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 (pairedt-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 watervs. 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 watervs. 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, andP=0.002, respectively) and had returned to baseline by 240 minutes (P=0.52,P=0.08, andP=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.Austin O'Bichere is supported by a grant from St. Mark's Hospital/Northwick Park Institute for Medical Research and Dansac Limited. Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Boston, Massachusetts, June 24 to 29, 2000.     

Biofeedback therapy for rectal intussusception

Background Surgery for isolated internal rectal intussusception is controversial due to high morbidity. Therefore, there is interest in other forms of treatment that are safe and effective. The aim of this study was to determine outcome and identify predictors for success of biofeedback therapy in patients with rectal intussusception. Methods We retrospectively evaluated the results of electromyography (EMG)–based biofeedback in 34 patients with rectal intussusception without any other major pelvic floor or colonic physiologic disorder. Results A total of 34 patients (7 men) had undergone at least 2 biofeedback sessions. The patients had a mean age of 68.5 years (SD=11.4 years). In the 27 patients with constipation, the frequency of weekly spontaneous bowel movements (mean±SD) was 2.0±6.8 before and 4.1±4.6 after biofeedback (p<0.05). The frequency of weekly assisted bowel movements decreased from 3.8±3.5 before to 1.5±2.2 after therapy (p<0.005). The number of patients who experienced incomplete evacuation decreased from 17 (63%) to 9 (33%) (p<0.05). Thirty–three percent of patients had complete resolution of the symptoms, 19% had partial improvement, and 48% had no improvement. Patients with constipation lasting less than nine years had a 78% success rate vs. 13% in patients who were consti– pated more than 9 years (p<0.01). In seven patients with incontinence, the frequency of daily incontinence episodes decreased from 1.0±0.7 before to 0.07±0.06 after biofeedback (p<0.05). The fecal incontinence score decreased from 13.1±4.2 before to 4.6±3.6 after treatment (p<0.005). Two patients (29%) were completely continent following biofeedback, 2 had partial improvement, and 3 (43%) had no significant improvement. There was no mortality in either group. Conclusions Biofeedback is a safe and effective treatment option for constipation and fecal incontinence due to rectal intussusception in patients who are willing to complete the course of treatment. Long–standing constipation is less effectively cured by biofeedback.     

Biofeedback training in patients with fecal incontinence

PURPOSE: This study was undertaken to assess the functional results of biofeedback training in patients with fecal incontinence in relation to clinical presentation and anorectal manometry results. METHODS: Twenty-six consecutive patients with fecal incontinence were treated with biofeedback training using anorectal manometry pressure for visual feedback. Ten patients had passive incontinence only, six patients had urge incontinence, and ten patients had combined passive and urge incontinence. RESULTS: Patients with urge incontinence had a lower maximum voluntary contraction pressure (92 ± 12 mmHg) and lower maximum tolerable volume (78 ± 13 ml) than patients with passive incontinence (140 ± 43 mmHg and 166 ± 73 ml). Twenty-two patients completed the treatment, five patients (23 percent) showed excellent improvement, nine patients (41 percent) had good results, and eight (36 percent) patients showed no improvement. At follow-up on average of 21 months after therapy, 41 percent of our patients reported continued improvement. The maximum tolerable volume was higher in those with excellent (140.4 ± 6.8 ml) or good (156.3 ± 6.64 ml) results of therapy than it was in those with poor results (88.5 ± 2.5 ml). Greater asymmetry of the anal sphincter also correlated to poor results. CONCLUSION: Biofeedback therapy improved continence immediately after training and at follow-up after 21 months, but the initial results were better. The urge fecal incontinence seems to be related to function of the external anal sphincter and to the maximum tolerable volume. Low maximum tolerable volume and anal sphincter asymmetry were associated with a poor outcome of therapy     

造口治疗师连续护理干预在永久性肠造口患者中的应用

目的总结本科造口治疗师对永久性肠造口患者实施连续护理干预的经验。 方法由具有获世界造口治疗师协会认可的执业资格证书的造口治疗师全职负责,对永久性肠造口患者实施全程连续性的护理干预。包括：术前宣教、造口定位、造口志愿者探访及术前心理辅导,术后造口观察和评估、术后心理护理、指导患者掌握造口护理知识,指导和协助选择造口袋,术后宣教及出院指导,造口并发症的预防和处理,定期组织造口联谊会,电话随访、咨询等护理干预措施。 结果有效地预防和治疗了造口并发症,提高了造口人的生活质量。 结论造口治疗师连续护理干预为肠造口患者提供专业化和延续性的护理服务,值得推广应用。     

