Postoperatively, enema administration is started, progressively reaching approximately 1,000 mL per day after 1 week. The final frequency of enema administration and the volume of water used are determined by trial-and-error during the first months of treatment. Usually, irrigation is performed every day or every alternate day with a median of 1,300 mL of water. The time used per procedure is, on average, about 50 min [28].

The cornerstone of achieving successful results with the Malone procedure is the continuous help and support provided by dedicated, specialized nurses on an outpatient basis, especially when treatment is initiated. Treatment is often initially troublesome and time-consuming, with the need for adjustment of the frequency of enema administration and the volume of water used. Additional oral laxatives might support the process, but local complications with the conduit are quite common. As a result, the Malone technique also requires commitment from a motivated patient with a willingness to deal with these practical challenges.

Since its introduction, the Malone procedure has been proven to be safe and effective among children suffering from fecal incontinence or chronic constipation due to spina bifida or anorectal malformations [14, 15, 17, 18, 29–31]. The results obtained in children have been confirmed in long-term data in large patient series [31–37].

Antegrade colonic irrigation recently has been introduced for use in adults. No Cochrane review, nor any systematic review, has been published to date, although the evidence in favor of its use has been based on several single-center patient series [16, 25, 28, 35, 38–40, 42–49, 51], which are reviewed in Table 24.1. In summary, adults with severe chronic idiopathic constipation, outlet obstruction, or fecal incontinence can improve considerably by resorting to antegrade colonic irrigation. Excluding known double publications, a total of 277 patients with antegrade colonic irrigation have been evaluated, and successful outcome was found in 204 (74 %). However, it must be emphasized that the long-term results are sparse: one study examined the time course with antegrade irrigation and found that commitment to the treatment seemed to deteriorate over time [44].

There may be a tendency for patients with neurogenic bowel dysfunction to obtain better results [28, 39, 40, 43, 48]. A decision analysis has even suggested that antegrade colonic irrigation is the most efficient treatment modality for neurogenic bowel dysfunction in the event that conservative bowel management fails [52]. However, this analysis did not consider the more simple approach of using transanal irrigation [41]. With respect to available studies of transanal irrigation, the majority are retrospective in design and do not use commonly accepted bowel function scores. However, a few studies using either bowel function scores or prospective data collection found significant improvement in symptoms and well being [35, 42, 45, 47, 49], although these findings were not necessarily echoed by an improvement in social relations and quality of life [42, 45, 47].

Although the functional results and patient satisfaction with antegrade colonic irrigation are pronounced, the procedure has a considerable minor morbidity, especially in the form of localized complications at the site of the stoma, which might overshadow the functional benefits of the treatment. In this respect, stomal stenosis is found in 23–55 % of the cases [28, 31, 33, 35, 37, 44, 53]. In the majority of patients, this problem can be managed with simple dilatation, even though surgical revision is occasionally needed. Another complication is refluxing leakage of mucus and liquid feces through the conduit, which is reported in up to 53 % of the patients [28]. This usually can be controlled by a simple wound bandage or, in more severe cases, by the insertion of a gastrostomy tube [40, 46, 54, 55]. Both stomal stenosis and refluxing leakage of mucus and liquid might be avoided by introducing a simple silicon button (the “ACE stopper”) after removal of the initial catheter [56]. In total, complications are found in up to 88 % of patients. The localized complications seem to be independent of the type of conduit [28]; however, others have found the tapered ileal neoappendicostomy to be superior [46, 47, 57], preferring this conduit to the original appendicostomy as described [47].

Perforation of the conduit (cecal perforation) is a potential complication that requires prompt diagnosis and early intervention [58, 59]. In a series of 187 children with antegrade colonic irrigation who were reviewed over a 13-year period, perforation of the conduit was seen in 7 patients (3.7 %), of whom 2 required laparotomy and 5 needed endoscopic catheter placement to solve this problem [58]. At our institution, one patient had encountered perforation because of forceful removal of a catheter. The perforation was treated with endoscopic placement of a Mic-key button (MIC-KEY, Ballard Medical Products, Draper, Utah) [28].

If patients no longer need antegrade colonic irrigation or find the side effects unacceptable, they can stop using the stoma. It will then often close, leaving the patient no worse off than before the operation. In cases of continuous secretion from a nonfunctioning appendicostoma, formal appendectomy is needed.

