Retrograde Enemas Research Articles

Prospective study on the effects of mechanical bowel preparation under the enhanced recovery after surgery concept on electrolyte disturbances and functional recovery after robotic surgery for urologic tumors in older adults

BackgroundMechanical bowel preparation (MBP) involves the cleansing of bowel excreta and secretions using methods such as preoperative oral laxatives, retrograde enemas, and dietary adjustments. When combined with oral antibiotics, preoperative MBP can effectively lower the risk of anastomotic leakage, minimize the occurrence of postoperative infections, and reduce the likelihood of other complications. To study the effects of MBP under the Enhanced Recovery After Surgery (ERAS) concept on postoperative electrolyte disorders and functional recovery in older people with urological tumors undergoing robot-assisted surgery.MethodsOlder people with urological tumors undergoing robot-assisted surgery were randomly divided into two groups. The experimental group (n = 76) underwent preoperative MBP, while the control group (n = 72) did not. The differences in electrolyte levels and functional recovery between the two groups after radical surgery for urological tumors were observed.ResultsThe incidence of postoperative electrolyte disorders was significantly higher in the experimental group compared to the control group, with incidence rates of 42.1% and 19.4%, respectively (P < 0.05). Subgroup analysis showed that the electrolyte disorder was age-related (P < 0.05). There were no significant differences between the two groups in terms of postoperative complications, gastrointestinal function recovery, laboratory indicators of infection, body temperature, and length of hospital stay (P > 0.05).ConclusionUnder the accelerated recovery background, preoperative MBP increases the risk of postoperative electrolyte disorders in older people with urological tumors and does not reduce the incidence of postoperative complications or promote postoperative functional recovery.

Do preoperative factors predict success of antegrade continence enemas in children?

IntroductionAntegrade continent enemas (ACE) procedures are one treatment option in children with medically refractory constipation or encopresis and predicting success is difficult. We hypothesize that there are preoperative factors that can be identified to help with patient selection and family counseling. MethodsWe conducted a retrospective study of children who underwent a cecostomy or appendicostomy for an ACE program between 2015 and 2021. Underlying diagnosis, pre-operative bowel regimen and imaging were analyzed. Patients were reviewed for success at 3-, 6- and 12-months post-procedure. Data was analyzed with Fisher's Exact, Kruskal-Wallis and logistic regression where applicable with significance defined as p < 0.05. ResultsForty-three children were identified; 28 were male, 15 were female, mean age at time of operation was 8 years old. 76% were considered successful at 3-months, 86% at 6-months, and 87% at 12-months post- procedure. Univariate analysis showed that a pre-ACE retrograde enema program predicted success at 3-months (94% vs. 64% p = 0.03) but no difference at 6- or 12-months. At one year after ACE procedure there was a significant reduction in number of enteral medications (2 to 0, p < 0.01) and 94% of patients were on one or fewer at one year follow-up. Age, gender, weight at time of operation, contrast enema, anorectal manometry and colonic transit time results were not predictive of outcomes. ConclusionIn this study, we characterized expected time to success in our population as well as identified use of a pre-operative retrograde enema program as a potential predictor of success at 3-months in children undergoing an ACE procedure. Level of evidenceIV. Type of studyPrognosis study.

Endoscopic Decompression with a Transanal Drainage Tube for the Treatment of Hirschsprung's Disease in Newborns

Background: To evaluate the effectiveness and safety of endoscopic decompression with a transanal drainage tube (ED-TDT) in the treatment of neonatal Hirschsprung's disease (HD). Materials and Methods: Six newborns (4 boys and 2 girls; age at operation 9-29 days, median 24 days) were admitted to our hospital due to the delayed passage of meconium after birth, abdominal distension, and vomiting. HD was diagnosed by the retrograde enema radiography. All patients underwent ED-TDT for decompression of the dilated colon. During the operation, an endoscope was inserted through the anus to the ascending colon or ileocecal region, which was then used to insert a guidewire to the ascending colon. The endoscope was then removed, and a colorectal drainage tube was introduced over the guidewire. This drainage was placed until a pull-through procedure was performed. Results: The ED-TDT was successfully performed in all newborns. The intraoperative rectal biopsy confirmed the diagnosis of HD. The duration of the operation was 25-70 minutes (median 52.5 minutes). There were no perforations, bleeding, or other complications after surgery. After surgery, the abdominal distention was significantly relieved, and the babies could be fed with milk after 6 hours. These babies were discharged after 2-11 days (median 2.5 days) and underwent a pull-through procedure after 1-3 months (median 3 months). Conclusions: ED-TDT is a safe and effective treatment for neonatal HD before a pull-through procedure. It could be used as an alternative therapy to colostomy.

