The value of the MACE (Malone antegrade colonic enema) procedure in adult patients

Review article: diagnosis, management and patient perspectives of the spectrum of constipation disorders

BACKGROUND

Chronic constipation is a common, heterogeneous disorder with multiple symptoms and pathophysiological mechanisms. Patients are often referred to a gastroenterology provider after laxatives fail. However, there is limited knowledge of the spectrum and management of constipation disorders.

AIM

To discuss the latest understanding of the spectrum of constipation disorders, tools for identifying a pathophysiologic-based diagnosis in the specialist setting, treatment options and the patient's perspective of constipation.

METHODS

Literature searches were conducted using PubMed for constipation diagnostic criteria, diagnostic tools and approved treatments. The authors provided insight from their own practices.

RESULTS

Clinical assessment, stool diaries and Rome IV diagnostic criteria can facilitate diagnosis, evaluate severity and distinguish between IBS with constipation, chronic idiopathic constipation and dyssynergic defecation. Novel smartphone applications can help track constipation symptoms. Rectal examinations, anorectal manometry and balloon expulsion, assessments of neuromuscular function with colonic transit time and colonic manometry can provide mechanistic understanding of underlying pathophysiology. Treatments include lifestyle and diet changes, biofeedback therapy and pharmacological agents. Several classes of laxatives, as well as prokinetic and prosecretory agents, are available; here we describe their mechanisms of action, efficacy and side effects.

CONCLUSIONS

Constipation includes multiple overlapping subtypes identifiable using detailed history, current diagnostic tools and smartphone applications. Recognition of individual subtype(s) could pave the way for optimal, evidence-based treatments by a gastroenterology provider.

The Malone antegrade continence enema adapting a transanal irrigation system in patients with neurogenic bowel dysfunction

INTRODUCTION

Patients with severe neurogenic bowel dysfunction (NBD) may undergo the Malone antegrade continence enema (MACE) surgery to perform antegrade bowel irrigation (ABI). The standard approach may be prevented by a previous appendectomy or complicated by appendicular stenoses and/or stomal leakages. We present the experience by our tertiary referral center for NBD, adopting a modified surgical technique, based on a neoappendix with the terminal ileum to preserve the natural anti-reflux mechanism of the ileocecal valve and avoid stool leakage, and a largely available transanal irrigation (TAI) system to catheterize the neoappendix and perform ABI.

CASE PRESENTATION

Three individuals with NBD successfully underwent our modified MACE program. Case 1 had cauda equina syndrome. He underwent surgery at 40. Case 2 was a man who suffered from spinal cord dysfunction due to acute disseminated encephalomyelitis, functionally T12 AIS B, at 57. Case 3 was a man with traumatic L1 AIS B paraplegia. At 60 he underwent surgery after 29 years since the injury. He needed a surgical revision due to a postoperative subcutaneous infection. After 121, 84 and 14 months from surgery, the three individuals performed ABI every 2 days, presented functional stomas, had no fecal incontinence, and reported an NBD score of 6, compared to 40, 33 and 35 pre-operatively.

DISCUSSION

To our knowledge, this is the first report of MACE combining a tapered terminal ileum conduit and an adapted TAI system. Our approach proved to be a safe and effective strategy for severe NBD avoiding a colostomy.

[The paraplegic patient-Characteristics of diagnostics and treatment in visceral surgery]

BACKGROUND

Patients with paraplegia develop syndrome-specific complications relevant to visceral surgery, which occur in the context of the acute spinal shock or as a consequence of the progressive neurogenic bowel dysfunction (NBD) with the formation of an elongated colon and/or megacolon. Moreover, acute abdominal emergencies, such as acute appendicitis, cholecystitis, diverticulitis and ileus images, pose particular challenges for the clinician when the clinical signs are atypical or even absent. The expansion of indications for obesity surgery to include patients with a paraplegic syndrome, whose independence and quality of life can be impaired due to the restricted mobility, especially by obesity, is becoming increasingly more important.

OBJECTIVE

This article provides an overview of the special requirements and aspects in the treatment of this special patient collective and to show the evidence of paraplegia-specific visceral surgery treatment.

MATERIAL AND METHODS

Targeted literature search in Medline and Cochrane library (German and English, 1985-2020).

