Anastomotic leakage in colorectal surgery is a very important issue. Although many studies have shown the positive effects of enteral glutamine Gln on anastomotic healing, none has assessed the effects of administering Gln via an enema for anastomotic healing. To fill this study gap, this study investigated the intraluminal effect of administration of Gln enema on the healing of colonic anastomosis in a rat model. Thirty Wistar albino rats were divided into three groups containing 10 rats each and were subjected to distal left colon transection and anastomosis. After sacrifice on postoperative day 5, anastomotic healing, burst pressure, tissue hydroxyproline levels, and histological parameters were measured, and group values were compared via statistical analysis.
This shows up on an X-ray to give clear images of the bowels. Bristol Stool Scale. As the current study was the first to investigate the effects of the administration of a Gln Celeb navels on anastomotic healing in an Wet enemas model of colon anastomosis, the findings presented here are important. Wet enemas far as I can tell, doctors who issue this warning to parents have no actual experience with enemas. Effect of glutamine on protein synthesis in isolated intestinal epithelial cells. A: No, despite warnings from WebMD Wett the contrary. Thirty male Wistar albino rats were divided into three groups containing 10 rats each and were subjected to distal left colon transection and anastomosis. Brasken P.
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An enema is a great way to stimulate a bowel movement.
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But in another regard my experience has been the polar opposite of Dr. Today, doctors freak out. Is there merit to these warnings? In a word: no. As I detail in The M.
Book : Anthology Edition , enemas are safe for children as long as 1. She was legendary. Once he discovered his regimen was effective a story I tell in The M. Book: Anthology Edition , he asked the local pediatricians to send him their bedwetting patients. Of course, Dr. I urge you to share this post with medical professionals who doubt the safety of enemas for children. Now, on to the questions! Q: Can enemas cause electrolyte imbalance?
Ask your doctor. The concern about electrolytes pertains to over-the-counter pediatric enemas that contain phosphate, an electrolyte that draws water into the colon. Electrolytes are substances in the blood — including sodium, potassium, calcium, and magnesium — that perform critical jobs such as regulating our nerve and muscle function, our hydration level, and our blood pressure. Certainly an electrolyte imbalance is a big deal, potentially causing damage to the kidneys and heart, even death.
But this does not happen in healthy children who are limited to one enema per day. How, in theory, could enemas cause an electrolyte imbalance? Well, when a child is given an enema containing phosphate, the colon absorbs this electrolyte; if the colon absorbs too much, the child could end up with a dangerously high phosphate level. But the human body does an excellent job of controlling our electrolyte levels! A child with normal kidney function will simply pee out the extra phosphate.
Any increase will be negligible. Complications from enemas are so uncommon that a review of 39 studies conducted over 50 years found a total of only 15 cases of electrolyte imbalance in children ages 3 through Over 50 years. The vast majority of these cases involved children who had a chronic disease or were given more than one enema in a day. I have never had a patient develop an electrolyte imbalance from enemas.
Nonetheless, if you or your doctor remain concerned about electrolyte imbalance, you can do M. These work well for many children and have no chance of interfering with electrolyte levels. Or, you can purchase an enema bag and tubing and use saline solution, a much less expensive option that also poses zero chance of causing an electrolyte imbalance.
I discuss various options in The M. Be sure you read the book carefully. I did hear from one mom who accidentally gave her child twice the recommended dose of Pedia-Lax phosphate enema solution for a few days because she confused phosphate enemas with pure saline enemas.
In some children, the regular M. The child who got the extra phosphate did not suffer any consequences, but the advice remains: Do not give a child more than the recommended dose of a phosphate enema. Q: Will children on M. A: No, despite warnings from WebMD to the contrary. In such cases, your bowel may stop working normally and you may have ongoing constipation.
For most people with occasional constipation, a bulk-forming laxative such as psyllium or a stool softener such as doscusate is a better and safer product. I have no idea if WebMD is sponsored by the makers of oral laxatives or if the unnamed person who wrote this paragraph has ties to products in competition with enemas. Daily enemas clear out the rectum, giving it a chance to regain the sensation and strength to empty fully and regularly.
Once that happens, the child will no longer need enemas. One of the goals for a child on M. Once the rectum bounces back, your child will be able to poop without enemas. For occasional constipation, oral laxatives are fine, and for children on M.
Is Miralax poisoning children? I discuss here. However, as my research clearly indicates, osmotic laxatives are a dramatically inferior treatment for any child constipated enough to have accidents. Q: Can daily enemas damage the sphincter? A: No! Think about it: An enema tip is around the diameter of a pencil. The stool of a constipated child is as wide as a jumbo sausage!