A novel technique for antegrade colonic irrigation is percutaneous endoscopic colostomy (PEC). An adaption of the technique for endoscopic placement of a feeding tube into the stomach is used: an artificial tube is placed in the left colon or even in the right colon. Initially, PEC was used to decompress the colon in cases of recurrent sigmoid volvulus or chronic intestinal pseudo-obstruction [60, 61], but the insertion of this tube also allows the bowel to be flushed from the tube to the anus. The benefits of this approach may be that the antegrade nature of the irrigation may work better than retrograde irrigation. Another benefit lies in the minimally invasive nature of the procedure used to place the tube, which is usually performed with the patient mildly sedated by local anesthesia and as an ambulatory procedure. Interventional procedure guidance has been published by the National Institute for Health and Clinical Excellence in the UK [62].

The functional results of PEC for symptom control are encouraging. In children with refractory constipation, 90 % achieved control of symptoms [63]. In adults with severe constipation or neurologic bowel dysfunction, these findings were confirmed [64–66]: a recent retrospective single-center review found that PEC could be considered effective in 81 % of patients [67]. However, the functional results might deteriorate in the long term because of complications. In this series [67], two patients died because of complications, 18 of 27 developed localized sepsis, and conduit-related complications were frequent. As a consequence, only 2 of 28 PECs remained in situ at follow-up. Others have reported severely delayed complications with [68] and high failure rates [64] of PEC. Despite initial symptom control with PEC, widespread or indiscriminate use of the technique cannot be ­recommended at this time.

In most cases, right antegrade colonic irrigation, in which the conduit for irrigation is in the cecum, yields a satisfactory outcome; however, in some cases, the pathology treated lies in the left colon or in the rectum. It may, therefore, be physiologically more attractive to deliver the enema at a place nearer to the site of pathology. As an alternative to PEC for left colonic disease, several novel surgical approaches have been proposed. A continent colonic conduit has been described by Williams et al. [69] providing a catheterizable channel leading from the skin to the colonic lumen, which incorporated a full-thickness intussuscepted valve akin to the valve used in the Kock ileal reservoir to prevent reflux [70]. The colonic conduit can be placed anywhere in the colon including the descending and the sigmoid colon. The operation is more complex, and the technical complications involved in the procedure are similar to those of the different types of neoappendicostomies. A retubularized ileal segment, as described by Monti et al. [71], or a tube made from the greater curvature of the stomach [72], also can be anastomosed to the sigmoid colon. Finally, a retubularized descending colon also has been suggested [73, 74]. The common indications reported in the literature for the left antegrade continence enema are childhood bowel dysfunction, which arises from spina bifida [75], idiopathic constipation, Hirschsprung’s disease, or anorectal malformations. A recent review found that continence was achieved in 87 of 93 children (94 %) [76]. It also has been used as a ­salvage procedure to treat refractory constipation or fecal incontinence after functional failure of a dynamic graciloplasty [77]. The indications and results are in accordance with the right antegrade continence enema. Whether the left antegrade continent enema and the continent colonic conduit provide any functional advantage over the right antegrade continent enema remains to be studied [78].

Because antegrade colonic irrigation has been proven to be more efficient than retrograde colonic irrigation [79, 80], a combination of an appendicostomy with a sigmoid colostomy has been suggested for antegrade colonic irrigation in selected surgery for colorectal cancer to improve colostomy care [81]. During irrigation, patients flush the colon via the appendicostomy and the bowel empties though an irrigation sleeve inserted directly into the toilet commode (Fig. 24.3). In a recently published article about its use in 25 patients, 14 of whom had neurogenic bowel dysfunction [28], there was a reported functional success in 72 % of cases, suggesting that there is advantage in the possible improved efficacy of antegrade rather than retrograde irrigation with an inert residual colon.

Constipation-associated symptoms such as abdominal pain, bloated sensations, and nausea may remain unchanged in spite of irrigation [42], and transient side-effects during irrigation such as mild abdominal cramps, nausea, chills, and tiredness after use are present in 50–63 % of patients [16, 28, 40]. The goal of the irrigation is to induce antegrade peristalsis alongside the simple mechanical washout effect of the sudden installation of a relatively large volume of irrigation fluid in a short time. Studies have shown that colonic mass movements can be introduced by enemas [82], ­bisacodyl [83], and balloon distension [84]. It is likely that the mild abdominal cramps arise from the induced effect of irrigation.

Using a scintigraphic dual-isotope technique [79], significant backflow through the ileocolic anastomosis to the ileum was reported in three patients with an ileal neoappendicostomy. Backflow also was found to the terminal ileum in a patient with a cecal flap created as a neoappendicostomy; however, the mild and transient side effects in these patients were not different from those in patients without backflow. Moreover, hydrogen breath tests failed to demonstrate bacterial overgrowth of the neoterminal ileum in another study [49]. In the same study, gallbladder emptying, gastric emptying, and orocecal transit times remained unchanged compared with baseline and there were no signs of bacterial overgrowth of the neo-terminal ileum that might compromise the absorption of bile acids and vitamins.