RESULTS AND CONCLUSION

The clinical treatment of paraplegic patients requires in-depth knowledge of the pathophysiological changes at the different height of the paraplegia (upper versus lower motor neuron) and the phase of the disease (spinal shock versus long-term course). Missing or atypical clinical symptoms of acute diseases delay a quick diagnosis and make early diagnosis essential. The evidence for surgical treatment of the acute and chronic consequences of NBD is based on small retrospective series and case reports, as is that for special indications such as obesity surgery.

Japanese Practice Guidelines for Fecal Incontinence Part 3 -Surgical Treatment for Fecal Incontinence, Fecal Incontinence in a Special Conditions- English Version

In Japan, the surgical treatment for fecal incontinence (FI) can be performed using minimally invasive surgery, such as anal sphincteroplasty and sacral neuromodulation (SNM), as well as antegrade continence enema (ACE), graciloplasty, and stoma construction. In addition, currently, several other procedures, including biomaterial injection therapy, artificial bowel sphincter (ABS), and magnetic anal sphincter (MAS), are unavailable in Japan but are performed in Western countries. The evidence level of surgical treatment for FI is generally low, except for novel procedures, such as SNM, which was covered by health insurance in Japan since 2014. Although the surgical treatment algorithm for FI has been chronologically modified, it should be sequentially selected, starting from the most minimally invasive procedure, as FI is a benign condition. Injuries to the neural system or spinal cord often cause disorders of the sensory and motor nerves that innervate the anus, rectum, and pelvic floor, leading to the difficulty in controlling bowel movement or FI and/or constipation. FI and constipation are closely associated; when one improves, the other tends to deteriorate. Patients with severe cognitive impairment may present with active soiling, referred to as "incontinence" episodes that occur as a consequence of abnormal behavior, and may also experience passive soiling.

Neurogenic bowel dysfunction

The symptoms of neurogenic bowel dysfunction (NBD) comprise constipation and fecal incontinence. These have a major impact on quality of life and dignity. Bowel symptoms occur in the majority of patients with chronic neurological diseases like multiple sclerosis, spinal cord injury, and Parkinson’s disease. Management relies on obtaining a careful bowel history, including assessment of bowel function prior to the onset of neurological symptoms. Objective measures of NBD are available and important in terms of monitoring response for what are often intensely personal and difficult-to-elicit symptoms. Conservative management begins by establishing an effective and regular bowel regime by optimizing diet and laxative use. If this is insufficient, as seen in about half of patients, transanal irrigation has been shown to reduce NBD symptoms and improve quality of life. Failing that, there are more invasive surgical options available. This review aims to provide practical guidance for the clinician who encounters these patients, focusing on a stepwise approach to assessment, interventions, and monitoring.

Anterograde colonic irrigations by percutaneous endoscopic caecostomy in refractory colorectal functional disorders

PURPOSE

In case reports or small studies, percutaneous endoscopic caecostomy (PEC) has been proposed as an alternative to the Malone intervention to perform antegrade colonic enemas. Our goal was to assess the feasibility, efficacy, and tolerance of PEC in a large group of patients with refractory colorectal functional disorders.

METHODS

From September 2006 to April 2014, all patients undergoing PEC for constipation, fecal incontinence, and incontinence after rectal resection in two expert centers were studied. The PEC procedure consisted in anchoring the caecum to the abdominal wall (caecopexy) and placing a specifically designed tube in the colonic lumen to perform antegrade enemas. The quality of life (GIQLI), constipation (Kess), and incontinence (Cleveland) scores were assessed before PEC and at 3, 6, 12, and 24 months.

RESULTS

A total of 69 patients were included. GIQLI scores were significantly improved in constipation group (n = 43), incontinence group (n = 19), and rectal resection group (n = 10). In the constipation group, Kess score decreased from 25.9 before PEC to 20.6 at 2 years (p = 0.01). In the incontinence and post-rectal resection groups, Cleveland scores decreased from 14.3 before PEC to 2.7 at 6 months (p = 0.01) and to 10.4 at 2 years (p = 0.04). Overall, PEC was considered successful by patients in 58%, 74%, and 90% of cases, in constipation, incontinence, and rectal resection groups, respectively. Chronic pain (52%) at the catheter site was the most frequent complication.

