improved outcomes in colon and rectal surgery stenosis or hernia. Experienced plastic surgeons can carefully use liposuction techniques to remove subcutaneous fat around the stoma. Obviously, care must be taken to not injure the stoma during the procedure and to leave a flat smooth peristomal skin surface for the ostomy faceplate. Once the fatty tissue is removed, it will not be redeposited despite additional weight gain. Ostomy Reversal Reversal of temporary stomas should be undertaken as soon as physiologically feasible to reestablish gastrointestinal continuity and for psychological improvement. This of course implies that the purposes of the stoma placement has been met and the patient is capable and a candidate for another operative procedure. There are two main operative approaches to ostomy reversal, local or via a laparotomy. While both approaches are associated with inadver- tent enterotomies, bleeding, wound infections, and anastomotic complications, the biggest advantages of the laparotomy approach is improved exposure and the ability to reexplore the abdomen. Certainly, the type of ostomy is important to consider when plan- ning the operative approach as loop ileostomies are technically the least challenging to reverse and often amenable to local rever- sal. Although a local approach is preferred, patients with a prior Hartmann’s procedure or those in which the distal remnant is not available via a local approach are obviously forced to undergo a repeat laparotomy. Surprisingly, there is a paucity of recent data that highlights the potential perils of this seemingly benign opera- tion. The most recent study, published in 2005, was a retrospective review of 533 patients undergoing stoma closure at the University Hospital of Vienna.(70) The majority of the patients (51%) under- went reversal of a colostomy, 44% had closure of an ileostomy, and 5% had combined reversals of both a colostomy and an ileostomy. All patients underwent a laparotomy using the intraperitoneal approach. Their 30-day mortality was 3% (15 patients) with rates similar for either ileostomy or colostomy reversal. Causes of death were multisystem organ failure after nonsurgical complications in nine patients, and anastomotic leakage, missed small bowel injury, and cecal perforation in the remaining six patients. Overall com- plications were 20%, with anastomotic leakage (5%), ileus (4%), postoperative bleeding (2%), and wound infection (2%). When analyzing patient related factors between survivor and nonsur- vivors, only advanced patient age was found to be statistically significant. This study, which highlights the potential morbidity of stoma reversal, also emphasizes the importance of meticulous surgical technique required in these challenging patients with reoperative abdomens. Our approach to ostomy reversal begins with a thorough pre- operative evaluation which includes interrogation of the distal colon with either a barium enema and/or endoscopy. The primary reason for which sentinel procedure was performed is important to consider since it may reveal if the purposes of the ostomy has been met and potentially alter the decision on reversal. An obvi- ous but sometimes overlooked step should also be the evaluation of the patient’s sphincter tone and ability to control fecal stream once continuity has been restored. This may require not only clinical evaluation, but formal documentation through anorectal physiology testing including manometry. Baseline poor sphincter tone or incontinence should be considered a contraindication for ostomy reversal in all but the rarest of cases. Finally, additional patient factors which can be altered, such as nutritional status, steroid use, and tobacco abuse, should be optimized before sur- gery. When planning the operative approach for end colostomy reversals, additional factors to consider before embarking on the operation should include the expected amount of adhesive disease likely to be encountered or previously encountered (i.e., review prior operative notes), whether there is a history of prior abdomi- nal or pelvic radiation, concomitant pathology such as the pres- ence of incisional hernias, and the type of ostomy. For instance, patients with multiple prior surgeries and a history of radiation will most likely benefit from a laparotomy approach that includes preoperative ureteral stent placement, while those patients with loop ostomies without any other comorbidities can be managed with a local approach. Whether a stapled or hand-sewn anasto- mosis is performed is up to the surgeon’s discretion. Key technical points in each method, however, is to ensure adequate mobiliza- tion and visualization of the distal colonic or rectal stump with resection of both the exteriorized bowel or end stump back to normal healthy bowel before the anastomosis. Finally, delayed primary closure is performed for the area in which the stoma was placed and drains are not routinely placed. COnClusiOn Beyond bringing a loop of bowel to the skin surface, there are a wide variety of issues that a surgeon needs to consider when creat- ing a stoma. Having a thorough understanding of the indications Figure 33.11 Mercedes or triangular closure. A. Stoma site with fascia closed, B. Initial approximation of skin and subcutaneous fat, C. Completed closure with small area in center left open for drainage and secondary healing. (A) (B) (C) ostomies for stoma placement, the technical details for the various ostomies, and the physical and psychological impact of living with an ostomy will aid the surgeon in caring for these unique patients. Finally, understanding the potential complications from ostomy place- ment and having the knowledge to correctly deal with them is an essential tool for all providers and emphasizes the importance of a multidisciplinary team of specialists. REFERENCES 1. Sutherland AM, Orbach CE. Psychological impact of cancer and cancer surgery. II. Depressive reactions associated with surgery for cancer. Cancer 1953; 6: 958–62. 2. Follick MJ, Smith TW, Turk DC. Psychosocial adjustment following ostomy. 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Quality of life with a temporary stoma: ileostomy vs. colostomy. Dis Colon Rectum 2000; 43: 650–5. 33. Leong AP, Londono-Schimmer EE, Phillips RK. Life-table analysis of stomal complications following ileostomy. Br J Surg 1994; 81: 727–9. 