Int J Colorectal Dis (2008) 32:195–200 common problems of MACE are stoma stenosis and leakage [16, 17]. The results in our hospital of antegrade irrigation by an appendico-cecostomy were described earlier [23]. In this study, four patients performed antegrade irrigation via a colostomy or a MACE with good results. O’Bichere et al. performed an experimental study investi- gating the effect of retrograde vs antegrade colonic irrigation in pigs. That study demonstrates that colonic emptying is more efficient with antegrade irrigation compared to retrograde irrigation [27]. Although a reason- able success rate can be achieved with antegrade irrigation (64–85%) [15–17], retrograde colonic irrigation is preferred above antegrade irrigation as initial treatment because of its non-invasive nature and benign complications. The amount of water used for irrigation was higher in patients with fecal incontinence compared to patients with constipation. This can be explained by the difficulty of retaining water in the rectum in case of fecal incontinence. Theoretically, the amount of water retained in the rectum is higher in patients with constipation. The grade of colonic emptying by irrigation in constipated patients by means of scintigraphy was investigated by Christensen et al. [14]. The effect of retrograde colonic washout was significantly better in idiopathic fecal incontinence compared to idio- pathic constipation, and its effect correlated with the extent to which the irrigation fluid had entered the colorectum. Surgical treatment of fecal incontinence gives an overall success of 50–84%, depending on the etiology of fecal incontinence and type of surgical procedure [28–32]. Success percentages in DGP vary from 42–92% [1–5]. The success rate of 80% of colonic irrigation is comparable to the success rate of surgical treatment for fecal inconti- nence. Sixty-one percent of the patients that received the questionnaire completed it. Even when we assume that the patients who did not complete the questionnaire were dissatisfied with the treatment (bad case scenario), the success rate in the present study would still be 50%. It is important to realize that this is a selected group of patients with persistent incontinence and/or constipation after DGP. Regarding the fecal incontinence, this group of patients represents the 8–58% (assuming 42–92% success after DGP) with insufficient results of DGP [1–5]. Regarding the different underlying causes for fecal incontinence before DGP, the patients with a trauma to the anal sphincter have the lowest success rate and the patients with a spinal cord lesion have the highest success rate. It is not possible to draw conclusions about the statistical significance of these results because of the limited group size. Previous studies already reported an increased incidence of constipation after DGP [3, 6, 8, 11, 12]. In this study, we included 22 patients that were constipated after DGP, of which 11 patients had constipa- 199 tion in combination with persistent fecal incontinence. It is important to realize that many patients are incontinent for feces after periods of severe evacuation problems. These evacuation problems are present again after treatment of the fecal incontinence. Its etiology is not well understood, but is likely to be multifactorial [33, 34]. This is known after all surgical procedures for fecal incontinence [35]. Constipa- tion can be due to technical problems such as a tight graciloplasty, which can be solved by revision of the DGP. It is also possible that nerve tissue around the anus sustains damage during the operation, causing pudendopathy which cannot be treated by revisional surgery. Previous surgery in the pelvis, like an abdomino-perineal resection (eight patients in this study), is known to have a very high rate of obstructed defecation, probably due to reduced rectal sensitivity and pelvic floor dysfunction [36]. Constipation related to physical impairment, like a disturbed sensation and/or motility because of a congenital cause or degener- ation, is difficult to treat [9]. These patients are usually served well with colonic irrigation. Surgical treatment of constipation is troublesome and only indicated in a selected group of patients with intractable constipation. The bowel frequency usually increases, but abdominal pain and bloating persists in most patients [37]. In this study, 90% of the patients were satisfied with the irrigation, and in 30%, the constipation resolved with colonic irrigation. The final step of treatment after the colonic irrigation in the patients of this study would be a colostomy or ileostomy. In the study of Norton et al., the majority of the patients with fecal incontinence managed by a colostomy reported to be positive about the stoma. However, a few could not adapt to the stoma and disliked it intensely [38]. Harris et al. investigated patients with fecal incontinence or constipation managed with a stoma. Many of these patients reported that lifestyle restrictions were imposed by the stoma, and almost half of the patients felt stigmatized. Up to a third of these patients had significant depression, especially the younger women [39]. Cultural issues also have an important impact on the acceptance of a stoma [40]. Keeping these disadvan- tages of a definitive stoma in mind, colonic irrigation offers an attractive alternative, which is worthwhile trying before proceeding to a definitive stoma. Conclusion Colonic irrigation is an effective alternative for the treatment of persistent fecal incontinence after DGP and/or recurrent or onset constipation additional to unsuccessful or (partially) successful DGP. Colonic irrigation is an undervalued and often forgotten treatment option, which deserves its rightful place among the other treatment modalities.