CONCLUSIONS

Percutaneous endoscopic caecostomy for antegrade colonic enemas improves significantly the quality of life of patients with colorectal disorder refractory to medical treatment.

Neurogenic bowel management for the adult spinal cord injury patient

BACKGROUND

Bowel function can be markedly changed after a spinal cord injury (SCI). These changes, and the care associated with managing the changes, can greatly impact a person's quality of life over a lifetime.

PURPOSE

The purpose of the SIU-ICUD workgroup was to identify, assess, and summarize evidence and expert opinion-based themes and recommendations regarding bowel function and management in SCI populations.

METHODS

As part of the SIU-ICUD joint consultation of Urologic Management of the Spinal Cord Injury, a workgroup was formed and comprehensive literature search of English language manuscripts regarding bowel physiology and management plans for the SCI patient. Articles were compiled, and recommendations in the chapter are based on group discussion and follow the Oxford Centre for Evidence-based Medicine system for levels of evidence (LOEs) and grades of recommendation (GORs).

RESULTS

Neurogenic bowel symptoms are highly prevalent in the SCI population. Patients with injuries above the conus medullaris have increased bowel motility and poor anorectal sphincter relaxation. Patients with injuries below the conus are more likely to have an areflexic colon and low sphincter tone. Conservative management strategies include diet modification and anorectal stimulation. There are few evidence-based pharmacologic interventions, which improve fecal transit time. Intestinal ostomy can be an effective treatment for reducing hours spent per week on bowel management and colostomy may be easier to manage than ileostomy due to solid vs liquid stool.

CONCLUSIONS

By understanding physiology and treatment options, patients and care teams can work together to achieve goals and maximize quality of life after injury.

Medical and surgical management of neurogenic bowel

PURPOSE OF REVIEW

Neurogenic bowel dysfunction (NBoD) commonly affects patients with spina bifida, cerebral palsy, and spinal cord injury among other neurologic insults. NBoD is a significant source of physical and psychosocial morbidity. Treating NBoD requires a diligent relationship between patient, caretaker, and provider in establishing and maintaining a successful bowel program. A well designed bowel program allows for regular, predictable bowel movements and prevents episodes of fecal incontinence.

RECENT FINDINGS

Treatment options for NBoD span conservative lifestyle changes to fecal diversion depending on the nature of the dysfunction. Lifestyle changes and oral laxatives are effective for many patients. Patients requiring more advanced therapy progress to transanal irrigation devices and retrograde enemas. Those receiving enemas may opt for antegrade enema administration via a Malone antegrade continence enema or Chait cecostomy button, which are increasingly performed in a minimally invasive fashion. Select patients benefit from fecal diversion, which simplifies care in more severe cases.

SUMMARY

Many medical and surgical options are available for patients with NBoD. Selecting the appropriate medical or surgical treatment involves a careful evaluation of each patient's physical, psychosocial, financial, and geographic variables in an effort to optimize bowel function.

Meta-analysis of antegrade continence enema in adults with faecal incontinence and constipation

BACKGROUND

Faecal incontinence and constipation affects up to 20 per cent of the general population, and can be a significant source of distress. The antegrade continence enema (ACE) procedure has been shown to be an effective alternative treatment option for children, but its use in adults requires clarification. A systematic review and meta-analysis was performed to determine outcomes of the ACE procedure in adults with faecal incontinence and constipation.

METHODS

PubMed, MEDLINE and the Cochrane Library (from January 1990 to January 2015) were searched for studies that reported outcomes of ACE in adults with faecal incontinence and constipation. The primary outcome measure was successful use of ACE in the management of symptoms, as determined by continued use at follow-up.

RESULTS

Seventeen observational studies involving 426 patients (265 female patients; median age 42 (range 17-84) years) with faecal incontinence (165 patients), constipation (209) or both (52), who had undergone the ACE procedure, were analysed. At a median follow-up of 39 months, the pooled success rate was 74·3 (95 per cent c.i. 66·1 to 82·6) per cent (P < 0·001). For patients with faecal incontinence the pooled success rate was 83·6 (75·0 to 92·1) per cent, compared with 67·7 (55·1 to 80·3) per cent in patients with constipation (both P < 0·001).