Yes, stool is softer than plastic, but the sphincter of a constipated child is plenty accustomed to stretching wider than it does when you insert an enema. In fact, pointing this out to children is a great way to ease any fear they might have of having an enema. Q: Can daily enemas damage the intestinal mucosa? A: The mucosa is the inner lining of the colon, and in a small minority of children, phosphate enemas can irritate this lining, a condition called colitis.
If your child feels internal burning with phosphate enemas this is different from discomfort upon inserting the nozzle , I recommend switching to a different type of enema. I have never treated a child who developed colitis from enemas, but I have spoken to other doctors who have, and I do watch for signs. Q: How long is it OK to maintain daily enemas?
A: This is usually not an issue, as bedwetting and accidents typically resolve after the day M. These children need to keep going with daily enemas. I do not advise tapering to every other day until a child has five to seven completely dry days and nights. But when a child shows little to no improvement — it happens, unfortunately — I advise moving on to M.
In The M. Book , I explain what constitutes "progress" and when to move on. Either way, parents should not be concerned that continuing with daily enemas well past 30 days is unsafe.
My concern is that it can be ineffective. There is always a next step to try. Q: Will daily enemas traumatize children? No studies have considered whether a regimen such as M. As far as I can tell, doctors who issue this warning to parents have no actual experience with enemas. Certainly many parents and children are apprehensive, if not downright afraid, when they start doing enemas. Mostly they fear enemas will hurt, and sometimes they do hurt. For most families, enemas quickly become routine, even something to look forward to.
He was constipated and had stomach aches for over 2 years with nothing else helping. Now he's going on his own, dry and clean all day and no tummy aches. Does she want them to end one day? But she is perfectly content because she has seen how getting them helps. And it helped her to be comfortable pooping at school because she can feel the urge now. Yet another mom posted that it was oral drugs, like Miralax, that caused her daughter distress. My daughter loves her enemas! I hear stories like this all the time.
Yet many doctors simply refuse to believe children are fine with enemas. No one likes them. Indeed, M. Chronic constipation in children is a notoriously stubborn problem, and in my experience, aggressive treatment is the only kind of treatment worth doing.
Get Dr. Hodges' updated recommendations for treating bedwetting and accidents! Must-read books for kids by Steve Hodges, M. September 20, September 3, June 4, April 16, April 11, February 5, January 17, December 19, December 11, November 9,
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How to Give Yourself an Enema | Tummy Temple | Colonics & Naturopathy
Anastomotic leakage in colorectal surgery is a very important issue. Although many studies have shown the positive effects of enteral glutamine Gln on anastomotic healing, none has assessed the effects of administering Gln via an enema for anastomotic healing. To fill this study gap, this study investigated the intraluminal effect of administration of Gln enema on the healing of colonic anastomosis in a rat model.
Thirty Wistar albino rats were divided into three groups containing 10 rats each and were subjected to distal left colon transection and anastomosis. After sacrifice on postoperative day 5, anastomotic healing, burst pressure, tissue hydroxyproline levels, and histological parameters were measured, and group values were compared via statistical analysis. Group III was found to have the highest mean bursting pressure and tissue hydroxyproline levels and the lowest mean ischemia score.
While the values of these parameters were not found to differ significantly among the groups, the lack of significance may have been due to the limited number of subjects examined. Administration of a Gln enema may have a positive effect on anastomosis in terms of bursting pressure and histopathological parameters. Future research should examine administration of a preoperative Gln enema as a means of decreasing the traumatic effects of the enema and identifying its applicability in surgical practice.
Every year, thousands of intestinal anastomosis surgeries are performed worldwide. Despite developments over the last 50 years, anastomotic complications remain the major complications of gastrointestinal anastomosis, and the procedure continues to pose the risk of morbidity and mortality [ 2 ]. Surgeons are very concerned with this high leakage rate and the morbidity and mortality associated with it. As even the most experienced and technically proficient surgeons may confront leakage, development of specific technical applications and pharmacological agents for better anastomotic healing and reduction in leakage has been a major research topic in contemporary surgery.
Glutamine Gln is the most abundant amino acid in the plasma and the free amino acid pool of the body [ 5 ]. While considered a nonessential amino acid under normal circumstances, Gln is considered essential during periods of severe disease and malnutrition [ 6 ]. When the intracellular concentration of Gln is reduced during surgery, trauma, sepsis, and other severe conditions, body stores are rapidly depleted [ 7 , 8 ].
With its trophic effects on the intestinal mucosa and mitigation effect on permeability, Gln is indispensable for the maintenance of intestinal metabolism and function [ 9 , 10 ].