A technique to reconstruct the anal sphincters following iatrogenic stretching related to a pull-through for Hirschsprung disease

Soiling and fecal incontinence are troubling complications which can occur after a pull-through for Hirschsprung disease. They can usually be improved with proper medical management, but in some cases are the result of an anatomic defect related to overstretching of the sphincters and/or damage of the anal canal. For such patients the treatment of this true fecal incontinence is limited to a structured bowel management program with ante- or retrograde enemas to achieve social continence. Herein we report two such patients with overstretched sphincters and loss of the dentate line after an initial pull-through and describe a sphincter tightening technique to improve bowel control.

Medical and surgical management of neurogenic bowel

Neurogenic bowel dysfunction (NBoD) commonly affects patients with spina bifida, cerebral palsy, and spinal cord injury among other neurologic insults. NBoD is a significant source of physical and psychosocial morbidity. Treating NBoD requires a diligent relationship between patient, caretaker, and provider in establishing and maintaining a successful bowel program. A well designed bowel program allows for regular, predictable bowel movements and prevents episodes of fecal incontinence. Treatment options for NBoD span conservative lifestyle changes to fecal diversion depending on the nature of the dysfunction. Lifestyle changes and oral laxatives are effective for many patients. Patients requiring more advanced therapy progress to transanal irrigation devices and retrograde enemas. Those receiving enemas may opt for antegrade enema administration via a Malone antegrade continence enema or Chait cecostomy button, which are increasingly performed in a minimally invasive fashion. Select patients benefit from fecal diversion, which simplifies care in more severe cases. Many medical and surgical options are available for patients with NBoD. Selecting the appropriate medical or surgical treatment involves a careful evaluation of each patient's physical, psychosocial, financial, and geographic variables in an effort to optimize bowel function.

Role of preoperative retrograde enema on inflammatory and healing parameters in colonic anastomosis: experimental study in dogs

ObjectiveThe purpose of this experimental study was to compare the inflammatory and wound healing response of dogs submitted to colonic anastomosis with and without preoperative retrograde enema. MethodsThe study included two groups of 31 female dogs (Canis familiaris). G-I (control): no preoperative bowel preparation; G-II (study): preoperative retrograde enema using a 10% glycerin solution. All the animals were submitted to laparotomy and colotomy at 20cm from the anal verge, followed by closure with a running extramucosal single-layer suture (Prolene® 000). The animals were then anesthetized and euthanized on the 7th (n=10) or 21st (n=20) postoperative day (POD) to remove the anastomosed colon segment for histological and immunohistochemical analysis evaluating the parameters: anastomotic edema, vasoproliferation, abdominal adhesions, type I and III collagen, nitric oxide and myeloperoxidase. The observed differences were analyzed with the Mann–Whitney test for nonparametric data and Student's t test for unpaired samples and parametric data. ResultsOne animal from G-I and one from G-II died on POD 7 and POD 10 due to anastomotic complications and sepsis, respectively. The groups did not differ significantly with regard to inflammatory and healing parameters, although the levels of mature collagen were significantly lower in the animals submitted to preoperative bowel preparation. ConclusionIt has been shown that both procedures are safe to be used, however, the group with bowel preparation showed a lower amount of mature collagen in the immediate postoperative period and may be constituted a preventive factor for surgical complications for this type of surgical procedure, although no evidence in this study could be determined.

Percutaneous endoscopic caecostomy for severe constipation in adults: feasibility, durability, functional and quality of life results at 1 year follow-up.

