Experimental study of faecal continence and colostomy irrigation

Role of transanal irrigation in the treatment of anterior resection syndrome

BACKGROUND

Transanal irrigation(TAI) has been reported to be an inexpensive and effective treatment for low anterior resection syndrome(LARS). The aim of the present prospective study was to evaluate the use of TAI in patients with significant LARS symptoms at a single medical center.

METHODS

Patients who had low anterior resection for rectal cancer between April 2015 and May 2016 at the Careggi University Hospital were assessed for LARS using the LARS and the Memorial Sloan-Kettering Cancer Center Bowel Function Instrument (MSKCC BFI) questionnaires 30-40 days after  surgery or ileostomy closure (if this was done). Quality of life was evaluated using a visual analog scale and the Short Form-36 Health Survey. All patients with LARS score of 30 or higher were included (early LARS) as were all patients with a LARS score of 30 or higher referred 6 months or longer after surgery performed elsewhere (chronic LARS) in the same study period. Study participants were trained to perform TAI using the Peristeen™ System for 6 months, followed by 3 months of enema therapy following a similar protocol.

RESULTS

Thirty-three patients were enrolled in the study. Six patients stopped the treatment. The 27 patients (19 early LARS and 8 chronic LARS) who completed the study had a significant decrease in the number of median daily bowel movements [baseline 7 (range 0-14); 6 months 1 (range 0-4); 9 months 4 (range 0-13)]. The median LARS Score fell from 35.1 (range 30-42) (baseline) to 12.2 (range 0-21) after 6 months (p < 0.0001) and then rose to 27 (range 5-39) after 3 months of enema therapy. There was no difference in LARS score decrease at 6 months between the patients with early and chronic LARS (22.5 and 23.9 respectively; p=0.7) and there were no predictors of score decrease. Four components of the SF-36 significantly improved during the TAI period. The MSKCC BFI score significantly improved in several domains. Twenty-three patients (85%) asked to continue the treatment with TAI after the study ended.

CONCLUSIONS

TAI appears to be an effective treatment for LARS and results in a marked improvement of continence and quality of life.  Patients may be assessed and treated for LARS early after surgery since the treatment benefit is similar to that observed in patients with LARS diagnosed  6 months or longer after surgery. The potential rehabilitative role of TAI for LARS is promising and should be further investigated.

The antegrade continence enema procedure and total anorectal reconstruction

Patients may present with anal incontinence (AI) following repair of a congenital anorectal anomaly years previously, or require total anorectal reconstruction (TAR) following radical rectal extirpation, most commonly for rectal cancer. Others may require removal of their colostomy following sphincter excision for Fournier's gangrene, or in cases of severe perineal trauma. Most of the data pertaining to antegrade continence enema (the ACE or Malone procedure) comes from the pediatric literature in the management of children with AI, but also with supervening chronic constipation, where the quality of life and compliance with this technique appears superior to retrograde colonic washouts. Total anorectal reconstruction requires an anatomical or physical supplement to the performance of a perineal colostomy, which may include an extrinsic muscle interposition (which may or may not be 'dynamized'), construction of a neorectal reservoir, implantation of an incremental artificial bowel sphincter or creation of a terminal, smooth-muscle neosphincter. The advantages and disadvantages of these techniques and their outcome are presented here.

Consensus review of best practice of transanal irrigation in adults

STUDY DESIGN

Review article.

OBJECTIVES

To provide a consensus expert review of the treatment modality for transanal irrigation (TAI).

METHODS

A consensus group of specialists from a range of nations and disciplines who have experience in prescribing and monitoring patients using TAI worked together assimilating both the emerging literature and rapidly accruing clinical expertise. Consensus was reached by a round table discussion process, with individual members leading the article write-up in the sections where they had particular expertise.

RESULTS

Detailed trouble-shooting tips and an algorithm of care to assist professionals with patient selection, management and follow-up was developed.

CONCLUSION

This expert review provides a practical adjunct to training for the emerging therapeutic area of TAI. Careful patient selection, directly supervised training and sustained follow-up are key to optimise outcomes with the technique. Adopting a tailored, stepped approach to care is important in the heterogeneous patient groups to whom TAI may be applied.