Based on these findings, administration of oral Gln or glutamic acid has been recommended as a means of supporting the basal membrane after bowel surgery and reducing the side effects of bowel surgery [ 10 ]. Perioperative Gln support has been reported to increase anastomosis durability by improving epithelial integrity via increasing the amount of mature collagen and accelerating healing [ 5 , 11 , 12 , 13 , 14 ].
In a colitis model, prophylactic use of topical Gln was shown to reduce colonic inflammation [ 15 , 16 ]. Supporting this finding, Wischmeyer et al. Administration of a Gln enema has been shown to have positive effects on mucosal healing in inflammatory bowel disease and chronic pouchitis. However, to our knowledge, no study has evaluated the effects of Gln enema on anastomotic healing.
To fill this study gap, we investigated the effects of administration of a Gln enema on anastomotic healing in an animal model. Permission to conduct the study was obtained from the Akdeniz University Animal Research Ethics Committee, and all procedures were conducted in accordance with the Code of Ethics of the World Medical Association Declaration of Helsinki for experiments involving animals.
Thirty male Wistar albino rats were divided into three groups containing 10 rats each and were subjected to distal left colon transection and anastomosis.
Postoperatively, group I the control group was administered no treatment, group II was administered 2 mL of physiological saline via an enema i.
Surgery was performed under nonsterile, but clean, conditions between 9 AM and 12 AM to avoid the effects of diurnal changes. All surgeries were performed by a single surgeon blind to the subjects' grouping. Oral intake was resumed 6 hours postsurgery. Every day from postoperative day 1, all subjects in groups II and III were administered an enema every 12 hours.
Under ether anesthesia, an 8-French feeding tube lubricated with After infusion the rats were maintained in an inverted position for 30 seconds to ensure uniform distribution of the liquid. After sacrifice on postoperative day 5, the abdomen was reopened, and the segment of anastomosis was located. While adhesions were protected to prevent damage to the anastomosis, abscesses, anastomotic separations, and leakages were carefully identified and examined.
The pressure level at the time of fluid leakage or the pressure level at which a sudden pressure drop occurred, as measured on the monitor, was recorded as the anastomotic bursting pressure. After the bursting pressure had been measured 1 cm proximal and 1 cm distal to the anastomosis, the colon segment was resected and divided into two equal parts passing through the anastomosis. The rats were subsequently sacrificed by using the intracardiac blood collection method.
Working material was obtained by centrifuging the resulting solution for 20 minutes at 5, rpm. The myeloperoxidase MPO level was measured in accordance with the method proposed by Grisham et al. After mg of intestinal mucosa had been homogenized with the addition of 5 mL of cold 0. The resulting pellet was dissolved in a phosphate buffer of 0. MPO determination was spectrophotometrically determined at a wavelength of nm for the supernatant.
In accordance with the method proposed by Erel [ 19 ], total antioxidant status TAS was determined by using automatic measurement methods with 2,2'-Azino-bis 3-ethylbenzothiazolinesulfonic acid. Determination of total oxidant status TOS was based on measurement of the oxidation of ferrous ion-o-dianisidine complex to ferric iron in the oxidants present in the sample by using a spectrophotometric measurement [ 20 ].
The advanced oxidation protein product AOPP level was measured by using the spectrophotometric method described by Witko-Sarsat et al. Sections of 4. The scale hat that includes many factors associated with wound healing described by Biert et al.
The results of the analysis of the bursting pressure and the tissue hydroxyproline level by using the Shapiro-Wilks test showed a normal distribution. Nonparametric measurements and comparisons of the three groups in terms of pathology were performed by using the Kruskal-Wallis test. The Bonferroni-Dunn test was used as a post hoc test for significant conditions.
Analysis of variance was performed for comparisons of the three groups in situations where a normal distribution was assumed, and Tukey test was performed for pairwise comparisons. During the placement of instruments to measure the burst pressure, one subject in group I and two subjects in group II experienced separation of the anastomosis. These subjects were, therefore, excluded from the determination of the anastomosis bursting pressure. Analysis of the remaining subjects indicated that anesthesia and surgical treatment were not associated with mortality in any subject and that bursts had resulted from the anastomosis in all subjects.
Evaluation of the burst pressure measurements showed a normal distribution. In accordance with these results, we concluded that administration of a Gln enema was not statistically significantly associated with the colonic anastomosis bursting pressure. The results of comparisons of the biochemical measurements are shown in Table 2. The results of a post hoc analysis binary comparison of the comparative data obtained by biochemical measurements and identification of significant differences among the groups are shown in Table 3.
As can be observed, the results of three tests of independent group differences indicated that the TAS, TOS, and MPO levels of at least one group were significantly different from those of the other groups. Based on these data, we concluded that administration of a Gln enema has no statistically significant effect on the colonic anastomosis model in terms of tissue hydroxyproline levels.