The percutaneous endoscopic ceacostomy (PEC) for antegrade colonic enemas (ACE) has recently been proposed as a less invasive alternative to the Malone procedure in chronic constipated patients. Although the feasibility and safety of this innovative approach has been demonstrated, its functional results remain unknown. The aim of this study was to evaluate constipation symptoms and quality of life 1 year after the PEC placement. From Oct 2007 to Apr 2011, 21 severely constipated patients who required ACE were prospectively included. They underwent endoscopic placement of Chait caecostomy catheter (Cook Medical). Patients completed standardized questionnaires to assess constipation (KESS) and quality of life (GIQLI) scores pre PEC placement and at 1 year. Adverse events and caecostomy use data were also documented. The caecostomy catheter was successfully placed in 19 patients. Complications were all minor, including chronic wound pain (n = 9), serous leakage (n = 7), superficial wound infection (n = 2) and accidental catheter removal (n = 2). Chronic wound pain led to definitive catheter removal in 5 (26 %) patients. One patient died from unrelated cause before the end of the follow-up. At 1 year, 11 (61 %) of the alive patients still performed ACE. During the period of ACE administration, 14 (74 %) patients suspended use of laxatives and retrograde irrigations. Constipation and quality of life scores were available in 15 patients. Median KESS score improved from 25 (12-39) before PEC to 17 (6-34) 1 year after PEC (p < 0.05). Median GIQLI score increased from 69 (25-108) to 95 (48-119) (p < 0.05). PEC placement achieves satisfying functional and quality of life results, and allows approximately 3/4 of patients to suspend laxatives and retrograde enemas. Nevertheless, 1/4 of the patients ask for the PEC removal because of chronic wound pain. In order to improve long-term durability of the device, a better prevention of pain is required.

Peritonitis After Endoscopic Caecostomy With a Chait Trapdoor Catheter

Peritonitis After Endoscopic Caecostomy With a Chait Trapdoor Catheter

Rectal perforation as a result of self‐administration of retrograde enema in an elderly dementia patient

Rectal perforation as a result of self‐administration of retrograde enema in an elderly dementia patient

Rectal Cancer Surgery With or Without Bowel Preparation

To assess with a single-blinded, multicenter, randomized trial, the postoperative results in patients undergoing sphincter-saving rectal resection for cancer without preoperative mechanical bowel preparation (MBP). The collective evidence from literature strongly suggests that MBP, before elective colonic surgery, is of no benefit in terms of postoperative morbidity. Very few data and no randomized study are available for rectal surgery and preliminary results conclude toward the safety of rectal resection without MBP. From October 2007 to January 2009, patients scheduled for elective rectal cancer sphincter-saving resection were randomized to receive preoperative MBP (ie, retrograde enema and oral laxatives) or not. Primary endpoint was the overall 30-day morbidity rate. Secondary endpoints included mortality rate, anastomotic leakage rate, major morbidity rate (Dindo III or more), degree of discomfort for the patient, and hospital stay. A total of 178 patients (103 men), including 89 in both groups (no-MBP and MBP groups), were included in the study. The overall and infectious morbidity rates were significantly higher in no-MBP versus MBP group, 44% versus 27%, P = 0.018, and 34% versus 16%, P = 0.005, respectively. Regarding both anastomotic leakage and major morbidity rates, there was no significant difference between no-MBP and MBP group: 19% versus 10% (P = 0.09) and 18% versus 11% (P = 0.69), respectively. Moderate or severe discomfort was reported by 40% of prepared patients. Mortality rate (1.1% vs 3.4%) and mean hospital stay (16 vs 14 days) did not differ significantly between both groups. This first randomized trial demonstrated that rectal cancer surgery without MBP was associated with higher risk of overall and infectious morbidity rates without any significant increase of anastomotic leakage rate. Thus, it suggests continuing to perform MBP before elective rectal resection for cancer.

