleft. In the original article describing the technique, 27 patients who underwent the procedure after undergoing multiple failed operations were described.(40) They all healed completely, most having the sutures removed at 1 week, and none recurred after a mean follow-up period of 20 months. A series of 24 patients treated with the same technique but without drain placement reported no hematomas, seromas, or infections, and patients returned to work in 3 weeks. They had no recurrences with a follow-up of 10 months.(41) This procedure is a useful option for patients who have failed previous attempts at cure or who have chronic unhealed wounds. Other rotational flap techniques have been described for this disease, along with myocutaneous flaps and skin grafting. The rhomboid flap is another commonly used operation. Limberg or Dufourmentel flaps are some of the more common variations of this type of flap. For this flap, a rhomboid incision is made which includes the diseased tissue, with the vertical axis being along the gluteal cleft. This is carried down to the sacrococcygeal fascia. A triangle of skin and subcutaneous fat is incised lateral to this and then rotated into the defect.(Figure 21.7) A drain may be placed per surgeon preference. Patients stay in the hospital on average 4 days and sutures are removed in approximately 10 days. In a series of 53 patients with 24 month follow-up, 13% developed wound infec- tions, 7% recurred, and all had an average healing time of 2 weeks. (42) Another study reported on the results of 200 patients who underwent Limberg rhomboid flap reconstruction. These patients had an overall recurrence rate of 2.5%, with complications includ- ing minimal flap necrosis in 3%, seroma formation in 1.5%, and wound infection in 1.5%. The average length of stay was 3.1 days and time to return to work was 12.8 days.(43) Other fasciocutane- ous flaps which have been described include V-Y flaps, Z-plasty, W-flaps, and a variety of other rotational flaps. The goal of all of them is to allow the surgeon to excise the diseased tissue as widely as necessary and close the defect primarily without tension while flattening the gluteal cleft. All these flaps have similar complication and recurrence rates, and the choice of which to utilize in each case depends on the size of the defect to be closed and the individual surgeon’s experience with each. The Nonhealing Sacral Wound Fortunately, most patients have limited disease that responds to conventional treatment. However, a few patients present with large open sacral defects, either due to complications of wide excision left to close secondarily, or as a result of failed primary closures. Several myocutaneous rotational flaps have been described for closing large wounds, which fortunately are not encountered very frequently. Flaps based on the gluteus maximus are frequently used to cover sacral wounds with good results. These techniques are beyond the scope of this book and are most often performed in conjunction with plastic surgeons. Another adjunct to sacral wound healing may be the vacuum wound closure system. Vacuum wound closure systems may be useful in patients who have defects which are not able to be closed primarily for a variety of reasons, and have been used extensively in defects due to pressure ulcers, traumatic wounds, and post- surgical perineal defects. A series of five patients with extensive complex infected pilonidal sinuses underwent excision with placement of a vacuum sponge.(44) Patients used the device for 6 weeks, after which wet-to-dry dressing changes were initiated. Complete epithelialization was observed in 12 weeks. One patient did not tolerate the device, and another required a return to the operating room for further debridement, after which the wound healed with use of the vacuum device. Pilonidal disease presents many treatment challenges, and therefore, multiple treatment approaches exist. Depending on the specifics of each case and individual surgeon experience, different approaches may be considered. An algorithm based on extent and chronicity of the disease is presented here. (Figure 21.8) PERIANAL HIDRADENITIS SUPPURATIVA Hidradenitis suppurativa is a chronic inflammatory disease of the apocrine sweat glands. The disease was first described by Velpeau (51) in 1832, and its association to sweat glands in the skin was described by Vernuil (52) in 1864. These glands are found prima- rily in the groin and axilla, which are the most common sites of involvement of disease. However, they can also be found in the perineum, perianal area, scrotum, and labia. Hidradenitis suppu- rativa affects patients beginning in adolescence and peaks around age 40. The incidence of hidradenitis suppurativa is estimated to be 1:300. Perianal disease appears to be more common in men.