Long-term results of electromyographic biofeedback training for fecal incontinence

PURPOSE: The aim of this study was to examine the long-term results of electromyographic biofeedback training in fecal incontinence. METHODS: Thirty-seven patients (1 male) received a customised program of 2 to 11 (median, 3) biofeedback training sessions with an anal plug electromyometer. Nine patients had persistent incontinence after anal sphincter repair, a further 8 patients had postsurgical or partial obstetric damage of the sphincter but no sphincter repair, 9 patients had neurogenic sphincter damage, and 11 patients were classified as having idiopathic fecal incontinence. Duration of voluntary sphincter contraction was measured by anal electromyography (endurance score) before and after treatment. A postal questionnaire was used to investigate the following variables: 1) subjective rating on a four-grade Likert-scale of the overall result of the biofeedback training; 2) incontinence score (maximum score is 18, and 0 indicates no incontinence); and 3) rating of bowel dissatisfaction using a visual analog scale (0 to 10). RESULTS: Twenty-two patients (60 percent) rated the result as very good (n=8) or good (n=14) immediately after the treatment period. Median endurance score improved from 1 to 2 minutes (P<0.0001). Median incontinence score improved from 11 to 7, and bowel dissatisfaction rating improved from 5 to 2.8 (bothP<0.0001). After a median follow-up of 44 (range, 12–59) months, 15 patients (41 percent) still rated the overall result as very good (n=3) or good (n=12). The incontinence score did not change during follow-up. Median bowel dissatisfaction rating deteriorated from 2.8 to 4.2 but remained better than before treatment. Poor early subjective rating and the need for more than three biofeedback sessions were predictive of worsening during follow-up. CONCLUSION: We think it is encouraging that in this study biofeedback treatment for fecal incontinence with an intra-anal plug electrode resulted in a long-term success rate in nearly one-half of the patients.     

The efficacy of loop colostomy for complete fecal diversion

In an attempt to evaluate the real efficacy of loop colostomy for fecal diversion, the authors studied 62 patients previously colostomized under emergency conditions. Radiologic series of the abdomen were taken after 200 gm of barium meal. The results showed that the colostomy provided complete diversion of the radiologic contrast in 53 patients (85 percent) and incomplete diversion in nine patients (15 percent). Analysis of the results revealed that incomplete fecal diversion was: 1) observed as of the 86th postoperative day, with a significantly higher frequency following the 10th postoperative month, and 2) significantly correlated with either colostomy retraction or prolapse. The authors present a diagram showing a possible interaction of factors responsible for incomplete fecal diversion in loop colostomy and conclude that: 1) retraction is probably the basic contributing factor for colostomy failure; 2) the prolapse, once reduced, propitiates sinking of the stoma, facilitating colostomy failure; 3) the common assumption that loop colostomy eventually fails to provide complete fecal diversion is further supported; 4) loop colostomy assures, over its usual duration, a satisfactory defunctionalization of the colon; and 5) use of improved techniques of colostomy construction may prolong complete fecal diversion.     

Burn and stricture of the ostomy due to colostomy irrigation

A case of burn and stricture of the ostomy subsequent to colostomy irrigation is reported. heretofore, perforation has been the only serious complication noted. In this case, it was necessary to reconstruct the ostomy because of the development of postburn stricutre.     

Biofeedback/relaxation training and exercise interventions for fibromyalgia: A prospective trial

Objective. To compare the effectiveness of biofeedback/relaxation, exercise, and a combined program for the treatment of fibromyalgia. Methods. Subjects (n = 119) were randomly assigned to one of 4 groups: 1) biofeedback/relaxation training, 2) exercise training, 3) a combination treatment, or 4) an educational/attention control program. Results. All 3 treatment groups produced improvements in self-efficacy for function relative to the control condition. In addition, all treatment groups were significantly different from the control group on tender point index scores, reflecting a modest deterioration by the attention control group rather than improvements by the treatment groups. The exercise and combination groups also resulted in modest improvements on a physical activity measure. The combination group best maintained benefits across the 2-year period. Conclusion. This study demonstrates that these 3 treatment interventions result in improved self-efficacy for physical function which was best maintained by the combination group.     

An assessment of colostomy irrigation

One hundred patients with permanent sigmoid colostomies were surveyed to determine their satisfaction and success with the “irrigation” technique of colostomy management. Most patients who irrigate their colostomies achieve continence. Odors and skin irritations are minimized. The irrigation method is economical, time efficient, and allows a reasonably liberal diet. It avoids bulky appliances and is safe. In appropriately selected patients, the irrigation technique is the method of choice for management of an end-sigmoid colostomy.     

