Seminars in Colon & Rectal Surgery RSS feed: Current Issue. Seminars in Colon and Rectal Surgery offers a comprehensive and coordinated review of a single, timely topic related to the diagnosis and treatment of proctologic diseases. Each issue is an organized compendium of practical information that serves as a lasting reference for colorectal surgeons, general surgeons, surgeons in training and their colleagues in medicine with an interest in colorectal disorders. 2010 Topics March Pelvic Floor Evaluation Tracy Hull June Reducing Morbidity Warren Enker http://www.seminarscolonrectalsurgery.com/?rss=yesElsevier Inc.en © 2010 Published by Elsevier Inc. Seminars in Colon & Rectal Surgery1043-1489211March 2010 © 2010 Published by Elsevier Inc. healthpermissions@elsevier.comhttp://www.seminarscolonrectalsurgery.com/article/PIIS1043148909000591/abstract?rss=yesFor health care providers, patients with pelvic floor problems can be one of the most complex and frustrating groups of patients we treat. There are many factors that must function in harmony for acceptable evacuation to occur at the correct moment. Minute changes in 1 aspect of the pelvis can lead to life altering results. Both ends of the spectrum can make patients miserable. I cannot imagine being afraid to leave my home and do daily activities for fear of having an uncontrolled spontaneous evacuation of stool. Likewise, sitting on the commode for hours daily, attempting to evacuate, and getting up only to feel you need to return to empty your rectum must be extremely frustrating. The degree patients go to alter their diet, activities, and schedule in an attempt to gain some control over their bowel problem amazes me.IntroductionTracy L. Hull10.1053/j.scrs.2009.10.001Seminars in Colon & Rectal Surgery 21, 1 (2010)2010-03-01Seminars in Colon & Rectal Surgery2010-03-01211S1043-1489(10)X0002-111http://www.seminarscolonrectalsurgery.com/article/PIIS1043148909000608/abstract?rss=yesPelvic floor disorders encompass symptoms, including urinary incontinence, pelvic organ prolapse, and fecal incontinence. Challenges to treating individuals with pelvic floor disorders include under-reporting of symptoms and inconsistent diagnostic criterion. Nearly 1 in 4 individuals in the United States has experienced a pelvic floor disorder. Incontinence disorders are more frequent in women and the prevalence increases with age. Obstetrical trauma is a common factor in the development of pelvic floor dysfunction. Morbidly obese individuals have a higher prevalence of pelvic floor disorders and weight loss may lead to improvement of symptoms. Evaluation and treatment should address the individual's productivity and quality of life in addition to anatomic and functional limitations. Pelvic floor disorders are best treated with a multidisciplinary approach.Pelvic Floor Disorders: Scope of the ProblemAmy L. Halverson, Anne-Marie Boller10.1053/j.scrs.2009.10.002Seminars in Colon & Rectal Surgery 21, 1 (2010)2010-03-01Seminars in Colon & Rectal Surgery2010-03-01211S1043-1489(10)X0002-125http://www.seminarscolonrectalsurgery.com/article/PIIS104314890900061X/abstract?rss=yesThe evaluation and testing of conditions attributed to the posterior compartment of the pelvic floor is an important component in the management of patients presenting with fecal incontinence, constipation, and anal pain. In recent years, numerous advances in radiological and physiological investigatory techniques have become available to the clinician. This can enable the underlying pathogenesis of the condition to be determined, which in turn can aid diagnosis and guide medical, behavioral, and surgical treatment. This review looks at current concepts and advances in the evaluation and testing of posterior pelvic floor disorders.Current Concepts in Evaluation and Testing of Posterior Pelvic Floor DisordersThomas C. Dudding, Carolynne J. Vaizey10.1053/j.scrs.2009.10.003Seminars in Colon & Rectal Surgery 21, 1 (2010)2010-03-01Seminars in Colon & Rectal Surgery2010-03-01211S1043-1489(10)X0002-1621http://www.seminarscolonrectalsurgery.com/article/PIIS1043148909000621/abstract?rss=yesFecal incontinence and constipation are benign conditions that can have a significant effect on the lifestyles of those affected. In order for clinicians to better understand a patient's baseline symptoms and, more importantly, to have a measure that can evaluate and compare different treatments and their outcomes, patient-validated self-report tools that assess symptoms and quality of life are essential.Measures for Fecal Incontinence, Constipation, and Associated Quality of LifeJennifer Y. Wang, Madhulika G. Varma10.1053/j.scrs.2009.10.004Seminars in Colon & Rectal Surgery 21, 1 (2010)2010-03-01Seminars in Colon & Rectal Surgery2010-03-01211S1043-1489(10)X0002-12226http://www.seminarscolonrectalsurgery.com/article/PIIS1043148909000633/abstract?rss=yesThe most common surgical treatment for fecal incontinence is sphincteroplasty, but this treatment option requires a localized anatomic sphincter injury and outcomes vary and tend to deteriorate with time. Other surgical techniques have therefore been developed. Postanal repair was designed to restore the anorectal angle with muscle plication of the posterior aspect of the anal canal. Initial improvement rates are acceptable, but only a small proportion of patients reports complete alleviation of symptoms and outcomes deteriorate with time. Suboptimal long-term outcome has lead to decreased use of the procedure. Electrostimulation of a transposed gracilis muscle around the anal canal can yield