Achieving Fecal Continence in Patients With Spina Bifida: A Descriptive Cohort Study

Fecal incontinence is a major problem in patients with myelomeningocele. We evaluate the results of a stratified approach aimed at obtaining fecal pseudo-continence in patients with myelomeningocele. We conducted a cross-sectional descriptive study of last file data in 80 patients 5 to 18 years old with myelomeningocele followed at our center. Beginning at birth patients with myelomeningocele were seen at least annually by the pediatric gastroenterologist, a member of the multidisciplinary "spina team." Constipation was treated with diet and osmotic laxatives. Starting at age 5 years, treatment was targeted at achieving pseudo-continence. A toilet training scheme was started, associated with induced defecation by digital stimulation. Retrograde tap water enemas were used in patients with unsatisfactory results. If retrograde enemas were unsuccessful, an antegrade continence enema procedure was proposed. For children unable to sit on a toilet regular manual evacuation of stools was advised. Eight of the 80 patients were fecal continent. Pseudo-continence was achieved in 50 of the 72 incontinent patients (69%), including 5 of 5 following only a strict toilet scheme, 21 of 24 (87.5%) performing retrograde enemas, 16 of 20 (80%) performing orthograde enemas through an antegrade continence device and 8 of 10 performing regular manual evacuation of stools. In 4 of the 20 patients (20%) performing orthograde enemas complications led to closure of the antegrade continence device. Treatment failed and was stopped in 17 patients. Success of treatment was not related to level of spinal lesion or degree of mobility. Fecal pseudo-continence was achieved in 58 of 80 patients (72.5%) with myelomeningocele.

Percutaneous Cecostomy for Management of Fecal Incontinence in Pediatric Patients

To report the authors' experience with percutaneous cecostomy and demonstrate its effectiveness in the management of pediatric patients with fecal incontinence. Between March 2002 and November 2006, 21 percutaneous cecostomy procedures were performed in 20 patients in whom classical therapeutic approaches for the management of fecal incontinence had failed. Eighteen patients had anorectal malformations, one had myelomeningocele, and one had chronic constipation. All procedures were performed under general anesthesia and fluoroscopic guidance. In all cases, an 8.5-F Dawson-Mueller catheter was placed in the cecum and exchanged after 45 days with a cecostomy button (ie, Trapdoor catheter). Data regarding complications, effectiveness of treatment, satisfaction, and quality of life were obtained by interviewing the patients' parents at follow-up consultation. Nineteen of 20 procedures were technically successful. There were no major complications. All patients' symptoms of incontinence improved. Ninety percent of patients in our series (n = 18) reported satisfaction with the procedure, mainly related to their independence and quality of life. Percutaneous cecostomy is a safe and effective procedure for the management of pediatric patients with fecal incontinence. Percutaneous cecostomy allows antegrade and more physiologic colon irrigation, avoiding the need for multiple retrograde enemas, achieving more patient independence, and improving quality of life.

A multicentre study of the management of disorders of defecation in patients with spina bifida

Patients with spinal dysraphism may have severe constipation and faecal incontinence. The impact of antegrade colonic enema (ACE) in the management of patients with spina bifida (SB) is analysed. In a multicentre cross-sectional study, constipation, faecal incontinence and faecal management were described. Cases surgically treated were identified. Data were collected from 423 patients, of whom 230 did not use any manoeuvre or laxatives to assist evacuation. Conventional treatment was used in 193 patients, including digital extraction in 39%, retrograde enema in 21% and oral laxatives in 52%. For intractable constipation and overflow of faecal incontinence, 47 patients were treated with ACE, of whom 41 used the method at a mean time of interview of 4.1 +/- 1.9 years after ACE operation; six abandoned ACE for conventional management. With ACE, faecal continence was significantly improved compared with conventional management, and neither retrograde rectal enema nor digital extraction were required. The conduit was fashioned to the right colon in 32 cases and to the left colon in nine cases. This study provides information on a multicentre experience in bowel management in SB patients. Whatever the technique used, ACE has improved faecal status compared with conventional therapy.