34. Londono-Schimmer EE, Leong AP, Phillips RK. Life table analysis of stomal complications following colostomy. Dis Colon Rectum 1994; 37: 916–20. improved outcomes in colon and rectal surgery 35. Porter JA, Salvati EP, Rubin RJ et al. Complications of colos- tomies. Dis Colon Rectum 1989; 32: 299–303. 36. Park JJ, Del PA, Orsay CP et al. Stoma complications: the Cook County Hospital experience. Dis Colon Rectum 1999; 42: 1575–80. 37. Cottam J, Richards K, Hasted A et al. Results of a nationwide prospective audit of stoma complications within 3 weeks of surgery. Colorectal Dis 2007; 9: 834–8. 38. Arumugam PJ, Bevan L, Macdonald L et al. A prospective audit of stomas analysis of risk factors and complications and their management. Colorectal Dis 2003; 5: 49–52. 39. Saghir JH, McKenzie FD, Leckie DM et al. Factors that predict complications after construction of a stoma: a retrospective study. Eur J Surg 2001; 167: 531–4. 40. Leenen LP, Kuypers JH. Some factors influencing the out- come of stoma surgery. Dis Colon Rectum 1989; 32: 500–4. 41. Pearl RK, Prasad ML, Orsay CP et al. Early local complica- tions from intestinal stomas. Arch Surg 1985; 120: 1145–7. 42. Gorfine SR, Bauer JJ, Gelerni IM. Continent ileostomies. In: MacKeigan JM, Cataldo PA, eds. Intestinal Stomas. Principles, Techniques, and Management. St. Louis: Quality Medical Publishing, 1993; 154–87. 43. Beck DE. Abdominal wall modification for the difficult stoma. Clin Colon Rectal Surg 2008; 20: 71–5. 44. Pemberton JH. Management of conventional ileostomies. World J Surg 1988; 12: 203–10. 45. Ien-Mersh TG, Thomson JP. Surgical treatment of colostomy complications. Br J Surg 1988; 75: 416–8. 46. Williams JG, Etherington R, Hayward MW et al. Paraileostomy hernia: a clinical and radiological study. Br J Surg 1990; 77: 1355–7. 47. Burns FJ. Complications of colostomy. Dis Colon Rectum 1970; 13: 448–50. 48. Sjodahl R, Anderberg B, Bolin T. Parastomal hernia in rela- tion to site of the abdominal stoma. Br J Surg 1988; 75: 339–41. 49. Franks ME, Hrebinko RL Jr. Technique of parastomal hernia repair using synthetic mesh. Urology 2001; 57: 551–3. 50. Kish KJ, Buinewicz BR, Morris JB. Acellular dermal matrix (AlloDerm): new material in the repair of stoma site hernias. Am Surg 2005; 71: 1047–50. 51. Rubin MS, Schoetz DJ Jr, Matthews JB. Parastomal hernia. Is stoma relocation superior to fascial repair? Arch Surg 1994; 129: 413–8. 52. Sugarbaker PH. Peritoneal approach to prosthetic mesh repair of paraostomy hernias. Ann Surg 1985; 201: 344–6. 53. Byers JM, Steinberg JB, Postier RG. Repair of parastomal her- nias using polypropylene mesh. Arch Surg 1992; 127: 1246–7. 54. Hopkins TB, Trento A. Parastomal ileal loop hernia repair with marlex mesh. J Urol 1982; 128: 811–2. 55. Morris-Stiff G, Hughes LE. The continuing challenge of parastomal hernia: failure of a novel polypropylene mesh repair. Ann R Coll Surg Engl 1998; 80: 184–7. 56. Rosin JD, Bonardi RA. Paracolostomy hernia repair with Marlex mesh: a new technique. Dis Colon Rectum 1977; 20: 299–302. 57. Kasperk R, Klinge U, Schumpelick V. The repair of large parastomal hernias using a midline approach and a pros- thetic mesh in the sublay position. Am J Surg 2000; 179: 186–8. 58. Tekkis PP, Kocher HM, Payne JG. Parastomal hernia repair: modified thorlakson technique, reinforced by polypropylene mesh. Dis Colon Rectum 1999; 42: 1505–8. 59. Berger D, Bientzle M. Laparoscopic repair of parastomal hernias: a single surgeon‘s experience in 66 patients. Dis Colon Rectum 2007; 50: 1668–73. 60. Kozlowski PM, Wang PC, Winfield HN. Laparoscopic repair of incisional and parastomal hernias after major genitouri- nary or abdominal surgery. J Endourol 2001; 15: 175–9. 61. Steele SR, Lee P, Martin MJ et al. Is parastomal hernia repair with polypropylene mesh safe? Am J Surg 2003; 185: 436–40. 62. Hedley AA, Ogden CL, Johnson CL et al. Prevalence of over- weight and obesity among US children, adolescents, and adults, 1999–2002. JAMA 2004; 291: 2847–50. 63. Livingston EH, Ko CY. Socioeconomic characteristics of the population eligible for obesity surgery. Surgery 2004; 135: 288–96. 64. Gendall KA, Raniga S, Kennedy R, Frizelle FA. The impact of obesity on outcome after major colorectal surgery. Dis Colon Rectum 2007; 50(12): 2223–37. 65. Duchesne JC, Wang YZ, Weintraub SL et al. Stoma complica- tions: a multivariate analysis. Am Surg 2002; 68: 961–6. 66. Evans JP, Brown MH, Wilkes GH, Cohen Z, McLeod RS. Revising the troublesome stoma: combined abdominal wall recontouring and revision of stomas. Dis Colon Rectum 2003; 46: 122–6. 67. Beck DE. Abdominal wall modification for the difficult ostomy. Clinics Colon Rectal Surg 2008: 16. 68. Castillo E, Thomassie LM, Whitlow CW et al. Continent ileostomy: Current experience. Dis Colon Rectum 2005; 48: 1263–8. 69. Steel MCA, Wu JE. Late stomal complications. Clinics Colon Rectal Surg 2002; 15: 199–207. 70. Pokorny H, Herkner H, Jakesz R et al. Mortality and compli- cations after stoma closure. Arch Surg 2005; 140: 956–60. 4 Operative and nonoperative therapy for chronic constipation Harry T Papaconstantinou CHALLENGING CASE A 33-year-old women presents with constipation of 8 years dura- tion. She goes 7–10 days between bowel movements, despite tak- ing multiple laxatives. She tried extra dietary fiber, polyethylene glycol, and lubiprostone, all without relief. Her lack of bowel activity is significantly impacting on her life style. CASE MANAGEMENT A barium enema demonstrates normal anatomy. A colonic transit study demonstrates 20 markers evenly distributed throughout the colon on day 5. A balloon expulsion test and anal manometry were normal. A diagnosis of colonic inertia is made and the patient is offered a total abdominal colectomy with an ileorectal anastomosis. INTRODUCTION Constipation is a common medical complaint resulting in over 2.5 million physician visits in the United States each year.(1) Reports have indicated that constipation is a significant problem with its prevalence ranging from 2 to 27%, and associated medica- tion costs of over $500 million each year.(2) Stool weight, transit time, and frequency of defecation correlate strongly with dietary fiber intake. It is estimated that the average daily consumption of fiber in the United States is <20 grams, therefore, the prevalence of constipation should be no surprise.