title: Long-term functional assessment of antegrade colonic enema for combined incontinence and constipation using a modified Marsh and Kiff technique.
abstract: OBJECTIVE
  Constipation and fecal incontinence can severely affect quality of life for patients, particularly when simultaneously present. Malone antegrade colonic enema enables periodic colonic emptying, thus preventing uncontrolled passage of feces and constipation.
  
  
  METHODS
  Eleven patients with fecal incontinence and severe constipation or perineal colostomy after Miles' operation underwent a modified Marsh and Kiff ileostomy for antegrade colonic enema. Before and after surgery, the patients were fully evaluated for gastrointestinal functions, including gallbladder and stomach emptying time, H(2)-breath test, colonic transit time, dynamic defecography, and anorectal manometry. The severity of incontinence and constipation was scored preoperatively and postoperatively by using the American Medical System score and Cleveland Clinic Constipation scale, respectively, whereas the quality of life was measured by the Gastrointestinal Quality of Life Index. The surgical technique involved division of the terminal ileum 10 to 15 cm from the ileocecal valve, anastomosis and intussusception of the ileum with the cecum, narrowing of the ileal conduit with a linear stapler, and a small, introflexed ileostomy with an advanced skin flap.
  
  
  RESULTS
  During the postoperative period, the mean American Medical System score decreased significantly from 77 to 11 (P<0.01) and the mean Cleveland Clinic Constipation score from 23 to 8.5 (P<0.01) with a significant improvement of quality of life. Antegrade colonic enema did not affect gallbladder, gastric, or orocecal transit time, which remained comparable with baseline. Colonic scintigraphy showed that antegrade colonic enema was efficient to clean the whole colon and rectum, leaving only 24 (range, 6-40) percent of the initial radioactivity after 30 minutes. Ileal manometry confirmed the presence of a high-pressure zone, preventing accidental reflux.
  
  
  CONCLUSIONS
  Modified Marsh and Kiff technique is a safe and effective surgical option to treat patients with combined fecal incontinence and severe constipation and those with perineal colostomy after Miles. It should be recommended as a last option before colostomy.
authors.affiliation: Department of Emergency and Organ Transplantation, General Surgery and Liver Transplantation Unit, University of Bari, piazza G Cesare, 11-70124, Bari, and Department of Surgical Unit, Ospedale Moscati, Avellino, Italy. altomare@clichiru.uniba.it
authors.forename: Donato F
authors.initials: DF
authors.lastname: Altomare
authors.forename: Marcella
authors.initials: M
authors.lastname: Rinaldi
authors.forename: Domenico
authors.initials: D
authors.lastname: Rubini
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Rubini
authors.forename: Piero
authors.initials: P
authors.lastname: Portincasa
authors.forename: Michele
authors.initials: M
authors.lastname: Vacca
authors.forename: Niccoli-Asabella
authors.initials: NA
authors.lastname: Artor
authors.forename: Giovanni
authors.initials: G
authors.lastname: Romano
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Memeo
mesh_terms: D000328:Adult; D000368:Aged; D003106:Colon; D003125:Colostomy; D003248:Constipation / Q000150:complications / Q000503:physiopathology / Q000628:therapy; D003672:Defecation / Q000502:physiology*; D004733:Enema / Q000379:methods*; D005242:Fecal Incontinence / Q000150:complications / Q000503:physiopathology / Q000628:therapy; D005260:Female; D005500:Follow-Up Studies; D016473:Gallbladder Emptying / Q000502:physiology*; D005746:Gastric Emptying / Q000502:physiology*; D005772:Gastrointestinal Transit / Q000502:physiology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011312:Pressure; D020127:Recovery of Function; D013997:Time Factors; D016896:Treatment Outcome