Treatment with retrograde transanal irrigation is apparently less effective in resolving constipation [85–87]. This could indicate that in constipation the bowel wall is inert and less prone to respond to stimuli with propulsive activity, as has been shown previously [88]. Nevertheless, scintigraphic studies have found that seven of eight patients with constipation had large antegrade segmental transport and significant emptying of the colon and rectum with antegrade colonic irrigation. This much more effective emptying suggests that antegrade colonic irrigation is, indeed, more efficient than transanal irrigation, where the initial flow of the irrigation fluid is opposite of the direction of the high-amplitude propagated contractions and the associated colonic mass movements. Support for this finding can be found in a study using a porcine model in which antegrade colonic irrigation was superior to retrograde colostomy irrigation [80] and in a small clinical study that has indicated that antegrade colonic irrigation outperforms retrograde stoma irrigation in improving stoma management and quality of life [81]. Thus, possible bowel inertia is most likely exceeded by antegrade colonic irrigation.

In the original description by Malone et al. it was suggested that a phosphate solution for antegrade colonic irrigation was optimal [89]. Other studies have advocated a variety of different irrigants [29, 31, 65, 90]. Alone or in combination, tap water, saline, phosphate, phosphosoda, polyethylene glycol, liquorice root solution, arachis oil, and antispasmodics before the enema have been individualized to each patient, but the use of these substances rests on limited scientific evidence. However, lessons from studies of colostomy irrigation ­provide some interesting perspectives.

In a porcine irrigation model, polyethylene glycol or 1.5 % glycine added to the irrigation fluid significantly enhanced colonic emptying compared with tap water, and colonic smooth muscle relaxation achieved by the addition of glyceryl trinitrate also improved evacuation [80]. A human study using glycerin suppositories to promote colostomy emptying failed, as expected, because of expulsion of the suppositories from the colostomy [91]. Another human study confirmed the superiority of a glyceryl trinitrate solution over tap water with respect to washout time and leakage rates, but side effects such as headaches and cramps might lower overall patient satisfaction with this approach [92]. It is likely that attendant smooth muscle relaxation allows more rapid entry of irrigation fluid into the colon and subsequent exit of the bowel effluent independent of colonic mass movements. Another human study found that polyethylene glycol (compared with tap water) significantly reduced washout times and resulted in fewer fecal leakage episodes, with higher satisfaction scores and a lower rate of use of stoma bags. In contrast, other human studies have failed to improve emptying by colostomy irrigation with the addition of bisacodyl, prostaglandin E₂ [93], prostaglandin F_2α [94], and foam enemas [95]. Further studies of different approaches to optimize colonic irrigation are needed.

Tepid tap water as an irrigation fluid [16, 40, 96, 97] is cheap, always available, and usually ensures an adequate bowel washout [65]. Avoiding overly chlorinated tap water and water that is undrinkable is advised. The volumes of tap water retained in the bowel after irrigation are normally too small to cause any significant disturbances in electrolytes, and it is unlikely that a hypo-osmolar irrigant causes any mucosal damage, making long-term use safe.

This has been confirmed in pediatric cases using tap water as an irrigation fluid, where plasma sodium values were within the normal range for all children [98], and in a case series of 71 pediatric patients using tap water for antegrade colonic enemas, where no significant electrolyte abnormalities were found during the first 8 months postoperatively [99]. The normal colon has an absorption potential of about 6 L per day [100], which results in quick absorption of any retained fluid. Under certain circumstances, however, caution is advised. From our daily practice it has been observed that patients who are only marginally dehydrated retain a relatively larger amount of irrigation fluid, resulting in less efficient evacuation after irrigation. With the use of tap water, the only effect of importance is insufficient irrigation, and a common adjustment to counteract this effect is to add phosphate or table salt to the enema. If the enema is still retained, the contribution of phosphate or sodium to the body may potentially cause hyperphosphatemia [101] or hypernatremia [102]. Caution also is advised when working with small children and fragile elderly patients, and in particular people with chronic renal failure [103].

The variety of treatment options for functional bowel problems reflects the heterogeneous background pathology and is an issue discussed extensively in this book. Few controlled trials have been performed, and treatment mainly is based on clinical experience or patient series with short follow-up [104

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