SPONSORSHIP

The review was financially supported by Coloplast A/S.

Fluid regimens for colostomy irrigation: a systematic review

Background  Various techniques for managing faecal evacuation have been proposed; however, colostomy irrigation is favoured as it leads to better patient outcomes. Alternative fluid regimens for colostomy irrigation have been suggested to achieve effective evacuation. Aim  The objective of this review was to summarise the best available evidence on the most effective fluid regimen for colostomy irrigation. Search strategy  Trials were identified by electronic searches of CINAHL, PubMed, MEDLINE, Current Contents, the Cochrane Library and EMBASE. Unpublished articles and references lists from included studies were also searched. Selection criteria  Randomised controlled trials and before-and-after studies investigating any fluid regimen for colostomy irrigation were eligible for inclusion. Outcomes measured included fluid inflow time, total wash-out time, haemodynamic changes during irrigation, cramps, leakage episodes, quality of life and level of satisfaction. Data collection and analysis  Trial selection, quality appraisal and data extraction were carried out independently by two reviewers. Differences in opinion were resolved by discussion. Main results  The systematic literature search strategy identified two cross-over trials that compared water with another fluid regimen. Owing to the differences in irrigating solutions used, the results were not pooled for analysis. Both the polyethylene glycol electrolyte solution and glyceryl trinitrate performed significantly better than water. Conclusion  There is some evidence to support the effectiveness of fluid regimens other than water, such as polyethylene glycol electrolyte and glyceryl trinitrate, for colostomy irrigation. Further well-designed clinical trials are required to establish solid evidence on the effectiveness of other irrigating solutions that might enhance colonic irrigation.

Irrigation practices in long-term survivors of colorectal cancer with colostomies

For some patients diagnosed with rectal cancer, surgery will involve the creation of a temporary or permanent ostomy. When the colostomy is located in the sigmoid or descending colon, regulation of fecal output can occur through irrigation, a procedure that involves instilling fluid into the bowel to flush out gas and fecal material. When successfully used, irrigation can prevent fecal output between irrigations, providing some control over colostomy output. The purpose of this article is to describe participants of a large, multisite, multi-investigator study of health-related quality of life in long-term colorectal cancer survivors who answered questions about colostomy irrigation and reported the potential advantages and disadvantages of the procedure. The article also will explore healthcare professionals' role in ensuring patients and family members are educated and well informed about their options regarding temporary or permanent ostomies.

The impact of stoma for bowel management after spinal cord injury

STUDY DESIGN

Multi-centre, retrospective self-report postal survey.

OBJECTIVES

To characterise spinal cord injured (SCI) individuals with a stoma, their stoma management and outcomes, to identify sources of information and support for decision making and to explore the impact of a stoma on life satisfaction.

SETTING

Five UK spinal cord injury centres.

METHODS

A study-specific questionnaire accompanied by self-concept, life satisfaction and mood measures, and three simple rating scales for satisfaction, impact and restriction on life were sent to all known ostomates at five participating centres.

RESULTS

Respondents were 92 individuals, mean age 56 years, mean duration of injury 26 years, 91% with colostomy. Multiple sources of information were utilised in deciding on surgery; discussion with other SCI ostomates was important. Duration of bowel care, faecal incontinence, bowel-related autonomic dysreflexia, dietary manipulation and laxative use were all significantly reduced following surgery. Rectal mucous discharge was the most common and bothersome post-stoma problem. Satisfaction with stoma was high; provision of sufficient information preoperatively was important, those with ileostomy were more dependent and less satisfied. Life satisfaction and physical self-concept were both lower in this sample than in previously reported samples of SCI individuals without reported bowel difficulties or stoma.

CONCLUSION

The findings of this study of self-selected respondents with a stoma for bowel management after SCI emphasised the benefits of stoma in selected individuals and the importance of timely intervention, the complexity of the associated decision-making and of preoperative counselling. The impact of bowel dysfunction on physical self-concept warrants investigation.