(3, 4) Furthermore, con- stipation adversely affects work-related productivity, educational performance, and results in significantly lower quality of life and higher psychological distress.(5, 6) Constipation is not a specific disease, but rather a constellation of symptoms. Physicians typically define constipation in objective terms of bowel movement frequency, specifically fewer than three bowel movements per week. However, constipation has different meaning to individual patients, and may be described as the need to strain to defecate, having hard stools, the inability to defecate at will, incomplete evacuation, or the infrequent passage of stool. Regardless of the ambiguity of defining constipation, patients fre- quently perceive the need for treatment due to advertising por- traying “regularity” as the secret to health and well-being.(7, 8) Therefore, it is important for the physicians to clarify patient’s intended meaning, and to establish a more objective definition for this subjective symptom. Recently, a consensus of parameters has been created and updated to more clearly define constipation and is known as the Rome III criteria (Table 34.1).(9) The estab- lishment of these parameters has provided more uniform defini- tion of constipation, and is a valuable tool to identify patients that require treatment. Successful treatment of constipation requires the accurate iden- tification of the underlying etiology of the symptom. In most patients, constipation is the direct result of specific medical condi- tions (Table 34.2) or side effect of medications (Table 34.3). These extracolonic causes can be easily identified in a careful and complete history and physical examination. Constipation for these patients is treated through medical management including alteration of their medications, prescription of laxatives, or dietary and lifestyle modifications. A small group of patients will have a functional dis- order of the colon and anorectum resulting in constipation. It is within this group of patients that colon and rectal surgeons can make the greatest impact, and is the focus of this chapter. Functional constipation can be divided into three groups: 1) slow-transit constipation, 2) pelvic floor dysfunction, and 3) combined slow-transit constipation and pelvic floor dysfunc- tion. Slow-transit constipation, also known as colonic inertia, is characterized by prolonged length of time for stool to pass through the colon.(10) Delay in stool transit is thought to be a primary dysfunction of the colonic smooth muscle (myopathy) or innervation (neuropathy). Pelvic floor dysfunction results in evacuation disorders, and is characterized by either difficulty or inability to expel stool from the anorectum.(11) Common disor- ders of pelvic floor dysfunction include obstructive defecation, pelvic floor dyssynergia, outlet obstruction, or anismus.(11–13) Table 34.1 Rome III diagnostic criteria for constipation. Criteria must be fulfilled for the last 3 months. Symptom onset at least 6 months before diagnosis . 1) Must include 2 or more of the following. a. Straining ≥25% of defecation. b. Lumpy or hard bowel movements ≥25% of defecation. c. Sensation of incomplete evacuation ≥25% of defecation. d. Sensation of anorectal obstruction ≥25% of defecation. e. Manual maneuvers to facilitate bowel movement ≥25% of defecation. f. Fewer than 3 defecations per week. 2. Loose stools are rarely present without the use of laxatives. 3. Insufficient criteria for irritable bowel syndrome Table 34.2 Medical conditions causing constipation. Endocrine and Metabolic Neurogenic Collagen Vascular and Musculoskeletal Chronic renal failure Autonomic neuropathy Amyloidosis Diabetes mellitus Cerebrovascular disease Dermatomyositis Hypothyroidism Dementia Myotonic dystrophy Hypercalcemia Depression Systemic sclerosis Hypokalemia Multiple sclerosis Scleroderma Pregnancy Muscular dystrophy Milk-alkali syndrome Parkinson’s disease Porphyria Spinal chord lesions Carcinomatosis Hirschsprung’s disease Chaga’s disease improved outcomes in colon and rectal surgery Recent advances in the analysis of colonic motility and pelvic floor physiology have allowed for the identification and classification of these two subtypes. This is important as treatment modalities are different. Surgery is indicated for patients with slow-transit consti- pation, while nonoperative treatment modalities, such as biofeed- back therapy, are effective in patients with pelvic floor dysfunction. Patients with mixed conditions require correction of the pelvic floor abnormality before undergoing an operation for slow-transit constipation. Patient selection is critical for treatment success. EVALUATION AND DIAGNOSTIC STUDIES Initial evaluation of patients with constipation is a complex task and starts with a careful history and physical examination. Most patients are reluctant to discuss these issues, and establishing a trustworthy relationship is important to define the nature of bowel dysfunction. Constipated patients present with a constellation of symptoms that include excessive straining to defecate, passage of hard stools, the inability to defecate at will, digital disimpaction, vaginal splinting, feeling of blockage at the anal opening, incom- plete evacuation, and/or the infrequent passage of stool. Details of defecatory characteristics and habits are helpful and should include stool frequency, stool consistency, stool size, and degree of straining during defecation. These patients should be asked about precipitating events and the duration and severity of the problem. A dietary history should be obtained to assess of the amount of daily fiber ingested and fluids consumed, as stool transit time and frequency of defecation correlate strongly with dietary fiber intake. (3, 4) If the patient has already been treated by a referring phy- sician it is important to know the number and types of laxatives used, patient compliance, and whether there was any improvement in symptoms. A long history of constipation refractory to dietary measures and laxative use is suggestive of functional constipation, while a history of recent onset should alert the physician to seek and exclude an organic cause such as neoplastic disease or stricture. A complete medical history will provide evidence of extracolonic causes of constipation such as diabetes, hypothyroidism, or cer- ebrovascular disease (Table 34.2). Detailed review of the patient’s medication list will identify specific medications that