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Constipation: The Evolving Role for Surgery Ursula Szmulowicz, MD Department of Colorectal Surgery Digestive Disease Institute Cleveland Clinic Foundation Shanghai, China March 12, 2011 Outline Normal defecation Definition of constipation Incidence History and evaluation Surgical options Colectomy Bypass Antegrade colonic enema Stoma Sacral nerve stimulation Normal Defecation Colonic and rectal motility Reservoir function of the rectum Rectal Sensation Expulsion Incidence Prevalence of 2-28% in Western populations Estimated 30 million affected 25.92% prevalence in Chinese adolescents Women men 1/2 women and 1/3 men age 65 Management of constipation costs $29 billion annually in the US $800 million spent on laxatives each year Constipation: Rome III Criteria Duration 3 months Symptom onset at least 6 months prior to diagnosis 2 or more of the following symptoms ≥ 25% of the time Excessive straining Lumpy or hard stools Sensation of incomplete evacuation Sensation of anorectal obstruction/blockage Manual maneuvers to assist in defecation ≤ 3 unassisted defecations per week Rare loose BMs without laxatives Etiology of Constipation Lifestyle Medications Medical illness Neurologic Endocrine/Metabolic Psychiatric Primary disease of the colon/anorectum Cancer Hirschsprung’s disease Proctitis Fissure Chronic Idiopathic Constipation Slow transit constipation (11%) Ineffective colonic propulsion Pelvic outlet obstruction (13%) Paradoxical puborectalis contraction Rectocele Combined (5%) IBS-C (71%) Pathophysiology of Slow-Transit Constipation Structurally normal colon and rectum Blunted gastrocolic response to meals Reduced colonic response to morning waking Impaired phasic colonic motor activity Decreased HAPCs—velocity, frequency, amplitude Increased periodic rectal motor activity Paucity of interstitial cells of Cajal Decreased level of motilin Concurrent upper GI motility disorder (77%) Detailed History Onset/duration of constipation Symptoms—freque