CONCLUSION

The ACE procedure is an effective long-term treatment option in patients with faecal incontinence and constipation, and should be considered before performing a definitive colostomy. Patients with faecal incontinence appear to respond better than those with constipation.

Use of Antegrade Continence Enema for the Treatment of Fecal Incontinence and Functional Constipation in Adults: A Systematic Review

BACKGROUND

Antegrade continence enema is a proximal colonic stoma that allows antegrade lavage of the colon for the treatment of fecal incontinence and functional constipation. Its role in the treatment of these conditions in adults has not been established.

OBJECTIVE

This review aimed to evaluate the clinical response and complications of antegrade continence enema in the adult population.

DATA SOURCES

A systematic literature search of MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases from January 1980 to October 2013 was conducted.

STUDY SELECTION

Studies reporting clinical outcomes of antegrade continence enema in adult patients were considered. Only studies with participants aged 16 years and older were selected.

INTERVENTION(S)

Use of the antegrade continence enema for the treatment of constipation and incontinence in adults was investigated.

MAIN OUTCOME MEASURES

The primary outcome was the number of patients irrigating their stoma. Secondary outcomes included the incidence of stoma stenosis, assessment of functional outcome, and evaluation of quality of life.

RESULTS

Overall, 15 studies were selected, describing outcomes in 374 patients. All of the reports were observational cross-sectional studies, and 4 were prospective. The number of participants still using their stoma ranged from 47% to 100% over a follow-up period of 6 to 55 months. Eleven studies reported achievement of full continence in 33% to 100% of patients. Four studies described functional outcomes, and 7 studies reported a wide range of patient satisfaction. The rate of stoma stenosis varied from 8% to 50%.

LIMITATIONS

There were considerable heterogeneities within and across studies. Most studies were of poor quality, as reflected in the Methodological Index for Nonrandomized Studies score.

CONCLUSIONS

Antegrade continence enema has been reported as an acceptable treatment of both functional constipation and fecal incontinence in adults across several analyses. There is wide variation regarding outcome measures. Larger prospective studies are required to assess the role of antegrade continence enema in the adult population.

Clinical outcome and efficacy of antegrade colonic enemas administered via an indwelling cecostomy catheter in adults with defecatory disorders

BACKGROUND

Antegrade colonic enemas are used in selected adult patients with defecatory disorders. Conduit stenosis requiring revisional surgery is common.

OBJECTIVE

The aim of the study was to determine whether stenosis could be avoided by using an indwelling antegrade continence enema catheter in an appendiceal or cecal conduit, and to describe medium-term clinical outcomes.

DESIGN

This study was a retrospective case series.

SETTING

The study was conducted at a tertiary referral hospital in Sydney, Australia.

PATIENTS

Adults administering antegrade colonic enemas to manage defecatory disorders were selected for the study.

METHODS

Patients with an indwelling antegrade continence enema catheter completed a face-to-face survey when they attended the clinic for catheter change. A postal survey was sent to nonattenders, and, if it was not returned, the patient was contacted, and the survey was completed by telephone. The survey asked about irrigation techniques, satisfaction, confidence to manage, and continence, using quantitative scores.

RESULTS

Fifty-four patients (45 female; mean age, 49 years) had constipation (n = 31), incontinence (n = 6), both incontinence and constipation (n = 2) or obstructed defecation due to gracilis neosphincter (n = 5), congenital anomalies (n = 8), or spinal injuries (n = 2). Thirty-five patients (65%) continued to irrigate for a mean follow-up of 5.5 years (range, 4 months to 13.7 years). Mean enema volume was 1178 mL (95% CI, 998-1357; range, 350-2000 mL), and half the patients added a stimulant to the irrigation. Mean total toileting time was 59 minutes (95% CI, 48-66; range, 15-120 minutes). Twenty-one patients had incontinence between irrigations, and in 17% incontinence was severe (St. Mark score >12). Satisfaction (visual analogue scale = 8.1) and confidence to partake in social activities (visual analogue scale = 8.2) and all-day activities (visual analogue scale = 7.1) were high. Complications included superficial wound infection (n = 15), wound infection requiring surgery (n = 6), paraconduit hernia (n = 2), and indwelling antegrade continence enema catheter dislodgement (n = 33). There was no conduit track stenosis.

LIMITATIONS

The study is a medium-term retrospective case series using patient-reported outcomes and clinical records without a control group.