are known to cause constipation (Table 34.3). A complete physical exam with specific emphasis on the abdo- men and perineum are important. A normal physical exam is not uncommon. A detailed anorectal exam starts with inspec- tion of the perianal skin. Perineal sensation and the anocutane- ous reflex are assessed by gently stroking the perineal skin with a cotton-tipped applicator stick. Absence of a reflex contraction of the external anal sphincter indicates the presence of neuropathy. A digital rectal examination is performed to identify the presence of an anorectal stricture, distal rectal mass, and the presence of stool or blood within the rectal vault. Positive findings require further aggressive evaluation including colonoscopy. During dig- ital examination, sphincter tone is assessed at rest and voluntary squeeze. It is important to ask the patient to bear down as if to defecate. This maneuver allows the examiner to determine relaxa- tion of the external anal sphincter and the presence of perineal descent. Absence of these features is suggestive of pelvic floor dysfunction or dyssynergic defecation.(11) Vaginal and biman- ual examination should be performed to rule out rectocoele as a cause of outlet obstruction constipation. Routine evaluation of the colon is performed when there is a lack of identifiable causes of constipation. This can be performed by colonoscopy, barium enema, or CT colonography. Although it has been reported that there is no increased incidence of colon or rectal neoplasia in patients with chronic constipation (14), rou- tine anatomic evaluation of the colon is performed to exclude tumors, strictures, and large bowel disease. Endoscopic evalua- tion of the colon may reveal evidence of chronic laxative abuse (melanosis coli), diverticular disease with stricture, malignancy, or colitis cystica profunda (internal rectal prolapse). Further work-up and treatment is dependent on the findings. However, in the absence of anatomic causes of constipation, patients should be initially treated with dietary and lifestyle modifications with or without medications. If initial treatment of constipation fails to improve the patient’s symptoms, further investigational stud- ies are required to differentiate between functional constipation types. It may seem intuitive that patients with slow-transit con- stipation would complain of infrequent bowel movements, while patients with pelvic floor dysfunction would report feelings of incomplete evacuation and excessive straining. However, recent reports show that symptoms alone do not differentiate between the subgroups of functional constipation.(6, 15, 16) In fact, up to 62% of patients with pelvic floor dysfunction report stool frequency of less than three bowel movements per week.(6) For this reason symptom assessment should be combined with objec- tive testing to better assess the nature of a patient’s complaint. Physiologic studies of the colon (colonic transit study) and pelvic floor (anorectal manometry, balloon expulsion test, defecogram, and electromyography) are required to differentiate between slow-transit constipation, pelvic floor dysfunction, and patients with mixed features, and accurate diagnosis is critical for treat- ment success. Colonic Transit Studies Self-reported stool frequencies correlate poorly with colonic transit, and patient’s recall of stool habits is often inaccurate indi- cating that subjective complaints are not sufficient to determine diagnosis. Colonic transit studies provide objective assessment of Table 34.3 Drugs associated with constipation. Anticholinergics Antidepressants Antipsychotics Cation-containing agents Aluminum (antacids, sucralfate) Bismuth Calcium (antacids, supplements) Iron supplements Neurally active agents Opiates Antihypertensives Ganglionic blockers Vinca alkaloids Calcium channel blockers Others Antihistamines Antiparkinsonian drugs Diuretics Nonsteroidal anti-inflammatory drugs operative and nonoperative therapy for chronic constipation stool movement through the colon, and are critical tests to iden- tify patients that will benefit from colectomy. Two methods are commonly used to measure colonic transit time and include radi- opaque marker methods and scintigraphic techniques. Studies have shown that that these two tests correlate well to each other and are sensitive for identifying colonic transit delays in patients with slow-transit constipation.(17, 18) Objective documentation of slow-transit constipation is critical for patient selection for surgery, and has been shown to significantly improve outcomes after colectomy (90% vs. 67%).(19, 20) Radiopaque Marker Test. The most common and widely used study of colonic transit time is the radiopaque marker method. This test was first described by Hinton et al. in 1969, and since that time several modifications have been described including single and multiple capsule techniques.(21–23) This study is performed by having the patient swallow a single capsule (Stizmarks; Konsyl ® Pharmaceuticles, Ft. Worth, Texas) containing 24 radiopaque mark- ers, and then tracking the markers by abdominal radiographs at 3 days and 5 days. Patients are instructed to stop laxatives, cathartics, and enemas for 2–7 days before ingestion of the capsule, and dur- ing the test period to prevent false results. In patients with normal colonic motility, by day 5 of the test 19 (80%) or more of the mark- ers will have passed through the colon and are either completely evacuated or found in the rectum. Patients with slow colonic transit show the presence of 6 or more markers scattered throughout the colon (Figure 34.1A). Patients with pelvic floor dysfunction such as functional obstructive or dyssynergic defecation, exhibit retention of 6 or more markers in the rectum or rectosigmoid region with a near normal transit of markers through the colon (Figure 34.1B). Although this test has been shown to be highly reproducible, when considering total abdominal colectomy for colonic inertia, it has been shown that patients have more favorable results if two marker studies have demonstrated slow-colonic transit times to confirm the diagnosis.