P0460 CONTROL OF FECAL INCONTINENCE IN PATIENTS WITH SPINA BIFIDA

Introduction: Fecal incontinence is a common problem in patients with spina bifida. We present the results of a systematic approach to treat this problem. Methods: From birth on, spina bifida patients are seen at least once yearly by a multidisciplinary team. One of the members of the team is a paediatric gastroenterologist. The aim of gastroenterological treatment is anal (pseudo-) continence, defined as having no involuntary stool losses more than once monthly*. The therapeutic approach consists of treatment of constipation since infancy by diet and osmotic laxatives aiming at at least 3 defecations/week. At the age of 5 years, an anal manometry is performed. Then, in patients being able to sit independently, a program of toilet training with a defecation diary is started. Digital stimulation is proposed. When this approach is unsuccesful, daily retrograde water enemas are started. If unsuccesful or too cumbersome, an antegrade continence enema (ACE) procedure is proposed. In children who are not able to sit independently on a toilet, regular manual evacuation of stools is performed. Data on treatment and degree of fecal incontinence are systematically noted during the yearly visit. We present an overview of the last file data in all 80 children with spina bifida older than 5 yrs (5 – 16 yrs) followed in our centre. Results:Table 1 summarizes treatment results.Table 1: Results in 80 patientsRetrograde enema’s are reported to take 30 min (median, 10–60) daily, whereas ACE takes 40 min (30 – 60) every two days. More children (10/16) with ACE than with retrograde enema’s (3/19) perform the procedure independently from caregivers. ACE was more succesful in attaining fecal continence than retrograde enema’s. However, 2/18 children returned to retrograde enema’s after stenosis of the continent stoma. Results of anal manometry were not predictive of attaining fecal (pseudo-)continence. The level of the spinal lesion was predictive of being able to sit independently, but not of anorectal function. Conclusion: A large proportion of children with spina bifida (68/80) can achieve fecal (pseudo-)continence from 5 years on.

Continent appendicostomy in the treatment of fecal incontinence

Fecal incontinence is common in children with anorectal anomalies or spina bifida. If it is possible to achieve fecal control, patients are given a large volume of enema once a day. Retrograde enemas are often unpleasant in children, particularly in adolescents. Malone procedure of antegrade appendicostomy achieves antegrade colonic irrigation. From 1996 to 2003 Malone antegrade appendicostomy was performed in 10 patients with fecal incontinence. The patients were aged from 5 to 24 years. In 4 patients fecal incontinence was due to an anorectal anomaly, and in 6 patients spina bifida. Preoperatively, all patients were given a clysma to control fecal incontinence. The patients, who remained clean with regular usage of the clysma for 24 hours or longer, fulfilled the criterion for the formation of continent appendicostomy. In 9 patients the cecal appendix was used to create a stoma, while in another one a lateral tubularized cecal flap was applied. In 3 patients a continent conduit was also done due to urinary incontinence. The follow-up period was from 1 to 8 years. A patient was reoperated due to stenosis of the stomal aperture, while another one has not been using the stoma because of social reasons. Continent appendicostomy is a simple surgery, which is effective in the control of fecal incontinence in most children. It is indicated only in patients in whom the rerograde clysma successfully cleans the colon and if patient and parents are motivated to use it. Possible complications, among which stenosis is the most frequent, can be solved with a reoperation.

Clinical Quiz

A 9-year-old boy, known to have Crohn disease, presented to the emergency room with a one-week history of increasing, colicky abdominal pain. He was diagnosed at four years of age with severe perianal and rectal disease. His disease was refractory to extensive medical management, and he required a diversion sigmoid colostomy and the establishment of a Hartmann pouch at seven years of age because of persistent anal stenosis and severe dyschezia. In addition to his abdominal pain, he reported the passage of flatus, but no stool, into his colostomy bag. His vital signs were stable; he was apyrexial and had a normal urine analysis. On examination, his abdomen was protuberant with a 15 by 12 cm mass in the hypogastric region extending down into the pelvis. The colostomy site in the left flank appeared healthy. Anal inspection revealed extensive scarring, and no anal orifice was readily identified. Imaging included an abdominal radiograph (Fig. 1), abdominal and pelvic sonography (Fig. 2), and retrograde colon study via his colostomy.FIG. 1. No Caption AvailableFIG. 2. No Caption AvailableWhat is the most likely diagnosis? A. Colostomy stenosis and obstruction B. Pelvic abscess C. Rectal mucocele D. Distended bladder due to outlet obstruction Answer: C. Rectal Mucocele The mucosal lining of a Hartmann's pouch secretes mucus, which must drain or it will accumulate over time. Inflammation, scarring and epithelialization of the anal canal obstructed the drainage in this case, causing a mucocele, which progressively enlarged. The abdominal radiograph indicated a soft-tissue mass arising from the pelvis, displacing bowel superiorly and to the right. Sonography demonstrated a markedly dilated hollow viscus arising from the deep pelvis and extending up to the left hypochondrium. There was no obvious connection to the stoma site. The mass was causing mild, left-sided hydronephrosis. Retrograde enema via the colostomy filled a normal caliber colon. The anus was probed open under general anesthesia and 1100 ml of mucus was evacuated. A Penrose drain was left across the anus to maintain patency. Comment: Mucoceles are commonly associated with the appendix and cranial sinuses. Rectal mucoceles are rare. The first reported pediatric case was an extraluminal pelvic mucocele in a patient with an imperforate anus following an endorectal pull-through operation with incomplete mucosal excision (1). There are case reports of rectal mucoceles following Hartmann's procedure for ulcerative colitis, and secondary to high anal sphincter tone following spinal trauma (2,3). Mucoceles have developed in defunctioned colon after pull-through surgery due to stenosis and retraction of the colonic stump (4,5). Scarring of the mucus fistula, or failure to creat a mucus fistula are other described contributing factors. In our patient, obstruction of the isolated distal colon was caused by severe, long-standing anorectal Crohn disease which caused scarring, stricture and epithelialization of the anal orifice. Treatment requires effective drainage or removal of the mucus-producing epithelium. This case illustrates a rare but interesting complication of Crohn disease.