Transanal irrigation for disordered defecation: a systematic review

Transanal irrigation for treatment of disordered defecation has been widely used among caregivers. Unique in its simplicity, reversible and minimally invasive, transanal irrigation has begun to find its place in the treatment hierarchy. Scheduled transanal irrigation aims to ensure emptying of the left colon and rectum. This prevents faecal leakage between washouts, providing a state of pseudocontinence, and re-establishes control over the time and place of defecation. Furthermore, regular evacuation of the rectosigmoid prevents constipation. The studies presented in this review represent the continuum of increasing evidence and knowledge of transanal irrigation for disordered defecation: from proof in principle through better knowledge of the physiology, towards establishing the indications and ensuring the safety of the treatment. Evidence of the superiority of transanal irrigation in spinal cord injury patients with neurogenic bowel dysfunction is provided, also from a health-economic perspective. Finally, a proposal is presented for an algorithm for the introduction of transanal irrigation for disordered defecation before irreversible surgery is considered.

Bowel management for the treatment of pediatric fecal incontinence

Fecal incontinence is a devastating underestimated problem, affecting a large number of individuals all over the world. Most of the available literature relates to the management of adults. The treatments proposed are not uniformly successful and have little application in the pediatric population. This paper presents the experience of 30 years, implementing a bowel management program, for the treatment of fecal incontinence in over 700 pediatric patients, with a success rate of 95%. The main characteristics of the program include the identification of the characteristics of the colon of each patient; finding the specific type of enema that will clean that colon and the radiological monitoring of the process.

Retrograde colonic irrigation for faecal incontinence after low anterior resection

BACKGROUND AND AIMS

This study aims to evaluate the therapeutic effect of retrograde colonic irrigation in patients with faecal incontinence after a low anterior resection for a rectal carcinoma.

MATERIALS AND METHODS

Patients with a previous low anterior resection, who were selected for treatment with retrograde colonic irrigation for faecal incontinence between 2005 and 2008, were included in the study. The data from the patients were gathered by chart research and an interview by phone.

RESULTS

Thirty patients were included in the study. Three patients died and one patient was not able to answer questions due to a cognitive disorder. The data of the remaining 26 patients were analysed. Five patients had already stopped with the retrograde colonic irrigation treatment due to side effects. Twelve of the 21 patients (57.46%) who still performed RCI became completely (pseudo)continent, three patients (14.2%) were incontinent for flatus and six patients (29.4%) were still incontinent for liquid stool. Five patients stopped with the retrograde colonic irrigation treatment due to side-effects.

CONCLUSION

Retrograde colonic irrigation is an effective method to treat patients with faecal incontinence after a low anterior resection for rectal carcinoma. Retrograde colonic irrigation is not invasive and has only mild side effects.

Issues in irrigation for people with a permanent colostomy: a review

Colostomy irrigation is a way of achieving faecal continence and is offered as an alternative method of stoma care management to wearing and emptying a colostomy appliance. This article summarizes an extensive literature review carried out to determine the benefits of irrigation to colostomists and barriers to its uptake. Colostomy irrigation is a method of stoma care management offering 'control' over bowel habit thus assisting the colostomist in the adjustment and adaptation towards their new way of life.

Long-term outcome and safety of transanal irrigation for constipation and fecal incontinence

PURPOSE

This study evaluated long-term results of transanal irrigation for defecation disturbances.

METHODS

Three hundred and forty-eight patients [248 women and 100 men; median age 52 years (range, 5-85)] suffering from constipation and fecal incontinence were introduced to transanal irrigation. Patients using transanal irrigation at follow-up received a mailed questionnaire describing bowel function and practical procedures. Results from patients not responding and patients no longer using transanal irrigation were drawn from hospital records and telephone interviews. Background variables were analysed using multivariate logistic regression.