(53) Pathophysiology Apocrine sweat glands are coiled tubular secretory structures which empty into the hair follicle. They are similar to eccrine sweat glands except that these empty directly to the skin. The etiology of hidradenitis suppurativa is unclear, but appears to be multifac- torial. Obstruction of the apocrine gland duct is likely to be the inciting event, leading to secondary infection and rupture of the Figure 21.7 Rhomboid Flap. (A) A rhomboid incision encompassing the pilonidal cyst and midline pits is marked on the skin, along with a lateral extension. The rhomboid is composed of 2 120º angles and 2 60º angles. Line BC is drawn at a 90º angle to Line CD. Line AB is drawn vertically down. All lines should be of equal length. The cavity is excised down to fascia and debrided. The flap is raised and mobilized to cover the defect. (B) The flap is rotated into the defect so that Point 2 meets Point E, Point 1 meets Point D, and Point A meets Point C. This results in a primarily closed wound and flattened gluteal cleft. (B)(A)  improved outcomes in colon and rectal surgery gland with extension into the surrounding dermis and subcutane- ous fat. The infection then spreads to neighboring glands and is manifested by cellulitis and abscess. Initially, the infection resolves with simple incision and drainage, but long-term disease recur- rence may lead to scarring and fistula formation. Microbiologic studies of the infected tissues have shown that skin flora is the usual pathogen for axillary disease, though enteric aerobes and anaerobes have also been isolated from perianal lesions. Many of the older studies were indeterminate as they evaluated superfi- cial swab cultures. However, cultures of deeper tissue have shown Staphylococcus aureus and coagulase-negative staphylococcus in most of the samples.(54) Diagnosis Patients with perianal hidradenitis present with recurrent peri- anal abscesses which may extend to involve the perineum, labia or scrotum, buttocks, or the inguinal region. The lesions may start out as a simple abscess, but tend to evolve with time into thick scarred skin with open wounds and chronically draining sinuses. Perianal fistulae may also be present. The differential diagnosis includes perianal abscess, furuncles, carbuncles, lymphogranu- loma venereum or other sexually transmitted diseases, pilonidal disease, tuberculosis, actinomycosis, cat-scratch disease, granu- loma inguinale, and Crohn’s disease. One way to differentiate the etiology of perianal fistulae is that cryptoglandular fistu- lae usually involve the dentate line and intersphincteric plane, whereas fistulae associated with hidradenitis are found in the dis- tal anal canal, where the apocrine glands are found. The dentate line is normal in cases of hidradenitis. It is important to examine other areas, such as the axilla and groin, as many patients with hidradenitis suppurativa will have concurrent involvement of these areas. Some factors which have been shown to be related to this disease include altered immune response, smoking, obesity, hormonal therapy, pregnancy, onset of puberty, familial factors, and Crohn’s disease.(55–57) The Lahey Clinic reported their expe- rience with 43 patients with perianal hidradenitis suppurativa. They found that 93% of the patients were male with a median age of 29 years. Patients were initially diagnosed with pilonidal disease (28%), anal fistula (37%), and perirectal abscess (16%). 72% of their patients were smokers.(58) In a series of 61 patients from The Cleveland Clinic, 24 (38%) were found to have concur- rent Crohn’s disease. All had perianal hidradenitis, and 20 had disease in other sites as well.(59) Often the diagnosis of perianal hidradenitis is delayed due to the similarity of symptoms with other perianal diseases and the possibility of other concurrent disease processes. In situations where patients are being treated for a certain condition and they are not improving, hidradenitis should be considered as a possible complicating factor. Long-term sequelae of perianal hidradenitis include disfiguring scars, local- ized or systemic sepsis, and carcinoma, including squamous cell or adenocarcinoma.(60–62) Nonoperative Management The treatment of perianal hidradenitis suppurativa is mainly surgical. However, there is a role for nonoperative management, particularly in the milder forms of the disease. Maintaining good hygiene of the area is imperative to control infection. Patients should keep the affected area clean and dry, reduce moisture, avoid constricting or irritating clothing, and lose weight. Topical antibiotics are often used in conjunction with systemic antibiotics or alone to control secondary infection. Topical clindamycin was shown in one double-blind randomized trial of 30 patients to be of benefit in controlling infection.(63) Systemic antibiotics are rarely indicated, except in cases with significant cellulitis or bacteremia. In light of the similarities between acne and hidradenitis suppurativa, isotretinoin has been used to treat hidradenitis successfully. Brown et al. (64) reported on a patient treated with 1 gm/kg of isotretinoin daily for 20 weeks. The patient had no significant change in her condition until 8 weeks into the treatment, at which point she began to note improvement. Ultimately, she had an excellent response with no relapse at the 18 week follow- up visit. Minor Algorithm for management of chronic pilonidal disease Chronic Pilonidal Disease Limited Disease Complicated Disease Large Wound Myocutaneous flaps Vacuum sponge Karydakis flap Rhomboid flap Cleft Lift (Bascom II) V-Y flap Z-plasty + contraindications to surgery - Hygiene - Depilation Midline excision ± closure or marsupialization Sinus excision Bascom operation Figure 21.8 Algorithm for management of pilonidal disease.  