196 Morbidity rates are high after DGP: complications associated with the technique can often be prevented or treated, but other complications like reduced sensitivity of the rectum by destruction of sensory nerves can be very hard to treat and often result in DGP failure [4, 8, 9]. Morbidity rates are lower and success rates higher in the hands of surgeons experienced in the technique [3, 10]. Constipation is a significant problem after graciloplasty, occurring in 13–90% of the patients after DGP [6–8, 11, 12]. Constipation due to technical failure, like a gracilis wrap that is too tight, can be treated by revisional surgery. Other causes of constipation can first be treated with dietary measures and medication. In case of pelvic floor dysfunc- tion, biofeedback training can be started [9]. When this first line treatment is unsuccessful, retrograde colonic irrigation can be considered. Colonic irrigation can also be used as an additional therapy or salvage therapy for persistent fecal incontinence after failed or partially failed surgery [13]. Not much is known about the success rate of retrograde colonic irrigation, as there is only a limited number of published studies [13, 14]. Antegrade irrigation through a colostomy or appendico- cecostomy is another technique for colonic irrigation, with a reasonable success rate of 64–85% [15–17]. In this study, the effectiveness of colonic irrigation for the treatment of persistent fecal incontinence and/or constipation after DGP was investigated. Materials and methods Patients with DGP and postoperative defecation disorders were selected for colonic irrigation between January 1999 and June 2003. The patients were offered colonic irrigation as additional or salvage therapy, as a colostomy was the final option for these patients. The inclusion criteria were invalidating fecal incontinence and/or constipation after DGP and a signed informed consent; exclusion criteria were patients not willing to perform the irrigation because of either embarrassment or wish for colostomy or patients physically and/or mentally not capable of performing irrigation. All patients visited the outpatient clinic of the University Hospital Maastricht. Relevant physical and medical history were collected. The patients could be divided in six groups according to the etiology of fecal incontinence before DGP: congenital, trauma (rupture/anal surgery), pudendopathy (PNTML> 2.6 ms), spinal cord lesion, cancer (abdominal perineal resection in rectumcarcinoma), and prolapse. The patients were asked to fill out a questionnaire. This questionnaire contained questions concerning the method of irrigation, the time needed for irrigation, the amount of water used, the frequency of irrigation, added substances to Int J Colorectal Dis (2008) 32:195–200 the irrigation water, and side effects of colonic irrigation. The endpoint was defined that irrigation had to be successful and satisfying for the patients. Successful irrigation was defined as reaching continence for feces (pseudo-continence) and/or complete resolution of strain- ing, feeling of incomplete evacuation, bloating abdomen, and abdominal pain during irrigation. The patient was considered satisfied when he or she indicated that the colonic irrigation rendered a major improvement of the quality of life. The improvement of quality of life was measured by a visual analog scale/ specific questions within the questionnaire. The irrigation was performed in most patients as retrograde irrigation; only four patients performed antegrade irrigation through an appendico-cecostomy or a colostomy. Patients with fecal incontinence can gain continence as a result of colonic irrigation. This is called pseudo-continence because these patients are only continent, as there is no fecal filling of the rectum and distal colon. The definition of resolved constipation was no straining and no feeling of incomplete evacuation after defecation. Defecation occurred during irrigation in most of these patients. The Biotrol® Irrimatic pump (Braun®; Fig. 1) or the irrigation bag (Braun®; Fig. 2) were used for colonic irrigation. The Irrimatic pump is an irrigation pump using a flexible tube with a cone-shaped end. The tube is introduced either in the anal canal in case of retrograde irrigation or placed in an appendico-cecostomy or colosto- my in case of antegrade irrigation. The pump can hold a maximum of 2 l. The patients were instructed to start the irrigation daily with 500 ml of water. Thereafter, the frequency and the amount of water were adjusted until a satisfactory result was achieved. Water used for irrigation was at body temperature; too cold water can cause abdominal cramps or collapse and too hot water can cause burns. Soap or laxatives could be added if necessary. The Fig. 1 Biotrol® Irrimatic pump (Braun®)