Closure of terminal and loop colostomy

The clinical course after closing of a temporary colostomy was studied in 56 patients, 26 with loop colostomy and 30 with terminal colostomy. No significant difference was found in the complication rate or hospital stay between the two groups. It is concluded that terminal colostomy is preferable, as a standard procedure, because it is more acceptable to the patient and gives a complete diversion of the fecal stream.     

Telephone vs. Face-to-Face Biofeedback for Fecal Incontinence: Comparison of Two Techniques in 239 Patients

PURPOSE Biofeedback is an effective treatment for patients with fecal incontinence, yet little is known about how it works or the minimum regime necessary to provide clinical benefit. This study compares the effectiveness of a novel protocol of telephone-assisted biofeedback treatment for patients living in rural and remote areas with the standard face-to-face protocol for patients with fecal incontinence. METHODS A new treatment program comprising an initial face-to-face assessment and treatment with transanal manometry and ultrasound biofeedback, followed by three treatments conducted via telephone and a final face-to-face assessment, was developed. Standard treatment involved five face-to-face treatment sessions with manometry and ultrasound. Patients from rural areas were offered the telephone-assisted treatment protocol. Data gathered prospectively included incontinence scores, a quality of life index, anal manometry, and external sphincter isometric and isotonic fatigue times. RESULTS A total of 239 consecutive patients treated between July 2001 and July 2004 were enrolled. There were no significant differences in demographic details, past history, or pretreatment measures of the two groups. Forty-six of 55 patients (84 percent) treated with the telephone protocol and 129 of 184 (70 percent) treated by the standard technique completed treatment. There were substantial, significant improvements after treatment, including 54 percent mean improvement in patient’s own rating of their incontinence in both groups; a mean decrease of 3.1 and 3.2 on the St. Mark’s incontinence score (from 7.9 to 4.7 and 7.4 to 4.2 of 13) and relative improvements of 128 and 130 percent in the quality of life index (from 0.29 to 0.65 and 0.3 to 0.69 of 1) for the telephone-assisted and standard groups respectively. Importantly, there were no significant differences between the telephone-assisted or standard groups in any outcome. Of patients who completed treatment, 78 percent were better or much better. CONCLUSIONS A less intensive regime of biofeedback seems to be equally effective as the standard intensive protocol. This finding adds weight to the evolving concept that the physical aspects of biofeedback treatment, such as manometry or ultrasound, may not be necessary in the treatment of most patients with fecal incontinence. This needs to be further tested in a randomized, controlled trial. Dr. Byrne was supported by the Notaras Fellowship from the University of Sydney and the Training Board of the Colorectal Surgical Society of Australasia. Reprints are not available.     

生物反馈治疗大便失禁的疗效评价

目的　评价生物反馈方法治疗大便失禁患者的疗效。方法　对 2 6例大便失禁患者进行生物反馈治疗 ,治疗前后分别做肛肠测压和肌电图检查 ,评价患者的肛门功能。结果　 2 6例患者肛管最大收缩压、收缩肌电振幅、持续收缩时间、直肠感觉阈值和感觉收缩时间治疗前、后均有显著差异 (P <0 .0 1)。结论　生物反馈治疗大便失禁有效     

Proximal end transverse colostomy in children

A method of end transverse colostomy which avoids colostomy prolapse in Hirschsprung's disease is described.     

Electrical Stimulation and Pelvic Floor Muscle Training With Biofeedback in Patients With Fecal Incontinence: A Cohort Study of 281 Patients

Purpose Pelvic floor rehabilitation is an appealing treatment for patients with fecal incontinence but reported results vary. This study was designed to assess the outcome of pelvic floor rehabilitation in a large series of consecutive patients with fecal incontinence caused by different etiologies. Methods A total of 281 patients (252 females) were included. Data about medical history, anal manometry, rectal capacity measurement, and endoanal sonography were collected. Subgroups of patients were defined by anal sphincter complex integrity, and nature and possible underlying causes of fecal incontinence. Subsequently patients were referred for pelvic floor rehabilitation, comprising nine sessions of electric stimulation and pelvic floor muscle training with biofeedback. Pelvic floor rehabilitation outcome was documented with Vaizey score, anal manometry, and rectal capacity measurement findings. Results Vaizey score improved from baseline in 143 of 239 patients (60 percent), remained unchanged in 56 patients (23 percent), and deteriorated in 40 patients (17 percent). Mean Vaizey score reduced with 3.2 points (P < 0.001). A Vaizey score reduction of ≥ 50 percent was observed in 32 patients (13 percent). Mean squeeze pressure (+5.1 mmHg; P = 0.04) and maximal tolerated volume (+11 ml; P = 0.01) improved from baseline. Resting pressure (P = 0.22), sensory threshold (P = 0.52), and urge sensation (P = 0.06) remained unchanged. Subgroup analyses did not show substantial differences in effects of pelvic floor rehabilitation between subgroups. Conclusions Pelvic floor rehabilitation leads overall to a modest improvement in severity of fecal incontinence, squeeze pressure, and maximal tolerated volume. Only in a few patients, a substantial improvement of the baseline Vaizey score was observed. Further studies are needed to identify patients who most likely will benefit from pelvic floor rehabilitation. Supported by grant 945-01-013 of the Netherlands Organization for Health Research and Development. Presented at the United European Gastroenterology Week, Copenhagen, Denmark, October 15 to October 19, 2005. Reprints are not available.     