(24) Scintigraphic technique. Scintigraphic defecography is another modality available to study colonic transit. Delayed-release cap- sules containing charcoal or polystyrene pellets radiolabeled with technetium-99m or indium-111 are coated with a pH-sensitive polymer methacrylate. The coating dissolves in an alkaline pH within the terminal ileum and cecum. Colonic distribution of the radioisotope is determined on scans taken 24 and 48 hours after capsule ingestion, and is highly sensitive and specific for identi- fying slow colon transit.(25, 26) Colon transit measurements by radiopaque markers and scintigraphic techniques correlate well with each other, and are sensitive for identifying colonic transit delays in patients with slow transit constipation.(18) When a diagnosis of slow-transit constipation is made, the physician must be aware of specific conditions that may be asso- ciated with this functional disorder and adversely affect surgical treatment with colectomy. First, slow-colonic transit constipation may be a component of a generalized gastrointestinal disorder such as panenteric intertia. A recent review has suggested that patients with this generalized gastrointestinal motility disorder have significantly diminished long-term success rate after colec- tomy for slow-transit constipation.(27) This is supported by the high rate of recurrent small-bowel obstruction (70%) in patients with panenteric intertia.(28) Collectively, these data suggest that whole gut transit studies should be considered before colectomy Figure 34.1 Colonic transit study using single capsule radiopaque markers. Abdominal radiographs shown were taken 5 days after capsule ingestion. The presence of >6 marks scattered throughout the colon is diagnostic for slow colonic transit (A). Retention of markers within the rectum and rectosigmoid region suggests pelvic outlet obstruction (B). (A) (B) 4 improved outcomes in colon and rectal surgery for slow-transit constipation, and include gastric emptying, upper gastrointestinal small bowel follow-trough, and choly- cystokinnin hepatic dimethyliminodiacetic acid (CCK-HIDA) scan. Colectomy in patients with a global gastrointestinal motility disorder is not likely to improve their symptoms and is discour- aged. Second, in patients with findings suggestive of pelvic floor dysfunction, up to two-thirds will exhibit mixed pattern consti- pation with both slow transit and obstructive delay.(29) Further pelvic floor physiology testing and treatment of the pelvic floor dysfunction is required before colectomy to improve outcomes and avoid treatment failure. Pelvic Floor Physiology Tests Patients with functional constipation due to pelvic floor dysfunc- tion and obstructive defecation have difficulty with evacuation of rectal contents. Normal evacuation requires the involuntary relaxation of the internal anal sphincter as well as the voluntary relaxation of the external anal sphincter and pelvic floor mus- cles. Failure of this coordinated effort results in outlet obstructive symptoms. Pelvic floor physiology testing can identify specific disorders such as blunting of the rectal anal inhibitory reflex (RAIR), paradoxical puborectalis contraction, and anatomic abnormalities that cause outlet obstruction. Common tests used to identify these disorders include anorectal manometry, balloon expulsion test, defecography, and electromyography. Anorectal Manometry. Anorectal manometry provides a comprehensive assessment of anal sphincter muscle tone and the anorectal sensory response to different stimuli. This test is useful in the evaluation of patients with obstructive defecation, and helps to detect abnormalities during attempted defecation such as pelvic floor dyssynergia or anismus.(30) The complete manometric evaluation of the anorectum includes determination of the resting pressure, squeeze pressure, length of the high-pres- sure zone, rectal compliance, RAIR, and the ability of the internal anal sphincter to relax with straining. In normal defecation, as rectal pressure rises there is a synchronized fall in the internal anal sphincter pressure. A blunted rectal sensation is a common finding in patients with functional obstructive defecation.(31) Absence of the RAIR suggests secondary causes of constipation such as Hirschsprung’s disease, Chagas disease, or previous sur- gery.(32–34) External sphincter muscle relaxation for the elimina- tion of stool is a learned response that is under voluntary control. Inability to perform this coordinated movement represents the chief pathophysiologic abnormality in patients with dyssynergic defecation and anismus, and may be due to impaired rectal con- traction, paradoxical puborectalis contraction, or impaired anal relaxation.(11, 35) Anorectal manometry has been shown to be inaccurate in the diagnosis of paradoxical puborectalis and dys- synergic defecation, and further testing with balloon expulsion test and electromyography should be performed to assist in diag- nosis.(36) Balloon Expulsion Test. The balloon expulsion test is a func- tional evaluation of the patient’s ability to defecate. In this test, a latex balloon is filled with 60 ml of warm water or air within the rectum. The patient is asked to expel the balloon in a pri- vate bathroom while sitting on the toilet. The physiologic posi- tion and privacy allow this method to more closely approximate normal evacuation. Normal subjects can expel the balloon within 1 minute.(37) While seeming trivial, it is important that patients do not flush the balloon as it can severely damage the plumbing. Inability to expel the balloon is suggestive of functional outlet obstruction such as paradoxical puborectalis contraction and dyssynergic defecation. The balloon expulsion test is a simple and accurate test that has been shown to have a high specificity (89%) and negative predictive value (97%) for excluding pelvic floor dyssynergia as a cause of constipation.(36, 38, 39) Defecography. Defecography is the real time imaging of patient defecation, and provides dynamic characterization of the interaction between the anal sphincter complex and the rectum in an attempt to define abnormalities in the pelvic floor. It pro- vides information on the anatomic and functional changes of the anorectum during defecation, and is effective in differentiating between anatomic and functional causes of obstructive defeca- tion. Before the test is performed, the patient is cleansed of stool using an enema. Barium paste is placed into the rectum, and with the aid of fluoroscopy the process of defecation is video-recorded. Static and real-time dynamic radiographic images are obtained during the process of defecation. Specific measurements such as the anorectal angle, perineal descent, and puborectalis length during stages of squeeze and push are calculated.