JIMSA July-September 2013 Vol. 26 No. 3 161 BACKGROUND Constipation has afflicted mankind since times immemorial. It was once called the Disease of all diseases. Approximately 80% of all individuals suffer from constipation at one point or another and nearly 33% of patients suffer from these problems more than occasionally. The symptoms of constipation include: excessive straining, hard stools, digitation, incomplete evacuation, a sense of anorectal blockage and less than three bowel movements per week. The most common causes of constipation are low fiber diet, lack of physical activity and the medical disorders such as thyroid disease, diabetes, irritable bowel syndrome, neurological disease, colon cancer and use of certain medications. In majority of patients presenting to the surgery clinics the general causes of constipation have already been ruled out and this creates a whole lot of challenges for the surgeon to provide an adequate diagnosis supplemented by proper investigation and henceforth the right treatment modality. Some of these patients are diagnosed by obvious findings on rectal examination or on colonoscopy while others still remain a dilemma. Those patients in whom no physical abnormality is detected are grouped as functional constipation or idiopathic constipation. This group of patients which was offered no surgical treatment due to lack of knowledge of underlying pathophysiology is now becomingthe point of interest for the surgical fraternity. EVOLUTION OF PATHOPHYSIOLOGY OF CONSTIPATION The evolution of concept of constipation and investigation into understanding the pathophysiology dates back to 16th century BC. The oldest book on constipation ‘Egyptian pharmaceutical papyrus’ offers a basic explanation of disease as the notion of poisoning of the body by material released from decomposing waste in the intestines 1 . This compelling suspicion shaped medical theory for more than three millennia; the personal physician to Louis XV of France in the 18th century was merely echoing the Ebers Papyrus when he warned that disease was the result of blood turned “faeculent” by contamination with “the depraved remains of concoction” in the intestines 2 . From the late 1700s onward European and American physicians were convinced that constipation was becoming ever more common Surgeon’s Domain: From Organic Constipation to Idiopathic Constipation. Shruti Sharma*, Brij B Agarwal Senior Consultant, Endosurgery, Sir Ganga Ram Hospital, New Delhi, India *Department of Surgery, Harlem Hospital Center, Columbia University Medical Center, New York, USA Correspondence: Dr. Brij B. Agarwal, Dr. Agarwal’s Surgery & Yoga, F-81&82, Street 4, Virender Nagar, New Delhi-110058, India Fax no. : 91-11-25861002; Website: www.endosurgeon.org; e-mail: endosurgeon@gmail.com because of changes in diet, exercise levels, and pace of life associated with urbanization. The late 19th century medical scientists formulated the theory of intestinal autointoxication, or self-poisoning from one’s own retained wastes. “The constipated person”, French physician Charles Bouchard declared, “is always working toward his own destruction; he makes continual attempts at suicide by intoxication. Indeed, from 1900 into the 1920s autointoxication was regarded by much of the medical profession and most of the public as the most insidious disease of all, since it was, in essence, all diseases. In books such as The Conquest of Constipation, The Lazy Colon, and Le Colon Homicide physicians on both sides of the Atlantic warned that the contents of the colon were “a burden, fermenting, decomposing, putrefying, filling the body with poisonous substances” and creating “sewer-like blood” 3 that autointoxication “is the cause of ninety per cent of disease”; and that “constipation shortens life 4 . A horde of device salesmen swept over the land as well, peddling an astounding collection of merchandise: enema and colonic irrigation equipment, abdominal support belts, abdominal massage machines, electrical stimulators, rectal dilators, and so on and on. Not the least intimidating of the cures for autointoxication was surgery, colectomy to be precise, popularised by the renowned surgeon of London’s Guy’s Hospital, Sir William Arbuthnot Lane. Between 1900 and 1920, Lane extirpated the colons of hundreds of constipates, maintaining that his streamlining of the human “drainage scheme” was “the most satisfactory result of surgery known to us at the present time 5 . Throughout the 50’s and 60’s the generalized causes of constipation were investigated and documented. The effects of various drugs and pathological diseases on intestinal motility and consequent constipation were progressively identified. Still a large number of patients had refractory idiopathic constipation not attributed to any identifiable cause. Until the last decade, surgeon’s role was mainly limited to investigation of underlying cause of constipation, management of acute and chronic bowel obstruction and correction of anorectal causes like fissure, fistula and piles. However, with the improved understanding of anorectal pathophysiological alterations, new surgical modalities were introduced for the treatment of idiopathic constipation. Abstract: Constipation is the most common disorder of defecation. Physicians have tried to treat the constipation by both pharmacologic and non pharmaco- logic measures in the past. Surgical intervention was sought only for the investigation of constipation or to treat the cases of constipation with an organic lesion. In recent decades the cases of idiopathic constipation in which no secondary cause is present have become the point of interest for many including surgeons. In 1990’s Dr. Antonio Longo, an Italian surgeon, proposed that many patients of chronic constipation present with symptom of straining at stool trying to overcome an obstruction but the physical examination reveals no form of obstruction. Such patients were put in a separate category of Obstructed Defecation Syndrome (ODS). Dr. Longo studied the morphological abnormalities in such patients and devised the method and instrumentation for a Stapled Trans Anal Rectal Resection popularly known as STARR which he demonstrated at 2nd World Congress of Coloproctology in Rome in year 1998. This article reviews how the understanding of underlying pathophysiology in cases of obstructed defecation has revolutionized the surgical treatment of constipation.