7108 The role of emergency colonoscopy in acute massive lower gastrointestinal bleeding.

Colonoscopy became a very important tool in the management of patients with lower gastrointestinal hemorrhage. We advocate the indication of colonoscopy as one of the first steps to investigate the patients with moderate and massive rectal bleeding. In the last twelve years we have examined 103 patients with massive lower gastrointestinal bleeding out of 6199 colonoscopies performed during this period. All these patients were submitted to colonoscopy after exclusion of upper gastrointestinal bleeding, by an endoscopy, and a proctological exam to detect anorectal diseases. Bowel preparation was achieved either with an anterograde prep with a 10% manitol solution or one or two saline retrograde enemas just to evacuate the major blood cloths. It was possible to determine the source of bleeding in 67% of the patients.Vascular malformation ( 10.7% ), infectious diseases ( 9.7% ), inflammatory bowel disease ( 8.7% ), later post polipectomies bleeding ( 8.7%), neoplasias( 5.8% ), and polyps( 4.8% ) were the predominant source of bleeding. Endoscopic control of active hemorrhage was achieved in 39% of the patients. Injectiontherapy with adrenaline solution or ethanolamine, application of argon beam, and polipectomy with monopolar snare cauthery were the main endoscopic modalities used. There were no major complications neither mortality in this series.

The Malone Antegrade Continence Enema Procedure in the Management of Patients with Spina Bifida

Background: In patients with spina bifida, traditional bowel management programs such as suppositories, retrograde enemas, and manual disimpaction have been largely unsatisfactory. The Malone antegrade continence enema (ACE) procedure has largely changed our approach to bowel management in this patient group. Study Design: Over a 3-year period between January 1994 and January 1997, 27 patients with spina bifida underwent the Malone ACE procedure at our institutions. At the time of their ACE procedure, four patients underwent simultaneous continent urinary diversion and three had simultaneous small-bowel bladder augmentation. All the patients were evaluated for 9 months or more after their procedure, and 10 of the patients have been followed for more than 2 years. Results: Postoperatively, predictable bowel control and continence were achieved in 19 of the 27 patients, but 6 had some rectal soiling requiring a sanitary pad. All patients were out of diapers and none reported stomal leakage. Eighteen of the 27 patients were able to manage independently and 9 required assistance. Two patients had stopped using their ACE stoma despite good technical results. The appendix was used as a catheterizable stoma in 15 of the 27 patients. The appendix was not available in 12 patients, so a tubularized cecal flap was used in 9 and a small-bowel neoappendix was created in 3. Complications included stomal stenosis in 5 patients, cecal-flap necrosis in 1, and stomal granulations in 3. Conclusions: We believe that the ACE procedure provides reliable colonic emptying and avoids fecal soiling in the majority of individuals, and we find it widely and enthusiastically accepted by patients with spina bifida.