CONCLUSIONS

With the use of the indwelling antegrade continence enema catheter, appendicostomy and cecostomy stenosis requiring revisional surgery was avoided. Antegrade colonic irrigation failed in about one-third of cases; in the 65% who continued to irrigate, satisfactory functional outcome was achieved.

Follow up of children undergoing antegrade continent enema: experience of over two hundred cases

PURPOSE

Antegrade continent enema (ACE) procedures have been used as a treatment of constipation and soiling. Little is known about the long-term results of these procedures, particularly as patients progress into adulthood. This study presents the long-term outcomes of ACE in children, with follow up into adulthood, over a fifteen-year period.

METHODS

A prospective database of all consecutive procedures performed from 1998 to 2013 by a single surgeon in a regional centre was analysed. Operative details and follow up by both paediatric and adult clinicians and stoma nurses were included.

RESULTS

During the study period 203 ACE procedures were performed in children with a median age of 9years 7months (3-17). Indications included chronic idiopathic constipation (CIC) resistant to medical treatment in 62% of cases, anorectal malformation in 18%, spinal cord abnormalities in 9% and Hirschprung's in 7%. After an average follow-up of 5.5years (0.5-15) 132 patients were still using their ACE. 113 (93%) regularly had a good result from the procedure, 8 a variable result and 1 poor. Soiling was prevented in 79 patients (75%), partially improved in 15 and persistent in 15. Over the study period 53 patients (26%) no longer used their ACE due to resolution of symptoms. In 32 of these patients the ACE was reversed at a median interval of 5years from formation (1-12). In 17 cases (8%) the procedure failed with significant symptoms persisting. Four of these patients were reversed and a further 11 went on to have other procedures including 5 restorative pouches and 4 stomas. Of the patients that no longer required their ACE the majority (81%) had a pre-operative diagnosis of CIC. Only 7% of ACE procedures performed for CIC failed compared to 26% for spinal cord abnormalities.

CONCLUSION

Many patients continue to use their ACE to good effect in long-term follow up. In this study over a quarter had resolution of their symptoms permitting reversal. This was more likely if they suffered idiopathic constipation.

Symptomatic treatment and management of multiple sclerosis

The range of symptoms which occur in multiple sclerosis (MS) can have disabling functional consequences for patients and lead to significant reductions in their quality of life. MS symptoms can also interact with each other, making their management challenging. Clinical trials aimed at identifying symptomatic therapies have generally been poorly designed and have tended to be underpowered. Therefore, the evidence base for the management of MS symptoms with pharmacologic therapies is not strong and tends to rely upon open-label studies, case reports, and clinical trials with small numbers of patients and poorly validated clinical outcome measures. Recently, there has been a growing interest in the management of MS symptoms with pharmacologic treatments, and better-designed, randomized, double-blind, controlled trials have been reported. This chapter will describe the evidence base predominantly behind the various pharmacologic approaches to the management of MS symptoms, which in most, if not all, cases, requires multidisciplinary input. Drugs routinely recommended for individual symptoms and new therapies, which are currently in the development pipeline, will be reviewed. More interventional therapies related to symptoms that are refractory to pharmacotherapy will also be discussed, where relevant.

Outcome of antegrade continent enema (ACE) procedures in children and young adults

OBJECTIVE

Intractable incontinence affects a large number of children and young adults in the US. The goal of this study is to evaluate the long-term outcomes of surgical access for administration of antegrade continence enemas (ACE) in affected children and young adults.

METHODS

Patients who underwent surgical procedure to enable administration of ACE from 1994 to 2011 were retrospectively reviewed. Data collected included patient demographics, primary diagnosis, surgical technique, conduit used, complications, follow-up duration, and social continence.