Tissues taken from the perianastomotic section were histopathologically examined for scoring of mucosal ischemia, anastomotic wound healing, granulation tissue formation, and histological changes in local inflammatory response according to the criteria described by Biert et al.
The results of comparison of the scores of the groups are shown in Table 4. Surgical resection and primary anastomosis are standard treatments for colorectal cancer and benign diseases such as diverticulitis and ulcerative colitis.
Anastomotic leaks cause morbidity, mortality, and an increase in the permanent stoma rate while contributing to recurrent malignant disease [ 24 ]. In consideration of these negative outcomes, development of technical applications and pharmacological agents that can increase anastomotic healing and reduce the leakage rate has been a primary focus of basic surgical research.
Although different pharmaceutical agents, including ileoprost, tacrolimus, eritroprotein, growth hormone, hyperbaric oxygen, and inhibitors of matrix metallaproteinaz, have been examined in experimental studies, none has been found superior in promoting anastomotic healing [ 25 ]. Gln, the most commonly found amino acid in the body, plays an important role in many metabolic reactions [ 5 ].
As such, Gln has become the one of the most-researched nutrients in the field of nutrition and a primary focus of metabolic support studies [ 26 ]. Surgery, trauma, sepsis, and other serious conditions decrease the concentration of the intracellular Gln pool, thus rapidly depleting body stores [ 7 , 8 ]. Although Gln depletion is inevitable in such conditions, replacement can improve nitrogen balance and immunosupression [ 27 ].
Gln is a preferred respiratory fuel for rapidly dividing cells such as fibroblasts, lymphocytes, and epithelial cells, as well as intestinal mucosa cells [ 28 ]. High-speed intake of Gln by these rapidly dividing cells provides ideal conditions for the synthesis of important molecules such as glutathione and nucleotides [ 29 ].
In addition, prolin, one of the products of Gln metabolism, is required for the production of collagen [ 5 , 30 ]. Based on such findings, Gln has been hypothesized to prevent bacterial translocation that can lead to septicemia and multiple organ failure by helping protect the integrity of the intestinal tract [ 32 , 33 ]. Gln not only also initiates the synthesis of glutathione, a major antioxidant that protects against free radical damage, but may also play a role in preventing tissue damage after shock and postischemic reperfusion [ 34 ].
In addition to serving as an effective barrier helping protect the intestine through improving its defense capacity, Gln facilitates the most appropriate immune defenses via several mechanisms. When the plasma Gln level is low, the T-lymphocyte level is suppressed [ 35 ], the neutrophil bactericidal function is impaired [ 36 ], and the macrophage phagocytic activity and the interleukin-1 production are decreased [ 37 ]. Many studies have examined the effect of Gln provision alone on anastomotic healing.
In an evaluation of the effects of oral Gln on colon anastomosis, Da Costa et al. Other experimental studies have examined the effects of Gln provision, together with that of other agents, on anastomosis.
Among them, Girgin et al. In a study use of Gln with symbiotics, Sapidis et al. In a study of the intra-abdominal sepsis model, Donmez et al. In an examination of the effects of topical use of Gln in a colitis model, Israeli et al.
In an experimental colitis model, Kaya et al. Wischmeyer et al. Use of an enema, the process of administering liquid into the rectum and colon through the anus for medical reasons, was first mentioned in the Ebers Papyrus in BC [ 42 ].
Common current uses of enemas include constipation relief, preoperative bowel preparation, administration of postoperative analgesia in children, and treatments for inflammatory bowel disease, radiation proctitis, pouchitis, and solitary rectal ulcers [ 43 ].
Although the literature identifies few possible adverse effects of an enema, it is known to have potentially life-threatening side effects, depending on the patient's position during enema application. These effects include perforation by the tip of the enema device, localized weakness of the rectal wall, and obstruction [ 44 ].
In practice, surgeons attempt to avoid using an enema to prevent trauma in the anastomosis area. To the authors' knowledge, no study before ours has examined the effects of enema administration after an anastomosis on healing. However, several studies have studied the other effects of enema administration.
In a study of anastomotic integrity after a rectal anastomosis in which a contrast enema was administered an average of 6—8 days after the anastomosis, Shorthous et al. The healing of an intestinal anastomosis can be considered a mechanical, biochemical, or histopathological process [ 46 ]. Among all parameters, the bursting pressure is considered a relatively accurate indication of anastomotic healing pathophysiology in the early period [ 47 ].
In accordance, studies examining the effects of both Gln alone and the addition of Gln to specialized forms of nutrition on anastomotic healing, have shown that it has positive effects on the bursting pressure [ 12 , 14 ].
Based on their findings, De Costa et al.