RESULTS

After a mean follow-up of 21 months (range, 1-116) 163 of 348 patients (47 percent) had a successful outcome from treatment with transanal irrigation. Success rates varied between patients with different underlying pathology: neurogenic bowel dysfunction, 67 of 107 (63 percent); anal insufficiency, 36 of 70 (51 percent); sequela to anorectal surgery, 14 of 48 (29 percent); idiopathic constipation, 27 of 79 (34 percent); and miscellaneous, 19 of 44 (43 percent). Factors correlating with positive outcome were neurogenic bowel dysfunction and anal insufficiency as underlying pathology, low rectal volume at urge to defecate, low maximal rectal capacity, and low anal squeeze pressure increment. Two nonfatal bowel perforations were found in approximately 110,000 irrigation procedures.

CONCLUSIONS

Transanal irrigation is simple and safe for long-term treatment for defecation disturbances with greatest benefit in patients with neurogenic bowel dysfunction.

Colonic irrigation for defecation disorders after dynamic graciloplasty

BACKGROUND AND AIMS

Dynamic graciloplasty (DGP) 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.

MATERIALS AND METHODS

Patients with defecation disorders after DGP visiting the outpatient clinic of the University Hospital Maastricht were selected for colonic irrigation as additional therapy or salvage therapy in the period between January 1999 and June 2003. The Biotrol(R) Irrimatic pump or the irrigation bag was used for colonic irrigation. Relevant physical and medical history was collected. The patients were asked to fill out a detailed questionnaire about colonic irrigation.

RESULTS

Forty-six patients were included in the study with a mean age of 59.3 +/- 12.4 years (80% female). On average, the patients started the irrigation 21.39 +/- 38.77 months after the DGP. Eight patients started irrigation before the DGP. Fifty-two percent of the patients used the irrigation as additional therapy for fecal incontinence, 24% for constipation, and 24% for both. Irrigation was usually performed in the morning. The mean frequency of irrigation was 0.90 +/- 0.40 times per day. The mean amount of water used for the irrigation was 2.27 +/- 1.75 l with a mean duration of 39 +/- 23 min. Four patients performed antegrade irrigation through a colostomy or appendicostomy, with good results. Overall, 81% of the patients were satisfied with the irrigation. Thirty-seven percent of the patients with fecal incontinence reached (pseudo-)continence, and in 30% of the patients, the constipation completely resolved. Side effects of the irrigation were reported in 61% of the patients: leakage of water after irrigation, abdominal cramps, and distended abdomen. Seven (16%) patients stopped the rectal irrigation.

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.

Colostomy irrigation: review of a number of technical aspects

OBJECTIVE: Performing a literature review about four technical aspects related to the colostomy irrigation: volume of water to be infused, postoperative moment to start the method's training sessions, maintenance of a 24-hour interval between the colostomy irrigations, and time spent for the execution of the procedure, aiming to contribute for the most adequate systematization of the method. METHODS: After searching in the designated sources, sixty-three articles were identified. RESULTS: It was observed that there is no consensus among the several authors: the volume of infused water varied from 500ml to 1500ml, although, in the clinical practice, the average infused volume is 1000ml; the postoperative moment to start the training sessions varied from five days to six months; the maintenance time of a 24-hour interval between the colostomy irrigations varied from two weeks to six months; time spent in the execution of the procedure varied from 20 to 90min. CONCLUSION: The knowledge of these results may be an encouragement to the nurses, especially stomatherapists, to reevaluate their practice, in order to standardize the technical aspects related to the procedure, having as basis the specialized assistance.

Electrical stimulation - an evolving concept in the treatment of colonic motor dysfunctions

Electrical stimulation of digestive organs is a new approach for the treatment of dismotility-based diseases affecting the gastrointestinal (GI) tract. The most significant advancement in this field has been obtained with stomach stimulation. As a result, a fully implantable stimulation system to treat gastroparesis - the 'Enterra' system - is now commercially available. Similarly, electrical stimulation of the colon may become a valuable alternative to drug therapy and surgical procedures in the treatment of colonic motor dysfunctions. Over the past decade, several stimulation patterns to modulate colon motility have been tested in animal and human models. The results of these studies are reviewed here in connection with aspects regarding physiological mechanisms activated by electrical stimulation of the colon.