The skin bridge loop colostomy

Loop colostomy formation commonly involves temporary support over a plastic bridge. We describe a technique of loop colostomy using a permanent skin bridge. By joining two inter-digitating skin flaps raised from the margins of the stoma, an adjustable bridge is formed that can accommodate colon loops of any diameter. In a series of twenty cases, our technique has been complication free and well tolerated by patients.     

Bio-feedback treatment of fecal incontinence： Where are we, and where are we going？

Fecal incontinence is a disabling disease, often observed in young subjects, that may have devastating psycho-social consequences. In the last years, numerous evidences have been reported on the efficacy of bio-feedback techniques for the treatment of this disorder. Overall, the literature data claim a success rate in more than 70% of cases in the short term. However, recent controlled trials have not confirmed this optimistic view, thus emphasizing the role of standard care. Nonetheless, many authors believe that this should be the first therapeutic approach for fecal incontinence due to the efficacy, lack of side-effects, and scarce invasiveness. Well-designed randomized, controlled trial are eagerly awaited to solve this therapeutic dilemma.     

Loop transverse colostomy

All large-bowel stomas (198) performed between 1970 and 1980 in a community hospital were reviewed. Twenty-nine stomas were loop transverse colostomies. There were five deaths, a complication rate related to the stoma of 28 per cent, and only 18 patients ever achieved colostomy closure. Our conclusions are as follows: (1) transverse colostomy is a holdover from the past; (2) “temporary” loop colostomy is a misnomer; (3) all colostomies should be end-bearing and matured primarily; (4) blind surgery invites tragedy; (5) loop transverse colostomy is a risky first stage with little benefit; (6) every colostomy should be placed as near as possible to the disease process; and (7) resection of the disease is the ideal first stage. Read at the meeting of the American Society of Colon and Rectal Surgeons, Colorado Springs, Colorado, June 7 to 11, 1981. This work was not supported by a fund or grant; it was done at St. Mary's Hospital and Medical Center, 450 Stanyan Street, San Francisco, California 94117.     

功能性便秘的生物反馈治疗

目的评价生物反馈方法治疗功能性便秘的疗效。方法对我院42例慢性功能性便秘患者进行生物反馈治疗,治疗前后进行临床评估、直肠和盆底肌电描记并进行对比分析。结果生物反馈治疗后患者临床症状改善,肌电图显示盆底肌和腹肌的矛盾运动消失,肛门外括约肌的收缩幅度有不同程度的增加,松弛幅度降低(P<0·05),总有效率为93%,改善伴随症状有效率70%,6个月随访复发率仅5·26%。结论生物反馈治疗功能性便秘有效。     