RESULTS

Sixty eighty patients underwent surgery to enable ACE; mean follow up was 61 months. Enteral conduit (EC) was performed in 19 patients, tube cecostomy catheters (CC) in 49. Meningomyelocele was diagnosed in 60% of patients. Mean age was 11 (1.67-53) years. Complications included tube dislodgement (43%), granulation tissue (46%), site infection (13%), leakage (32%), break in the tube (6%) and tract stenosis (6%). Complete social continence was achieved in 68%, partial continence was achieved in 29%, and no benefit was achieved in 3% of patients. The rate of complications and incontinence resolution following CC was 78% and 66%, and following EC 89% and 74%. The differences were not statistically significant. CC patients developed granulation tissue more frequently (53%) and leaks of fecal material less frequently (20%) compared to EC patients (26% and 53%) (p < 0.05 and < 0.01). Although children 7 years or younger developed more overall complications (94%) than older patients (69%; p < 0.05), there was not a significant difference in the frequency of any one complication or in the rate of continence, between the two groups. Multivariate analysis showed that EC is three times more likely to be complicated by fecal leakage. CC patients are at greater risk to develop granulation tissue (p < 0.05).

CONCLUSIONS

Most patients achieved social continence and improved hygiene with the aid of ACE. Younger children also benefited greatly from institution of ACE. CC was associated with fewer major complications such as leak of fecal contents than EC but required regular tube changes.

Consensus statement AIGO/SICCR diagnosis and treatment of chronic constipation and obstructed defecation (part II: treatment)

The second part of the Consensus Statement of the Italian Association of Hospital Gastroenterologists and Italian Society of Colo-Rectal Surgery reports on the treatment of chronic constipation and obstructed defecation. There is no evidence that increasing fluid intake and physical activity can relieve the symptoms of chronic constipation. Patients with normal-transit constipation should increase their fibre intake through their diet or with commercial fibre. Osmotic laxatives may be effective in patients who do not respond to fibre supplements. Stimulant laxatives should be reserved for patients who do not respond to osmotic laxatives. Controlled trials have shown that serotoninergic enterokinetic agents, such as prucalopride, and prosecretory agents, such as lubiprostone, are effective in the treatment of patients with chronic constipation. Surgery is sometimes necessary. Total colectomy with ileorectostomy may be considered in patients with slow-transit constipation and inertia coli who are resistant to medical therapy and who do not have defecatory disorders, generalised motility disorders or psychological disorders. Randomised controlled trials have established the efficacy of rehabilitative treatment in dys-synergic defecation. Many surgical procedures may be used to treat obstructed defecation in patients with acquired anatomical defects, but none is considered to be the gold standard. Surgery should be reserved for selected patients with an impaired quality of life. Obstructed defecation is often associated with pelvic organ prolapse. Surgery with the placement of prostheses is replacing fascial surgery in the treatment of pelvic organ prolapse, but the efficacy and safety of such procedures have not yet been established.

Combination of pseudocontinent perineal colostomy and appendicostomy: a new approach in the treatment of low rectal cancer

BACKGROUND

Abdominal perineal resection (APR) with applied colostomy remains the standard treatment for low rectal cancer; however, to date, a very high morbidity rate has been reported.

AIMS

The aims of this study were to assess fecal continence, persistence of disease-related symptoms, and quality of life in patients with low rectal cancer after APR and pseudocontinent perineal colostomy and concomitant appendicostomy.

METHODS

We included 17 patients with low rectal cancer who underwent APR at our hospital in this cross-sectional study. Following APR, pseudocontinent perineal colostomy and concomitant appendicostomy were performed. Patients then underwent antegrade colonic enema with tap water. Patients' symptoms, fecal continence, and quality of life were evaluated at regular time intervals.

RESULTS

After a median follow-up of 12 months, 15 of 17 patients completed the study period. All patients were able to perform an antegrade enema by themselves. Mean continence score was 7 (out of 20) based on the Wexner Scale scoring system. Mean global health status score was 78, physical function was 93, and emotional function was 88. Minor morbidity was observed in 6 patients (40%).

CONCLUSION

Pseudocontinent perineal colostomy with appendicostomy provides an acceptable level of continence and functional and emotional improvement in patients with low rectal cancer undergoing APR. Hence, this combinative method could be considered as an alternative for abdominal colostomy in selected patients.

