Trans-anal irrigation therapy to treat adult chronic functional constipation: systematic review and meta-analysis

Abstract

BackgroundTrans-anal irrigation (TAI) is used widely to treat bowel dysfunction, although evidence for its use in adult chronic functional constipation remains unclear. Long-term outcome data are lacking, and the effectiveness of therapy in this patient group is not definitively known.MethodsEvidence for effectiveness and safety was reviewed and the quality of studies was assessed. Primary research articles of patients with chronic functional constipation, treated with TAI as outpatients and published in English in indexed journals were eligible. Searching included major bibliographical databases and search terms: bowel dysfunction, defecation, constipation and irrigation. Fixed- and random-effect meta-analyses were performed.ResultsSeven eligible uncontrolled studies, including 254 patients, of retrospective or prospective design were identified. The definition of treatment response varied and was investigator-determined. The fixed-effect pooled response rate (the proportion of patients with a positive outcome based on investigator-reported response for each study) was 50.4 % (95 % CI: 44.3–56.5 %) but featured substantial heterogeneity (I2 = 67.1 %). A random-effects estimate was similar: 50.9 % (95 % CI: 39.4–62.3 %). Adverse events were inconsistently reported but were commonplace and minor.ConclusionsThe reported success rate of irrigation for functional constipation is about 50 %, comparable to or better than the response seen in trials of pharmacological therapies. TAI is a safe treatment benefitting some patients with functional constipation, which is a chronic refractory condition. However findings for TAI vary, possibly due to varying methodology and context. Well-designed prospective trials are required to improve the current weak evidence base.

European society of neurogastroenterology and motility guidelines on functional constipation in adults

“…Transanal irrigation using commercially available kits is being increasingly used for the management of bowel dysfunction, including FC. A systematic review and meta‐analysis of the available uncontrolled studies in FC suggested a 50% response rate, which is comparable to that obtained with pharmacological agents . Theoretically, this technique could lead to perforation, but a separate study addressing this possibility has suggested this risk is very low .…”

Predictive factors for compliance with transanal irrigation for the treatment of defecation disorders

“…Studies on adults with defecation disorders of mixed etiology have reported variable response rates to TAI[ 5 ]. The proportion of patients with a positive outcome with TAI ranges from 30%[ 16 ] to 78%[ 17 ].…”

“…TAI was first introduced into clinical practice by Shandling and Gilmour for children with neurogenic bowel dysfunction (NBD) related to spina bifida[ 3 ]. Based on its clinical efficacy in treating children with NBD, TAI was then applied to adults with NBD[ 4 ] and to children and adults with functional bowel disorders for whom traditional treatments had failed[ 5 ]. While short-term trials indicated that constipation and FI are significantly improved by TAI, compliance is difficult to maintain over time[ 6 , 7 ].…”

Anatomy, physiology, and updates on the clinical management of constipation

“…Patients with refractory constipation (unresponsive to various therapeutic options) can respond to trans-anal irrigation, which involves the introduction of water (70-1,000 mL) into the rectum and sigmoid colon. The response rates are significant (30-65%), so this can be used effectively as a conservative option before considering invasive treatments (Emmett, Close, Yiannakou, & Mason, 2015;Wilkinson-Smith et al, 2018). Indeed, surgery is a last resort and is reserved for only a small number of unresponsive patients, as it can cause more harm than good and will not guarantee restoration of neuromuscular function (Wilkinson-Smith et al, 2018).…”