Colon emptying induced by sequential electrical stimulation in rats

Electrical stimulation could be used to induce colon emptying. The present experiments were performed to establish a stimulation pattern to optimize the stimulation parameters and to test neural involvement in propulsion induced by electrical stimulation. Colon segments were sequentially stimulated using rectangular pulses. The resulting propulsive activity displaced intraluminal content in consecutive propulsion steps. The propulsion steps differed in displacement latency, distance, and velocity along the stimulated colon. Increasing the pulse duration or amplitude resulted in a decrease of the latency. Increasing the stimulation amplitude doubled the displacement distance. The frequencies tested in the present study did not affect propulsion. Inhibition of cholinergic and nitrergic pathways inhibited propulsion. Electrical stimulation can induce colonic propulsion. Motor differences are present along the descending colon. The most suitable combination of pulse parameters regarding colon stimulation is 0.3 ms, 5 mA, 10 Hz. Neural circuits are involved in propulsion when using these values.

Experimental model of fistula-in-ano

PURPOSE

This study was designed to create and evaluate an experimental porcine model of fistula-in-ano.

METHODS

Initial cadaveric dissection enabled refinement of the technique for fistula formation and histoanatomical study of the porcine anal canal. Subsequently, three surgically created fistulas were treated by seton drainage in each of eight male pigs (weight, 38-41 kg). After 26 days, magnetic resonance imaging at 1.5 Tesla was performed and setons removed under general anesthesia, enabling clinical and microbiologic track assessment. Two pigs were killed for histologic fistula track assessment.

RESULTS

Histoanatomical assessment noted a rudimentary internal anal sphincter, together with structures resembling anal glands. Artificial fistulas persisted during seton drainage and were more often associated with fecal than skin-derived organisms compared with both perineal and anal canal swabs (P = 0.002). All six fistulas assessed histologically had a lumen, and abundant surrounding granulation tissue similar to that seen in human fistula-in-ano. Epithelialization was not evident in any track. Fistulas were visualized as high signal tracks using magnetic resonance imaging.

CONCLUSIONS

Porcine anal anatomy resembles that of humans, and an experimental model proved suitable when assessed by magnetic resonance imaging, microbiology, and histologically, which demonstrated abundant granulation tissue. This model could be further used to investigate fistula treatments.

Long-term follow-up of retrograde colonic irrigation for defaecation disturbances

OBJECTIVE

Irrigation of the distal part of the large bowel is a nonsurgical alternative for patients with defaecation disturbances. In our institution, all patients with defaecation disturbances, not responding to medical treatment and biofeedback therapy, were offered retrograde colonic irrigation (RCI). This study is aimed at evaluating the long-term feasibility and outcome of RCI.

METHODS

Between 1989 and 2001, a consecutive series of 267 patients was offered RCI. All patients received instructions about RCI by one of our enterostomal therapists. Twenty-eight patients were lost to follow-up. A detailed questionnaire was sent by mail to 239 patients. The total response rate was 79% (190 patients). Based on the returned questionnaires it became clear that 21 (11%) patients never started RCI. The long-term feasibility and outcome of RCI was therefore assessed in the remaining group of 169 patients. Thirty-two patients were admitted with soiling, 71 patients with faecal incontinence, 37 patients with obstructed defaecation and 29 had defaecation disturbances after low anterior resection or pouch surgery.

RESULTS

According to the returned questionnaires, RCI was considered effective by 91 (54%) patients. Among patients with soiling and faecal incontinence, RCI was found to be effective in, respectively, 47 and 41% of the subjects. Despite of the reported effectiveness, 10 (67%) patients with soiling and 5 (17%) patients with faecal incontinence decided to stop. Among patients with obstructed defaecation and those with defaecation disturbances after low anterior resection or pouch surgery the effectiveness of RCI was found to be 65 and 79%, respectively. None of these patients ceased their therapy. The overall success-rate of long-term RCI was therefore 45%.