(40) Patients with paradoxical puborectalis contraction and dyssynergic def- ecation will exhibit failure of the anorectal angle to open, per- sistence of the puborectalis impression on the rectum, and poor rectal emptying of the barium paste.(41–43) It has been shown that patients with a diagnosis of paradoxical puborectalis on defecography have a high frequency of constipation symptoms. (44) Defecography is reported to be too sensitive for paradoxical puborectalis contraction and dyssynergic defecation leading to a high false-positive diagnosis, but this test does have the advantage of evaluating any coexistent pelvic floor pathology.(45) Anatomic causes of obstructive defecation are readily identifiable during defecography and include internal intussusception of the rec- tum, rectocoele, enterocoele, and sigmoidocoele. The physiologic importance of these findings is often unclear, and the surgeon must determine their significance to individual patient symp- toms and complaints to determine need for surgical repair. Electromyography. Surface electromyography (EMG) can be performed by anal plug, intraanal sponge, or concentric needle technique to diagnose patterns of anal sphincter and pelvic floor muscle dysfunction. Electrodes are used to record action potentials derived from motor units within contracting muscles. Recordings are taken at rest, squeeze, and push. In normal patients, the act of defecation and push is accompanied by a decrease in motor unit activity signifying relaxation of the anal sphincter complex (Figure 34.2A). Patients with dyssynergic defecation and para- doxical puborectalis contraction exhibit increased motor unit activity during push indicating an increase in anal sphincter complex contraction during defecation (Figure 34.2B). Studies have shown that the negative predictive value for this test is high (91%) indicating EMG can accurately rule out paradoxical pub- orectalis contraction; however, the positive predictive value is quite low when compared with defecography.(46–48) This sug- gests the need for comprehensive physiologic testing to accurately diagnose paradoxical puborectalis contraction. operative and nonoperative therapy for chronic constipation MEDICAL TREATMENT OF CONSTIPATION Initial treatment of functional constipation regardless of type is patient education, dietary and lifestyle modifications, and a trial of medical management. Education of the patient is criti- cal and should include explanation of normal physiologic bowel patterns.(49) It is important to communicate to the patient that their symptoms will not be corrected overnight, and modifica- tions of the treatment regimen may be required. In many patients a dietary and medication log can be helpful to accurately iden- tify fiber and water consumption, and medication compliance. A daily diary to record bowel movements, stool characteristics, and associated abdominal symptoms is useful when assessing responses to treatment. Patients should be encouraged to recog- nize and respond to the urge to defecate. Most patients who have a normal bowel pattern usually empty stools at approximately the same time every day suggesting this is in part a conditioned reflex.(50) Ritualizing bowel habits may be useful to establish a regular pattern of bowel movement and should be coordinated with physiologic events that stimulate colonic motility (walking and postprandial gastrocolic response).(11) General measures such as adequate hydration and regular exercise has overall health benefit; however, there is no evidence to support success in the treatment of chronic constipation, except in situations of dehy- dration.(51, 52) Indirect evidence exists, as epidemiologic stud- ies suggest that sedentary people are three times more likely to report constipation.(53) A diet high in fiber content increases stool weight and accelerates colonic transit time.(54) In contrast, a diet that is deficient in fiber may lead to constipation.(54, 55) Consensus exists that empiric treatment for constipation with a high-fiber diet is inexpensive and effective therapeutic intervention for addressing constipation- related bowel dysfunction.(56, 57) There is a clear dose response between daily fiber intake and fecal output that is enhanced by increased fluid intake. Dietary supplements such as bran may cause significant amounts of abdominal bloating and discomfort, which may decrease patient compliance. Gradual increase in dose may minimize these symptoms. Psyllium seed, methylcellulose, and cal- cium polycarbophil are bulk-forming laxatives that absorb water into the colonic lumen and increases fecal mass, which in turn stimulates motility and reduces colon transit time.(58) A literature review of articles dealing with 18 double-blind studies related to constipation found that dietary fiber supplements or bulk laxa- tives resulted in an average increase of 1.4 (95% CI, 0.6–2.2) bowel movements per week, while laxative agents other than bulk showed an increase of 1.5 (95% CI, 1.1–1.8) bowel movements per week. (59) Others have shown that fiber has limited value in patients with slow-transit constipation and pelvic floor dysfunction as patients with these conditions did not respond effectively to dietary sup- plementation with 30 grams of fiber per day.(56) Conversely, patients without an underlying motility disorder either improved or became asymptomatic with fiber therapy. Collectively, these data suggest that therapeutic trial of dietary fiber should be con- sidered as initial treatment for patients with constipation, although fiber supplements administered alone are probably more effective in normal transit or fiber deficiency constipation than slow transit constipation or pelvic floor dysfunction.(27) Failure of fiber therapy requires alternative choices of laxative medications. A list of common medications used to treat consti- pation is shown in Table 34.4. With so many potential options available, the choice of laxative therapy is subject to patient pref- erence, and physician opinion and consensus.