Colonic irrigation for defecation disorders after dynamic graciloplasty Background and aims Dynamic graciloplasty -LRB- DGP -RRB- improves anal continence and quality of life for most patients . However , in some patients , DGP fails and fecal incontinence is unsolved or only partially improved . Constipation is also a significant problem after DGP , occurring in 13 -- 90 % . Colonic irrigation can be considered as an additional or salvage treatment for defecation disorders after unsuccessful or partially successful DGP . In this study , the effectiveness of colonic irrigation for the treatment of persistent fecal incontinence and/or constipation after DGP is investigated . Introduction Dynamic graciloplasty -LRB- DGP -RRB- is a proven effective treatment for fecal incontinence . Success rates vary from 42 -- 92 % -LSB- 1 -- 5 -RSB- . Comparison of results is difficult because the outcome of this method seems to be influenced by the etiology of fecal incontinence , pre-existing stoma , length of follow-up , method of stimulation , and the surgeon 's experience -LSB- 1 , 6 -RSB- . DGP significantly improves quality of life and anal continence for most patients -LSB- 2 -RSB- . Quality of life and patient satisfaction scores correlate significantly with continence scores -LSB- 7 , 8 -RSB- . However , in some patients , fecal incontinence is unsolved or only partially improved after DGP . 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 -LSB- 4 , 8 , 9 -RSB- . Morbidity rates are lower and success rates higher in the hands of surgeons experienced in the technique -LSB- 3 , 10 -RSB- . Constipation is a significant problem after graciloplasty , occurring in 13 -- 90 % of the patients after DGP -LSB- 6 -- 8 , 11 , 12 -RSB- . 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 dysfunction , biofeedback training can be started -LSB- 9 -RSB- . 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 -LSB- 13 -RSB- . Not much is known about the success rate of retrograde colonic irrigation , as there is only a limited number of published studies -LSB- 13 , 14 -RSB- . Antegrade irrigation through a colostomy or appendico-cecostomy is another technique for colonic irrigation , with a reasonable success rate of 64 -- 85 % -LSB- 15 -- 17 -RSB- . 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 -LRB- rupture/anal surgery -RRB- , pudendopathy -LRB- PNTML > 2.6 ms -RRB- , spinal cord lesion , cancer -LRB- abdominal perineal resection in rectumcarcinoma -RRB- , 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 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 -LRB- pseudo-continence -RRB- and/or complete resolution of straining , 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 -LRB- Braun ® ; Fig. 1 -RRB- or the irrigation bag -LRB- Braun ® ; Fig. 2 -RRB- 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 colostomy 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 pump works on a storage battery , and the speed of water ejection can be regulated . The working mechanism of the irrigation bag is similar , except for the water ejection , which is induced by gravity . Fig. 1Biotrol ® Irrimatic pump -LRB- Braun ® -RRB- Fig. 2Irrigation bag -LRB- Braun ® -RRB- Data analysis was performed by using SPSS 14.0 -LRB- SPSS release 14.0 , SPSS , Chicago , USA -RRB- , with the Mann -- Whitney U test . P ≤ 0.05 was considered statistically significant . Data are given as the mean values with the standard deviation . Results The questionnaire was sent to 74 patients . Fourteen patients did not wish to participate in the study for various reasons , and 14 patients did not return the questionnaire . Forty-six patients -LRB- 62 % -RRB- could be included for analysis of which 37 were female -LRB- 80 % -RRB- , and these patients had an overall mean age of 59.3 ± 12.4 years . Complications of the DGP occurred in 23 -LRB- 50 % -RRB- patients of which 10 patients had two or more complications . Twenty-two patients suffered from constipation , 35 patients were still incontinent for feces , and seven patients had pain in the IPG pocket , leg , or anus . The medical history besides the DGP is mentioned in Table 1 . On average , the patients started the irrigation 21.39 ± 38.77 months after the DGP . Eight patients already used irrigation before DGP . Table 1Medical historyMedical historyNumber of patients -LRB- percentage of total -RRB- Anal rupture during delivery13 -LRB- 28 % -RRB- Anal repair14 -LRB- 30 % -RRB- Prolapse operation19 -LRB- 41 % -RRB- Hysterectomy17 -LRB- 37 % -RRB- Abdomino-perineal resection for rectum carcinoma8 -LRB- 17 % -RRB- Sigmoid resection for sigmoiditis2 -LRB- 9 % -RRB- Cholecystectomy8 -LRB- 17 % -RRB- Anus atresia1 -LRB- 2 % -RRB- Twenty-four -LRB- 52 % -RRB- patients used irrigation as an additional therapy for fecal incontinence in partially failing DGP . Eleven -LRB- 24 % -RRB- patients used irrigation for constipation and 11 -LRB- 24 % -RRB- patients for both . Most patients -LRB- 91 % -RRB- used the irrigation pump . Three patients added soap and one patient an enema to the water to achieve a better result . These were patients with constipation or a combination of fecal incontinence and constipation . Irrigation was usually performed in the morning -LRB- 70 % -RRB- and sometimes in the evening -LRB- 16 % -RRB- . The frequency of irrigation was 0.90 ± 0.40 times per day . The amount of water used for irrigation was 2.27 ± 1.75 l with duration of 39 ± 23 min . Seventy-four percent of the patients with fecal incontinence irrigated in the morning , 17 % in the evening , and 9 % twice a day . For the patients with constipation , these numbers are , respectively , 45 , 18 , and 36 % . Ninety percent of the patients with a combination of defecation disorders used the colonic irrigation in the morning . There was no significant difference in the frequency of irrigation between patients with fecal incontinence and patients with constipation -LRB- 0.92 vs 0.98 / day ; P = 0.108 -RRB- . The amount of water used for irrigation was higher in patients with fecal incontinence compared to patients with constipation , but this difference was not significant -LRB- 2.31 vs 1.91 l ; P = 0.484 -RRB- . There was no significant difference in the time needed for irrigation between patients with fecal incontinence and those with constipation -LRB- 40.8 vs 32.9 min ; P = 0.154 -RRB- . Overall , 81 % of the patients were satisfied with the irrigation , 80 % of the patients with fecal incontinence , 90 % of the patients with constipation , and 72 % of the patients with a combined defecation disorder . Thirty-seven percent of the patients with fecal incontinence reached -LRB- pseudo - -RRB- continence , and in 30 % of the patients , the constipation completely resolved -LRB- Fig. 3 -RRB- . In 29 % of the patients with a combined defecation disorder , the constipation resolved and they were -LRB- pseudo - -RRB- continent . Overall , satisfaction was related with symptomatic improvement . Only one patient with good symptomatic improvement was not satisfied because he felt that the irrigation was time-consuming and not practical . Fig. 3Success of rectal irrigation for defecation disorders Four patients , two with fecal incontinence , one with constipation , and one with both , performed antegrade irrigation through a -LRB- 3 -RRB- colostomy or an -LRB- 1 -RRB- appendico-cecostomy with good results , and all indicated that the irrigation improved their quality of life . The patients could be divided in six groups according to the underlying cause of fecal incontinence before DGP -LRB- Table 2 -RRB- . When the different etiologies before DGP were compared with the result during irrigation , the patients with a rupture or anal surgery had the worst results of irrigation . The patients with a spinal cord lesion seemed to have the best results . Table 2Success of rectal irrigation in different etiologies for fecal incontinence before DGPEtiologyNumber of casesSuccess -LRB- % -RRB- during irrigationCongenital11 -LRB- 100 % -RRB- Trauma143 -LRB- 21 % -RRB- Pudendopathy155 -LRB- 33 % -RRB- Spinal cord lesion53 -LRB- 60 % -RRB- Abdomino-perineal resection for rectum carcinoma83 -LRB- 37 % -RRB- Prolapse20 -LRB- 0 % -RRB- Total4515 -LRB- 33 % -RRB- Side effects of the irrigation were reported in 61 % of the patients : leakage of water after irrigation -LRB- 43 % -RRB- , abdominal cramps -LRB- 17 % -RRB- , and distended abdomen -LRB- 17 % -RRB- . Twenty-four -LRB- 53 % -RRB- patients changed the irrigation method during their course to improve the results . Seven -LRB- 16 % -RRB- patients stopped the rectal irrigation : in five patients , the result was unsatisfactory ; two other patients did not need the irrigation anymore because the complaints resolved completely . Finally , two patients received a permanent stoma . Discussion Colonic irrigation can be used effectively to treat defecation disorders when other conservative treatments fail or in addition to unsuccessful or partially successful surgical treatment -LSB- 18 -RSB- . Colonic irrigation is usually forgotten as an alternative conservative treatment for defecation disorders , although many health care takers are familiar with colonic irrigation , particularly , for its use as perioperative colonic cleansing -LSB- 19 , 20 -RSB- . Retrograde colonic irrigation is performed through the anorectum or via a colostomy . Only a few publications addressed to retrograde colonic irrigation are found in literature . Briel et al. -LSB- 13 -RSB- found a success rate of 38 % of retrograde colonic irrigation for fecal incontinence and a significant improvement in quality of life . Recently , another study reported a success rate of 41 % in patients with fecal incontinence and 65 % in patients with constipation -LSB- 18 -RSB- . The success rate is based on patient satisfaction . Although patient satisfaction is the primary goal of treatment , it is a subjective measure . In future research , this should be combined with objective measures such as validated quality of life questionnaires in a prospective study design . Antegrade colonic irrigation is especially known for the treatment of evacuation disorders in small children and can be performed through an appendico-cecostomy -LRB- MACE -RRB- or a cecostomy button -LSB- 16 , 21 -- 23 -RSB- . Alternative enteral access is a sigmoid tube or transverse colonic conduit for patients with a left colonic evacuation disorder -LSB- 24 -- 26 -RSB- . The most common problems of MACE are stoma stenosis and leakage -LSB- 16 , 17 -RSB- . The results in our hospital of antegrade irrigation by an appendico-cecostomy were described earlier -LSB- 23 -RSB- . 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 investigating 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 -LSB- 27 -RSB- . Although a reasonable success rate can be achieved with antegrade irrigation -LRB- 64 -- 85 % -RRB- -LSB- 15 -- 17 -RSB- , 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. -LSB- 14 -RSB- . The effect of retrograde colonic washout was significantly better in idiopathic fecal incontinence compared to idiopathic 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 -LSB- 28 -- 32 -RSB- . Success percentages in DGP vary from 42 -- 92 % -LSB- 1 -- 5 -RSB- . The success rate of 80 % of colonic irrigation is comparable to the success rate of surgical treatment for fecal incontinence . 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 -LRB- bad case scenario -RRB- , 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 % -LRB- assuming 42 -- 92 % success after DGP -RRB- with insufficient results of DGP -LSB- 1 -- 5 -RSB- . 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 -LSB- 3 , 6 , 8 , 11 , 12 -RSB- . In this study , we included 22 patients that were constipated after DGP , of which 11 patients had constipation 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 -LSB- 33 , 34 -RSB- . This is known after all surgical procedures for fecal incontinence -LSB- 35 -RSB- . Constipation 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 can not be treated by revisional surgery . Previous surgery in the pelvis , like an abdomino-perineal resection -LRB- eight patients in this study -RRB- , is known to have a very high rate of obstructed defecation , probably due to reduced rectal sensitivity and pelvic floor dysfunction -LSB- 36 -RSB- . Constipation related to physical impairment , like a disturbed sensation and/or motility because of a congenital cause or degeneration , is difficult to treat -LSB- 9 -RSB- . 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 -LSB- 37 -RSB- . 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 -LSB- 38 -RSB- . 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 -LSB- 39 -RSB- . Cultural issues also have an important impact on the acceptance of a stoma -LSB- 40 -RSB- . Keeping these disadvantages 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 -LRB- partially -RRB- successful DGP . Colonic irrigation is an undervalued and often forgotten treatment option , which deserves its rightful place among the other treatment modalities .

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colonic irrigation
fecal incontinence
constipation
dynamic graciloplasty