surgery for pilonidal disease and hidradenitis suppurativa side effects such as xerosis, cheilitis, and elevated serum alka- line phosphatase were reported, which resolved with comple- tion of treatment. Targeting the hormonal response of hidradenitis has also had some success, including one retrospective study of 64 female patients demonstrating that antiandrogen therapy was supe- rior to systemic oral antibiotics in controlling disease.(65–67) Other nonsurgical approaches have been attempted with varying degrees of success, including granulocyte-macrophage colony- stimulating factor (68), infliximab (69, 70), and oral zinc.(71) Surgical Management The centerpiece of treatment of hidradenitis is surgical excision. Incision and drainage has a limited role to relieve pain and pres- sure in cases of acute abscess. There is no long-term benefit to the procedure, as it does not remove any of the affected tissue, but may be necessary to relieve pain. Patients should receive sys- temic antibiotics to treat the overlying cellulitis if present and may require packing of the wound for several days. Unroofing of fis- tula tracts is another procedure which may be useful in controlling local infection, though this also does not excise the disease and therefore has no benefit in preventing recurrence. Excision of the diseased skin, including skin appendages and subcutaneous fat, is required to adequately control the disease. In mild cases, limited excision left to heal by secondary inten- tion is appropriate. Primary closure is usually not possible and is not advised, as the recurrence rate is increased. Rotational flaps or skin grafting are more successful wound closure methods. In a series of 106 patients, 70% underwent excision with primary closure and the rest had closure with skin grafts or flaps. 69% of the patients had a recurrence requiring surgery, the majority of whom were in the primary closure group.(72) A series of 8 patients with perineal hidradenitis who underwent wide exci- sion had their wounds either covered with meshed split-thick- ness skin graft (5) or left open to heal by secondary intention. (3) All patients healed well and had no surgical site recurrence, though two recurred in other areas.(73) A larger series including 56 patients with gluteal or perianal disease was reported recently. (74) Twenty-one (37.6%) and 17 (30.6%) patients had gluteal and perineal disease, respectively. Squamous-cell carcinoma and Crohn’s disease were observed in one patient each. Wide exci- sion was performed in all patients. Thirty-two patients (57.1%) were left to heal by secondary intention, and the remaining 24 patients underwent split-thickness skin grafting. Twenty-three patients received a diverting colostomy. Mean time for complete healing in the open wound group was 10 weeks and in the skin graft group was 6 weeks. Five patients (9%) required a second resection. Partial graft loss rate was 37.5% and only one patient had a recurrence. The benefits of skin grafting or rotational flaps include shorter healing times and less discomfort when com- pared to an open wound; however, some of the large defects that result from excision are difficult to adequately cover. When a large wound must be left open, a wound vaccum sponge or silas- tic foam may be of benefit. In summary, the primary approach to perianal hidradenitis suppurativa is surgical excision of all diseased tissue. The open defect that results may be left open to heal secondarily and heals uneventfully in most cases. 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Perianal hidradenitis suppurativa: early surgical treatment gives good results in chronic or recurrent cases. Br J Derm 1998; 139: 906–10.   Surgical treatment of fecal incontinence Ann C Lowry and Dimitrios Christoforidis CHALLENGING CASE A 35-year-old woman presents to your office with complains of fecal incontinence. She is G3 P3, all vaginal deliveries and one child was 8 pounds. The patient reports fecal soiling for the last year with progressive uncontrolled passage of flatus and occa- sional identification of stool in her undergarments that she was unaware of having passed. There is additional incontinence asso- ciated with athletic activity. The incontinence severely affects the patient’s life style. CASE MANAGEMENT A complete history identifies no additional risk factors. Physical examination reveals a thinned perineal body, decreased resting tone, weak squeeze (especially anterior), and an anterior sphinc- ter defect. A flexible sigmoidoscopy was normal, anorectal man- ometry documents low resting tone and squeeze pressure. An anal ultrasound confirms an anterior sphincter defect. The patient is recommended to undergo an overlapping sphincter repair. EPIDEMIOLOGY Fecal incontinence (FI) is a common and underreported condi- tion. It is embarrassing, stressful, and often leads to social isola- tion. Nevertheless, only a third of symptomatic patients in the USA discuss their fecal incontinence with their physician.