Biofeedback re-education of faecal continence in children

The purpose of this prospective study was to see if pretreatment anorectal motility can predict successful correction of faecal incontinence with biofeedback. Forty-seven consecutive children, aged 5 to 18 years, were treated. They had been treated for idiopathic constipation with faecal impaction, but had remained incontinent (n=15), had been operated for congenital anorectal malformations of high (n=19) or low (n=2) type, or had a number of organic congenital pelvic abnormalities (n=11). This consecutive series represents our entire experience with biofeedback for faecal incontinence, in the period from January 1 1983 to December 31 1989. In each patient, at the first session, anorectal manometry was performed. Resting pressures in the rectum, upper anal canal and lower anal canal were measured. The threshold of rectal sensation during distension, the maximal pressure during voluntary sphincteric contraction and the time to half decrease of sphineteric pressure because of muscular fatigue were also noted. The patient was then asked to make a voluntary sphincteric contraction, while the rectum was being distended with the volume at threshold for rectal sensation. In subsequent sessions, the rectum was also distended but without warning the patient, who was congratulated when he or she contracted the sphincter immediately after onset of rectal distension. Full continence was the criterion used to classify re-education as a success. Improvement or no change in continence was considered as failure of the treatment. Three parameters only improved after treatment: the threshold for rectal sensation which decreased (P<0.05), the maximal peak of voluntary contraction which increased (P<0.001), and the duration of this contraction which was prolonged (P<0.05). Patients who were to recover had, before treatment, lower threshold of rectal sensation (P<0.01), higher maximum voluntary contraction of the anal sphincter (P<0.05), and tended to have a higher resting tone in the anal canal (P=0.07). In addition, after biofeedback treatment, the decrease of threshold for rectal sensation (P<0.05), increase of maximal voluntary contraction (P<0.005) and maintained contractions (P<0.05) were more important in patients who became continent than in those who remained incontinent. Fifty per cent of the patients were cured from faecal incontinence by biofeed-back re-education. Success was much higher in patients initially seen for constipation and faecal incontinence (92%) than in the other patients (35%) (P<0.01). Patients with constipation had higher pressures in the upper anal canal, in addition to better voluntary contraction, and lower threshold of rectal sensation, both before and after treatment, than patients with other disorders. It is concluded that there is a correlation between cure from faecal incontinence and improvement in anorectal sensitive and dynamic parameters but that this may largely be due to the underlying disorder.

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Résumé Le but de cette étude prospective est de déterminer si l'examen de la motilité ano-rectale avant traitement permet de prédire le succès d'une rééducation par biofeedback de l'incontinence fécale. Une série consécutive de quarante-sept enfants âgés de 5 à 18 ans ont été traités. Ils avaient subi des traitements pour une constipation idiopathique avec impaction fécale mais étaient restés incontinents (n=15), avaient subi une correction chirurgicale pour une malformation ano-rectale congénitale haute (n=19) ou basse (n=2) ou étaient porteurs de plusieurs anomalies congénitales pelviennes (n=11). Cette série consécutive constitue la totalité de notre expérience de rééducation par biofeedback d'incontinences fécales durant la période allant du ler janvier 1983 au 31 décembre 1989. Une manométrie ano-rectale a été réalisée chez chaque patient lors de la première séance. La pression a été mesurée dans le rectum, la partie supérieure du canal anal et la partie inférieure du canal anal. Le seuil de perception au cours de la distension, la pression maximale durant la contraction volontaire et le temps pour entraîner une diminution de moitié de la pression sphinctérienne par fatigue musculaire ont été notés. Les patients ont réalisé une contraction volontaire sur demande alors que le rectum était distendu avec un volume correspondant au seuil de perception déterminé. Lors de séances successives, le rectum a été distendu sans prévenir le patient. Ce dernier a été félicité à chaque fois qu'il contractait son sphincter immédiatement après le début de la distension rectale. Seule une normalisation complète de la continence a été utilisée comme critère d'une rééducation efficace. Une amélioration ou une absence de changement dans la continence ont été considérées comme des échecs thérapeutiques. Seuls trois paramètres ont été améliorés par le traitement: le seuil de perception rectale a été abaissé (P<0,05), le pic de contraction volontaire est augmentée (P<0,001) et la durée de la contraction volontaire est prolongée (P<0,05). Les patients chez lesquels le traitement a été couronné de succès avaient avant celui-ci des seuils de sensation de la pression rectale abaissés (P<0,01), des pressions de contraction volontaire maximales du sphincter anal plus élevées (P<0,05) et avaient une tendance à avoir des pressions de repos du canal anal plus élevées (P=0,07). En plus, après traitement par biofeedback, la diminution du seuil de sensation rectale (P<0,05), l'augmentation de la pression de contraction volontaire (P<0,05) et le maintien d'une contraction (P<0,05) étaient plus importants chez les patients redevenus continents que chez ceux restant incontinents. 50% des patients ont été guéris de leur incontinence fécale par rééducation par biofeedback. Le succès était plus important chez les patients vus initialement pour constipation et incontinence fécale (92%) que chez les autres malades (35%) (P<0,01). Les patients avec une constipation présentaient des pressions plus élevées dans la partie haute du canal anal, une meilleure contraction volontaire et un seuil de perception rectale plus bas avant traitement et après traitement que les patients porteurs d'autres troubles. On conclut de cette étude qu'il y a une corrélation entre la guérison d'une incontinence fécale et l'amélioration des paramètres de sensibilité et dynamiques ano-rectaux mais que ceci dépend largement des troubles sous-jacents.