(60, 61) Although there are a variety of preparations available, the laxatives that are frequently recommended include milk of magnesia, lactulose, sorbitol, senna compounds, bisacodyl, and polyethylene glycol preparations. Milk of magnesia, magnesium citrate, and sodium phosphate are saline laxatives that are poorly absorbed or nonabsorbed osmotic preparations that result in secretion of water in the intestines to maintain isotonicity with plasma.(62) Use of these agents is not recommended in patients with cardiac and renal dysfunction because excessive absorption may lead to electrolyte abnormalities and volume overload. When ingested as hypertonic Figure 34.2 Electromyographic tracings in a patient with normal defecation (A) and paradoxical puborectalis contraction (B). Black arrows indicate push phase that normally corresponds with muscle relaxation and lower amplitude waves. (R rest; S strain; P push). (A) (B) improved outcomes in colon and rectal surgery solutions, there is a rapid osmotic equilibration that occurs, and overuse may result in significant dehydration.(62) Lactulose and sorbitol are nonabsorbable disaccharides that are effective osmotic laxative agents. Lactulose is a known substrate for colonic bacterial fermentation with resultant production of hydrogen, methane, carbon dioxide, water, acid and short-chain or volatile fatty acids.(63) These products act as osmotic agents and also stimulate intestinal motility and secretion. Lactulose has been shown to increase stool frequency in chronically constipated patients (64); however, abdominal bloating, discomfort, and flatulence are common side effects of this medication and may decrease patient compliance. Sorbitol is a poorly absorbed sugar alcohol that produces similar effects. In a trial of constipated men over the age of 65, sorbitol administered as a 70% syrup (10.5 g/15 mL; 15 to 60 mL daily) was equivalent to lactulose in improving symptoms.(65) Furthermore, it was cheaper and better tolerated during a 4-week trial. High-molecular-weight polyethylene glycol (PEG) is a large poly- mer with substantial osmotic activity that obligates intraluminal water.(66) It is routinely used with a balanced electrolyte solution for colon cleansing as polyethylene glycol electrolyte lavage solution (PEG-ELS). These solutions are safe and effective, and are routinely used for bowel preparations for colonoscopy and bowel surgery. (67) Other forms have been effectively used as laxatives for the treat- ment of constipation. PEG 3350 (MiraLax, Braintree Laboratories, Braintree, MA) is a large chemically inert polymer that also functions as an osmotic laxative. It does not contain salts that can be absorbed, and has been shown not to change measured electrolytes, calcium, glucose, blood urea nitrogen (BUN), creatinine, or serum osmolal- ity.(68) A recent randomized controlled multicenter trial has shown effectiveness of 17g of PEG 3350 laxative over a dextrose placebo, with greatest efficacy during the second week of the therapy.(69) An 8-week, double blind, placebo-controlled study showed that PEG 3350 administered to patients with chronic constipation increased stool frequency and accelerated left colonic transit, without induc- ing abdominal cramps or bloating. In a long-term multicenter study of PEG 4000, 14.6 g twice a day improved stool frequency, reduced straining effort, softened stools, and decreased the need for oral laxa- tives and enemas when compared with placebo (70); however, there was a high dropout rate (30% PEG 4000 and 60% placebo) which raises concerns about efficacy and tolerance. Stimulant laxatives. The stimulant laxatives have effects on mucosal electrolyte transport and gut motility. Commonly used laxatives in this category include bisacodyl and senna. Abdominal discomfort and cramping are common side effects of these agents. Bisacodyl produces defecation within 6 to 8 hours of taking the Table 34.4 Medications commonly used for constipation. Type Generic Name Trade Name Dosage Mechanism of action Fiber Bran – 1 cup/day Increase stool bulk Decrease colonic transit Increase gastrointestinal motility Psyllium Metamucil 1 tsp up to tid Methylcellulose Citrucel 1–2 tsp up to tid Calcium polycarbophil Fibercon 2–4 tabs qd Stool Softener Docusate Sodium Colace 100 mg bid Ineffective for constipation Osmotic agents Sorbitol 15–30 mL qd or bid Nonabsorbable disaccharides Lactulose Chronulac 15–30 mL qd or bid Accelerate colonic transit Polyethylene glycol Miralax 17 g/d Osmotic increase in intraluminal fluid Suppository Glycerine Up to daily Rectal stimulation Bisacodyl Dulcolax 10 mg daily Stimulants Bisacodyl Dulcolax 10 mg po up to 3x/wk Increase intraluminal fluid Antraquinones Senokot 2 tabs qd to 4 tabs bid Stimulation myenteric plexus Peri-colace 1–2 tabs qd Increase motility Saline laxatives Magnesium Milk of Magnesia 15–30 mL qd or bidn Osmotic increase fluid small bowel Stimulate CCK Decrease colon transit time Haley’s M-O 15–30 mL qd or bid Magnesium citrate 1 bottle Lubricant Mineral oil 15–45 mL Stool lubricantn Enemas Mineral oil retention 100–250 mL qd Stool softened and lubricated Tap water 500 mL Evacuation induced by distended colon; mechanical lavage Phosphate Fleet 1 unit Soapsuds 1500 mL Secretory agents Lubiprostone Amitiza 24 mg bid Stimulation of Chloride channels tid = three times a day; qd = daily; bid = twice a day. operative and nonoperative therapy for chronic constipation tablet, or 15 to 30 minutes after the suppository. It is believed to exert its effect by inducing high amplitude propagated con- tractions of the bowel, and is an effective rescue medication for chronic constipation.(27) Senna is member of the anthraquinone family of laxatives that are common constituents of herbal and over-the-counter laxatives. They are metabolized in the colon by bacteria into their active forms. In a trial of elderly nursing home residents (n = 77), a senna and fiber combination was reported to be better than lactulose in improving stool frequency, stool consistency, and ease of passage.(71) Furthermore, the senna and fiber combination was 40% cheaper than lactulose therapy. Side effects of these laxatives include allergic reactions, electro- lyte imbalance, melanosis coli, and “cathartic colon”. Melanosis coli is a result of chronic ingestion of anthraquinone-containing laxatives. This condition is an abnormal pigmentation of the colonic mucosa that is caused by the accumulation of apop- totic epithelial cells that are phagocytosed by macrophages.