(1) The reported prevalence of FI varies depending on the population studied and definition used. In nursing homes, it affects nearly 50% of residents.(2, 3) In a recent systematic review including 16 studies from across the world, the estimated prevalence of fecal incontinence (excluding flatus incontinence) varied from 0.4% to 18%. A community based US telephone survey found a prevalence of 2.2%.(4) A study from the UK analyzed over 10,000 questionnaires from community-dwellers using more strict cri- teria; Major FI, defined as soiling of underwear, outer clothing or bedding at least several times a month, was reported by 0.9 % adults aged 40–64 years and by 2.3% of adults aged 65 years and older.(5) In this and other epidemiology studies, men were found to be equally affected by FI as women. However, clinical series on FI are dominated by female patients as women seem to seek med- ical attention more often. The true reason for that is unknown. Beyond the psychological burden and the medical morbid- ity (such as urinary tract infections, skin breakdown, decubitus ulcers) FI causes significant expense. Estimating total costs is difficult because of imprecise prevalence data and frequency of coexisting medical conditions. By analogy, urinary incontinence was estimated to generate direct and indirect costs exceeding $14 billion in the year 2000 for US community dwellers.(6) In a US study of 63 women with FI secondary to obstetric injury, the average cost for evaluation and treatment of FI was 17,166 USD per patient in 1999.(7) FI is obviously a significant public health problem that deserves more attention. ETIOLOGY The physiology of the continence mechanism is complex. Sche- matically, continence requires an anal sphincter and a rectal reservoir that are anatomically intact, normally innervated, and coordinated, a manageable fecal bolus and an adequate level of awareness and desire to avoid incontinence. A great number of conditions, trau- matic events, diseases, or medication may affect continence at one or more of these levels at various degrees. FI is often multifactorial and causality is not always easy to establish. Therefore, it may be more appropriate to talk about risk factors rather than causes in the etiological assessment of a patient with FI. Anal sphincter In women with FI, the most prevalent risk factor is childbirth. The incidence of third or fourth degree tears identified clinically at the time of vaginal delivery is 0.6 to 9%.(8) The clinical inci- dence is an underestimate of the true sphincter injury rate, as demonstrated by studies employing ultrasound imaging. A meta- analysis of five large prospective studies assessing the integrity of the anal sphincter after vaginal delivery with 2-dimensional endosonography revealed a 27% incidence of anal sphincter defect in primiparous women and an 8.5% incidence of new sphincter defects in multiparous women.(9) Another study using improved 3-dimensional endosonography on 55 primiparous women reported evidence of trauma in 29% but only 11% had evidence of external sphincter injury.(10) Among those women with a documented third degree tear, FI will develop in one-third to two-thirds.(8, 9) In the general population the true incidence of persistent postpartum FI of solid stool is unknown but can be approximately estimated at 3%. Other than obstetric trauma, the anatomical integrity of the sphincter complex can be disrupted by iatrogenic trauma during anorectal surgery and accidental trauma or be the result of a congenital malformation such as imperforate anus. In addition to structural defects, alteration of sphincter inner- vation also contributes to decreased sphincter function. It is well recognized that traction injury to the pudendal nerve during pregnancy and delivery contributes to obstetric-injury-related FI.(11) Various conditions affecting the pelvic nerves, the spinal cord or the brain may also result in sphincter atrophy and loss of anal canal tone (Table 22.1). Rectum The reservoir function of the rectum may be impaired second- ary to a) loss of capacity after rectal resection or space occupying lesions, b) loss of compliance secondary to inflammatory bowel disease, pelvic radiation, rectal ischemia, or collagen vascular diseases and, c) loss of innervation following surgery, trauma, or neurologic degenerative disease. Rectal mucosal prolapse or full thickness rectal prolapse may cause FI by preventing complete  surgical treatment of fecal incontinence sphincter closure; if left untreated, these conditions may lead to sphincter and pudendal nerve damage. Fecal bolus Formed stool is easier to control than liquid stool. An accelerated intestinal transit with increased stool volume can cause urgency and soiling even in patients with normal anorectal function and will precipitate true FI in a patient with a weakened continence mechanism. Constipation on the other hand, can lead to impac- tion and overflow incontinence in patients with deficient rectal sensation combined with weakened sphincter