excellent results in selected patients. Complication rates are high when performed in nonspecialist centers, and the technique is currently not approved in the USA. Artificial bowel sphincter can restore acceptable anal continence and is used for treatment of end-stage fecal incontinence. A problematic high incidence of infection and erosion problems has been reported in some studies, which can hopefully be improved with a more stringent sterile protocol and centralization of the procedure to select specialist centers.Results of Traditional Surgical Treatment for Fecal IncontinenceAnders Mellgren10.1053/j.scrs.2009.10.005Seminars in Colon & Rectal Surgery 21, 1 (2010)2010-03-01Seminars in Colon & Rectal Surgery2010-03-01211S1043-1489(10)X0002-12729http://www.seminarscolonrectalsurgery.com/article/PIIS1043148909000645/abstract?rss=yesFecal incontinence is a devastating condition for patients and a challenge for physicians. There are many underlying causes that contribute to this major problem of which, a disrupted anal sphincter muscle is the only theoretically surgically treatable cause. Injury may be due to defects in the external anal sphincter and/or internal anal sphincter or a defect or a weakening of only the internal anal sphincter. A mere 20 years ago, the only available surgical methods were defect repair, levator muscle plication, or creation of a stoma. The internal anal sphincter is not amenable for surgical repair and despite initially promising short-term results of sphincteroplasty, the long-term outcomes have been very disappointing. The lack of reliable robust treatment prompted the development of new modalities, such as injectables and sacral nerve stimulation. These newer concepts seem to allow satisfactory results to patients with a variety of etiologies for their incontinence.Newer Concepts in Fecal Incontinence: Injectables and Sacral Nerve StimulationSherief Shawki, Steven D. Wexner10.1053/j.scrs.2009.10.006Seminars in Colon & Rectal Surgery 21, 1 (2010)2010-03-01Seminars in Colon & Rectal Surgery2010-03-01211S1043-1489(10)X0002-13036http://www.seminarscolonrectalsurgery.com/article/PIIS1043148909000657/abstract?rss=yesSurgical options for the management of rectal prolapse are extensive. Choosing the correct modality to suit patients needs requires an understanding of the principles of each approach and their benefits in correcting the underlying anatomical and functional defects. The abdominal approach has a lower recurrence rate and when performed laparoscopically, offers all the benefits of minimally invasive surgery including early return of bowel function, reduced analgesic requirements, and reduced time to discharge. The addition of resection to the rectopexy depends on the degree of constipation and redundancy of the sigmoid colon. It carries the risk of anastomostic leakage. The coexistence of slow-transit constipation or obstructed defecation will alter the management pathway. Patients with incontinence generally experience an improvement after the rectal prolapse is corrected unless they have significant pudendal neuropathy. Whether the rectopexy is performed with mesh, sutures, or tacks depends on surgeon preference. The technique applied for open or laparoscopic surgery is often determined by the surgeon's previous exposure and training. In patients with significant cardiorespiratory risk factors, a perineal approach consisting of a Delorme or Altemeier may be preferred. These techniques require a considerable skill base, and while there is a lower morbidity, this is at the expense of a higher recurrence rate. We would advise that repeat surgery for rectal prolapse be performed in a specialized center or by a surgeon with experience in the management of recurrent rectal prolapse.Rectal Prolapse Surgery: Choosing the Correct ApproachMyles R. Joyce, Tracy L. Hull10.1053/j.scrs.2009.10.007Seminars in Colon & Rectal Surgery 21, 1 (2010)2010-03-01Seminars in Colon & Rectal Surgery2010-03-01211S1043-1489(10)X0002-13744http://www.seminarscolonrectalsurgery.com/article/PIIS1043148909000669/abstract?rss=yesFor many individuals, emptying their bowels is an automatic event but for some, particularly women, the process of evacuating stool may be difficult. Pelvic evacuation dysfunction refers to a constellation of symptoms such as prolonged repeated straining at bowel movements, sensation of incomplete evacuation, the need for digital manipulation, and different postures to initiate or complete bowel movements. Evacuation disorders are a result of multiple factors that include anatomical (rectocele, enterocele, and sigmoidocele), physiological (impaired rectal sensation) and functional components (nonrelaxing puborectalis). A systematic and complete pelvic floor history and physical examination should be elicited on all patients with complaints consistent with pelvic evacuation dysfunction. Anorectal and radiological studies are very useful to determine different pathologic mechanisms that are not evident on clinical examination. Treatment is based on identifying the underlying etiology and may include medical therapy, biofeedback, surgery, or combination of all the 3 modalities. The treatment of defecatory disorders can be challenging and requires the coordinated attempts of gastroenterologists, surgeons, psychologists, physical therapists, and nutritionists.Overview of Pelvic Evacuation DysfunctionBrooke Gurland, Massarat Zutshi10.1053/j.scrs.2009.10.008Seminars in Colon & Rectal Surgery 21, 1 (2010)2010-03-01Seminars in Colon & Rectal Surgery2010-03-01211S1043-1489(10)X0002-14552