(72) “Cathartic colon” is an alteration of colon anatomy that was believed to be associated with chronic stimulant laxative use. Barium enema findings included colonic dilation, loss of haus- tral folds, strictures, colonic redundancy, and wide gaping of the ileocecal valve.(73) Initially, it was attributed to the destruction of myenteric plexus neurons by laxatives (74); however, more recent studies do not confirm those findings.(75) Current evidence sup- ports the safety of currently available laxatives at recommended doses for long-term use. Finally, anthraquinones have been pro- posed to have mutagenic effects and produce tumors in animal models. Several cohort studies and one case-control study failed to find an association between anthraquinones and colorectal adenomas or carcinoma.(76) Other drugs. Patients with severe slow-transit constipation may not respond to medical therapies described above. Ideally, slow-transit constipation should be treated with an agent that restores normal colonic function. Medications such as secretago- gues (lobiprostone, cholchicine, and misoprostol) and prokinetic agents (tegaserod, alvimopan, linaclotide) are currently under clinical trials for the treatment of constipation, and show promise for patients with slow-transit constipation. Lubiprostone is an oral bicyclic fatty acid that activates the type 2 chloride channels that are located on the intestinal epithelial cell leading to an active secretion of chloride in the intestinal lumen.(77) In healthy humans, this drug has been shown to slow gastric emptying, but accelerated small bowel and colonic transit time at 24 hours.(78) In a randomized control study with intent to treat analysis, lubiprostone significantly increased the number of spontaneous bowel movements per week, improved straining effort, improved overall satisfaction with bowel habits, and pro- duced softer stools when compared with placebo.(79) Colchicine is a microtubule formation inhibitor that is com- monly used to treat gouty arthritis. A significant side effect of colchicine is diarrhea. In an open labeled study of 7 patients with normal transit constipation, colchicine (0.6 mg orally 3 times per day) increased stool frequency and accelerated colon tran- sit time.(80) Furthermore, patients reported reduced symptoms of abdominal pain, nausea, and bloating. However, long-term use may be associated with neuromyopathy, and its use for chronic constipation is not supported. The prostaglandin E 1 analog misoprostol (1200 µg/d) has been shown to increase stool frequency and accelerate colonic transit (81); however, the drug is expensive and its beneficial effects appear to decline over time. Tegaserod is a serotonin 5-HT 4 receptor partial agonist that has been shown to increase gastic emptying and colonic transit time.(82) Large randomized controlled trials in the United States and Europe have reported that tegaserod increases the number of complete spontaneous bowel movements per week, relieves constipation-related symptoms, and improves overall bowel sat- isfaction.(79, 83) However, recent reports of 0.01% incidence of coronary and cerebrovascular events have suspended sales of tegaserod. Another drug, alvimopan, is a peripherally acting µ-opioid receptor antagonist. This drug does not cross the blood- brain barrier, and therefore, does not inhibit the analgesic effect of opioids. A physiologic study of alvimopan has shown that this drug reverses opioid-induced delayed colonic transit in healthy subjects.(84) These data were verified in another randomized trial of opioid-induced bowel dysfunction, and has been shown to be effective in the treatment of acute postoperative ileus.(85, 86) Further studies are necessary to determine efficacy of alvimo- pan on chronic constipation. BIOFEEDBACK THERAPY In patients with constipation due to pelvic floor dyssynergia, bio- feedback therapy is frequently recommended after failure of con- servative management described above.(87) Biofeedback therapy uses electronically amplified recordings of pelvic floor mus- cle contractions (EMG) or anorectal pressure tracings to teach patients how to relax pelvic floor muscles and to strain more effectively when they defecate.(12) The purpose of this therapeu- tic modality is to restore a normal pattern of defecation by using an instrument-based education program. The primary goals are to correct the underlying dyssynergy that affects the abdominal, rectal, and anal sphincter muscles, and to improve the rectal sen- sory perception. A series of training sessions are used to teach diaphragmatic breathing techniques to improve abdominal push- ing effort and to synchronize this with anal relaxation. Visual or auditory feedback is used to provide the patent input regarding performance during attempted defecation maneuvers. Studies on biofeedback therapy for the treatment of pelvic floor dyssynergia have been reviewed extensively.(88, 89) These reviews suggest that two-thirds of these patients benefit from biofeedback training, with individual studies reporting a 30 to 100% success rate; however, attempts to draw definitive conclu- sions about the usefulness and effectiveness of biofeedback for the treatment of pelvic floor dyssynergia-type constipation are difficult due to the lack of adequately controlled trials of suffi- cient sample size.(87) In a recent review of biofeedback therapy for pelvic floor dyssynergia, 4 of 27 (<15%) studies in the adult population were controlled, and only one well-controlled study had a sample size that was sufficient to provide meaningful statis- tical conclusions.(87) Biofeedback therapy for dyssynergic-type constipation is directed at coordinating pelvic floor muscle relaxation with intraabdominal pressure to generate an effective propulsive force. Instrumentation protocols in these patients require either EMG monitoring of muscle tone or anorectal pressures for biofeedback training. To . Parkinson’s disease Porphyria Spinal chord lesions Carcinomatosis Hirschsprung’s disease Chaga’s disease improved outcomes in colon and rectal surgery Recent advances in the analysis of colonic. following colostomy. Dis Colon Rectum 1994; 37: 916–20. improved outcomes in colon and rectal surgery 35. Porter JA, Salvati EP, Rubin RJ et al. Complications of colos- tomies. Dis Colon. an anorectal stricture, distal rectal mass, and the presence of stool or blood within the rectal vault. Positive findings require further aggressive evaluation including colonoscopy. During dig- ital