CONCLUSIONS

Long-term RCI is beneficial for 45% of patients with defaecation disturbances. In the group of patients who considered RCI effective and beneficial, discontinuation of therapy was only observed among those with soiling and faecal incontinence.

Randomized cross-over trial of polyethylene glycol electrolyte solution and water for colostomy irrigation

PURPOSE

Water for colostomy irrigation is largely absorbed by the colon, which may result in less efficient expulsion of stool. This study compared the outcome of colonic cleansing with water and polyethylene glycol solution.

METHODS

In a cross-over study, 41 colostomy irrigators were randomly assigned to water or polyethylene glycol solution irrigation first and then the other regimen, each for one week. Patients recorded fluid inflow time, total washout time, cramps, leakage episodes, number of stoma pouches used, and satisfaction scores (Visual Analog Scale, 1-10: 1 = poor, and 10 = excellent). The median and interquartile range for each variable was calculated, and the two treatments were compared (Wilcoxon's test).

RESULTS

Eight patients failed to complete the study. Thirty-three patients (20 females; mean age, 55 (range, 39-73) years) provided 352 irrigation sessions: water (n = 176), and polyethylene glycol solution (n = 176). Irrigation was performed every 24, 48, and 72 hours by 17, 9, and 7 patients respectively, using 500 ml (n = 1), 750 ml (n = 2), 1,000 ml (n = 16), 1,500 ml (n = 11), 2,000 ml (n = 2), and 3,500 ml (n = 1) of fluid. The median and interquartile range for water vs. polyethylene glycol solution were: fluid inflow time (6 (range, 4.4-10.8) vs. 6.3 (range, 4.1-11) minutes; P = 0.48), total washout time (53 (range, 33-69) vs. 38 (range, 28-55) minutes; P = 0.01), leakage episodes (2.3 (range, 1.7-3.8) vs. 0.7 (range, 0.2-1); P < 0.001), satisfaction score (5.8 (range, 4-7.5) vs. 8.8 (range, 8.3-10); P < 0.001), and stoma pouch usage per week (75 (range, 45-80) vs. 43 (range, 0-80); P = 0.008). No difference was demonstrated for frequency of cramps ( P = 0.24).

CONCLUSIONS

Polyethylene glycol solution performed significantly better than water and may be a superior alternative fluid regimen for colostomy irrigation.

Retrograde commercial colonic hydrotherapy

OBJECTIVE

To ascertain the current practice of commercial colonic hydrotherapy in the UK and to collect data on the profiles of both the practitioners and their clients. In addition to understand how colonic hydrotherapy is perceived by those who use it and how much economic benefit it generates for the practitioners. Information as to training and complications was sought.

PATIENTS AND METHODS

A questionnaire was sent to all 80 practitioners registered with the Association of Colonic Hydrotherapists (ACH) of the UK. The practitioners who responded were sent 10 questionnaires to be given to a group of consecutive clients. This client questionnaire included an SF-36 self-administered scoring system and a satisfaction survey. To understand the methodology and ritual of the hydrotherapy procedure a field trip was arranged and two of the authors (NJT and PJM) underwent one colonic hydrotherapy session with an experience practitioner.

RESULTS

Thirty-eight (48%) of practitioners responded to our practitioner survey and 242 client questionnaires were returned. One third of practitioners reported a previous clinical background and 32 (83%) were single-handed practitioners. The average time in practice was six years and with an average age of the hydrotherapists being 50 years (22-78 years). Estimated number of sessions conducted were 3200 (range 140-10 000). Average annual income before expenses per practitioner was estimated at pound 45 675. The clients' ages ranged was 18 and 82 years of age (mean 44 years) and had undergone an average of 35 hydrotherapy treatments (range 1-2500). Clients had lower SF-36 scores than the UK norm.

CONCLUSION

Colonic hydrotherapy is practised widely in the UK with an estimated 5600 procedures carried out by ACH practitioners monthly. It is not known how much activity is carried out by non-ACH members. ACH practitioners appear to be well trained and a proportion have medical backgrounds. Clients, who are often unhappy with orthodox medicine seem satisfied enough with the experience of colonic hydrotherapy to undergo regular purgings. No serious side-effects have been reported to us. Economic factors could be a driving force for the continuation of the practice as the monies earnt are not inconsiderable.