muscles. Central Nervous System Patients with dementia, some psychiatric disorders, or residual deficits from a stroke may lack awareness or interest in bowel function and become incontinent. This type of FI is more preva- lent in elderly and institutionalized patients. EVALUATION Assessment of severity There is no objective test that reliably correlates with patient reported frequency and type of fecal incontinence. Since the physi- cal morbidity associated with FI is minimal and the mortality practically null, morbidity and mortality data is not useful to measure severity. However, the impact of FI on quality of life is immense. Consequently, any effort to rate FI should be based on the patient’s reported frequency and type of FI and its effect on quality of life. Baxter et al. (12) categorized the available measures of FI into a) descriptive measures (e.g., Mayo Clinic FI Questionnaire, Osterberg Assessment of FI, and constipation), b) severity scores including grading systems (e.g., Parks’ scale, Williams scale) and summary scores (e.g., FI Severity Index (FISI), Cleveland Clinic Florida FI score (CCF-FI), Vaizey score) and c) impact measures which can be disease specific (e.g., Fecal Incontinence Quality of Life (FIQL), FI-Manchester Health Questionnaire) or global (e.g., SF-36). A diary is a useful way to document the frequency and type of FI episodes; the data can be used to calculate a score or simply reported as number of FI episodes per week or days with FI per week. In clinical practice, FI is often described as minor (mostly underwear staining and/or gas incontinence without uninten- tional loss of true bowel movements) or major (accidental loss of partial or whole bowel movements), urge or passive incontinence. Obviously, these descriptions are insufficient to compare patients in studies or to assess treatment outcome precisely. Popular measures in research are severity summary scores. They are usually based on frequency and type of FI episode. Some systems incorporate the use of a pad or the presence of lifestyle alteration. However, few scoring systems are based upon patient’s perspective in the assignment of values. Most of these scores attribute the same importance to episodes of gas incon- tinence as episodes of solid stool incontinence. An exception is the FISI which was designed based on patients’ numerical rat- ings of severity of various frequencies of gas, mucus, liquid stool, and solid stool incontinence.(13) Nevertheless, frequency-based scores, even with a meticulous use of a FI diary to register events, will overlook the fact that patients often make dramatic lifestyle changes to avoid FI episodes. Therefore, a validated impact meas- ure such as the FIQL (14) should be used in addition to severity summary scores. History and Physical The goals of a thorough history in a patient with FI are multiple. First, the interview should define character (seepage, passive/urge), severity, and impact on quality of FI. The character often suggests the underlying physiopathology. Generally, internal sphincter defects, prolapse or loss of sensation cause seepage and passive incontinence whereas external sphincter defects cause primarily urge incontinence. A deficient rectal reservoir through loss of capacity or compliance Table 22.1 Pathophysiology classification of risk factors for FI. Brain – central awareness Dementia CVA Brain tumor, infection, trauma Psychiatric disorder Psychotropic drugs Bowel – Fecal bolus Diarrheal states (malabsorption, IBD, infectious diarrhea, short gut syndrome, radiation enteritis, laxative abuse etc.) IBS Proctitis (radiation, IBD) Gastrointestinal stimulant drugs and foods (caffeine, alcohol, aspartamine etc) Anorectum – Neurologic impairment Spinal cord trauma, surgery, hernia, neoplasm Diabetes mellitus Multiple sclerosis spina bifida (myelo)meningocele pelvic fracture Pelvic radiation prostatectomy proctectomy obstetric injury rectal prolapse chronic straining pelvic floor descent aging idiopathic Rectum – anatomic impairment Sphincter-saving operations (low anterior resection, coloanal anastomosis, restorative proctectomy procedures) Rectal neoplasm Extrinsic compression Collagen vascular disease Rectal ischemia Pelvic radiation Rectal agenesis Anal sphincter – anatomic impairment obstetric injury anorectal surgery (fistula surgery, internal sphincterotomy, anal stretch, hemorrhoid surgery) anal impalement anal intercourse imperforate anus Pseudoincontinence anorectal condition: prolapsing hemorrhoids, rectal prolapse, fistula in ano troublesome hygiene: obesity, physical disability . Point E, Point 1 meets Point D, and Point A meets Point C. This results in a primarily closed wound and flattened gluteal cleft. (B)(A)  improved outcomes in colon and rectal surgery gland. 2002; 84(1): 29–32.  improved outcomes in colon and rectal surgery 20. Greenberg R, Kashtan H, SKornik Y, Werbin N. Treatment of pilonidal sinus disease using fibrin glue as a sealant. Tech. described by Velpeau (51) in 1832, and its association to sweat glands in the skin was described by Vernuil (52) in 1864. These glands are found prima- rily in the groin and axilla, which are the