Scintigraphic assessment of colostomy irrigation

OBJECTIVE: This study aims to evaluate colonic transport following colostomy irrigation with a new scintigraphic technique. MATERIALS AND METHODS: To label the bowel contents 19 patients (11 uncomplicated colostomy irrigation, 8 complicated colostomy irrigation) took 111In-labelled polystyrene pellets one and two days before investigation. 99mTc-DTPA was mixed with the irrigation fluid to assess its extent within the bowel. Scintigraphy was performed before and after a standardized washout procedure. The colon was divided into three segments 1: the caecum andascending colon; 2: the transverse colon; 3: the descending and sigmoid colon. Assuming ordered evacuation of the colon, the contribution of each colonic segment to the total evacuation was expressed as a percentage of the original segmental counts. These were added to reach a total defaecation score (range: 0-300). RESULTS: In uncomplicated colostomy irrigation, the median defaecation score was 235 (range: 145-289) corresponding to complete evacuation of the descending and transverse colon and 35% evacuation of the caecum/ascending colon. In complicated colostomy irrigation it was possible to distinguish specific emptying patterns. The retained irrigation fluid reached the caecum in all but one patient. CONCLUSION: Scintigraphy can be used to evaluate colonic emptying following colostomy irrigation.

Chemical colostomy irrigation with glyceryl trinitrate solution

PURPOSE

Colostomy irrigation may improve patient quality of life, but is time consuming. This study tests the hypothesis that irrigation with glyceryl trinitrate solution, by inducing gastrointestinal smooth muscle relaxation, may accelerate expulsion of stool by passive emptying, thereby reducing irrigation time.

METHODS

Fifteen colostomy irrigators(with more than 3 years' experience) performed washout with tap water compared with water containing 0.025 mg/kg glyceryl trinitrate. Fluid inflow time, total washout time, and hemodynamic changes occurring during glyceryl trinitrate irrigation were documented by an independent observer. Subjects recorded episodes of fecal leakage and overall satisfaction on a visual analog scale. Cramps, headaches, and whether or not a stoma bag was used were expressed as a percentage of number of irrigations. Comparison of fluid inflow time, total washout time, leakage, and satisfaction was by Wilcoxon's signed-rank test and headaches, cramps, and stoma bag use was by McNemar's test. Pulse rate (paired t-test), systolic and diastolic blood pressures (Wilcoxon's test) at 20 and 240 minutes after washout with glyceryl trinitrate solution were compared with baseline.

RESULTS

Fifteen patients (9 female), with a mean age of 53 (31-73) years, provided 30 sessions (15 with water and 15 with glyceryl trinitrate). Medians (interquartile ranges) for water vs. glyceryl trinitrate were fluid inflow time 7 (4-10) vs. 4, (3-5; P = 0.001); total washout time 40 (30-55) vs. 21, (15-24; P < 0.001); leakage 0 (0-1) vs. 0, (0-0; P = 0.02), satisfaction 10 (8-10) vs. 10 (9-10; P = 0.31). The number (percentage) of stoma bags, cramps, and headaches with water vs. glyceryl trinitrate were 7 (47 percent) vs. 7 (47 percent), P = 1; 1 (7 percent) vs. 14 (93 percent), P < 0.001; and 0(0 percent) vs. 14 (93 percent), P < 0.001, respectively. Changes in pulse (increase) and systolic and diastolic blood pressures (decrease) from baseline were maximal at 20 minutes (P < 0.001, P = 0.001, and P = 0.002, respectively) and had returned to baseline by 240 minutes (P = 0.52, P = 0.08, and P = 1, respectively).

CONCLUSION

Glyceryl trinitrate solution significantly reduces colostomy irrigation time compared with the generally recommended tap water. Patients suffer fewer leakages and are highly satisfied, but side effects are potential drawbacks. Other colonoplegic agent solutions should now be evaluated.