Consensus statement AIGO/SICCR diagnosis and treatment of chronic constipation and obstructed defecation (Part II: Treatment)

The second part of the Consensus Statement of the Italian Association of Hospital Gastroenterologists and Italian Society of Colo-Rectal Surgery reports on the treatment of chronic constipation and obstructed defecation. There is no evidence that increasing fluid intake and physical activity can relieve the symptoms of chronic constipation. Patients with normal-transit constipation should increase their fibre intake through their diet or with commercial fibre. Osmotic laxatives may be effective in patients who do not respond to fibre supplements. Stimulant laxatives should be reserved for patients who do not respond to osmotic laxatives. Controlled trials have shown that serotoninergic enterokinetic agents, such as prucalopride, and prosecretory agents, such as lubiprostone, are effective in the treatment of patients with chronic constipation. Surgery is sometimes necessary. Total colectomy with ileorectostomy may be considered in patients with slow-transit constipation and inertia coli who are resistant to medical therapy and who do not have defecatory disorders, generalised motility disorders or psychological disorders. Randomised controlled trials have established the efficacy of rehabilitative treatment in dys-synergic defecation. Many surgical procedures may be used to treat obstructed defecation in patients with acquired anatomical defects, but none is considered to be the gold standard. Surgery should be reserved for selected patients with an impaired quality of life. Obstructed defecation is often associated with pelvic organ prolapse. Surgery with the placement of prostheses is replacing fascial surgery in the treatment of pelvic organ prolapse, but the efficacy and safety of such procedures have not yet been established.

Consensus statement AIGO/SICCR diagnosis and treatment of chronic constipation and obstructed defecation (part II: treatment)

The second part of the Consensus Statement of the Italian Association of Hospital Gastroenterologists and Italian Society of Colo-Rectal Surgery reports on the treatment of chronic constipation and obstructed defecation. There is no evidence that increasing fluid intake and physical activity can relieve the symptoms of chronic constipation. Patients with normal-transit constipation should increase their fibre intake through their diet or with commercial fibre. Osmotic laxatives may be effective in patients who do not respond to fibre supplements. Stimulant laxatives should be reserved for patients who do not respond to osmotic laxatives. Controlled trials have shown that serotoninergic enterokinetic agents, such as prucalopride, and prosecretory agents, such as lubiprostone, are effective in the treatment of patients with chronic constipation. Surgery is sometimes necessary. Total colectomy with ileorectostomy may be considered in patients with slow-transit constipation and inertia coli who are resistant to medical therapy and who do not have defecatory disorders, generalised motility disorders or psychological disorders. Randomised controlled trials have established the efficacy of rehabilitative treatment in dys-synergic defecation. Many surgical procedures may be used to treat obstructed defecation in patients with acquired anatomical defects, but none is considered to be the gold standard. Surgery should be reserved for selected patients with an impaired quality of life. Obstructed defecation is often associated with pelvic organ prolapse. Surgery with the placement of prostheses is replacing fascial surgery in the treatment of pelvic organ prolapse, but the efficacy and safety of such procedures have not yet been established.

Managing neurogenic bowel dysfunction

This series of articles for rehabilitation in practice aims to cover a knowledge element of the rehabilitation medicine curriculum. Nevertheless they are intended to be of interest to a multidisciplinary audience. The competency addressed in this article is 'The trainee consistently demonstrates a knowledge of the pathophysiology of various specific impairments including bowel dysfunction' and 'management approaches for specific impairments including bowel dysfunction'.

Neurogenic bowel dysfunction: pathophysiology, clinical manifestations and treatment

Bowel dysfunction (e.g., fecal incontinence, infrequent or difficult defecation) are both frequent and severely troubling problems for patients with spinal cord injury, multiple sclerosis and Parkinson's disease. The etiology of these symptoms is complex; there may be autonomic and pelvic nerve dysfunction (with attenuation of voluntary motor function and impaired anorectal sensation and anorectal reflexes), or generalized systemic factors (e.g., altered diet and behavior, impaired mobility, psychological disturbances or drug adverse effects). The mainstay of current treatment is adapting a conservative approach towards reversing the systemic effects and optimizing the mechanics of defecation through the use of laxatives and irrigation approaches. When successful, this approach improves both evacuation and incontinence symptoms, with associated improvements in quality of life and independence. Future therapies may be directed at modulating pelvic innervation through electrical stimulation. Stoma formation remains an option for patients refractory to other approaches.

Neurogenic colorectal and pelvic floor dysfunction

Constipation and faecal incontinence are common symptoms among patients with spinal cord injury (SCI), myelomeningocoele (MMC), multiple sclerosis (MS), Parkinson's disease (PD) and stroke. Faecal incontinence in SCI, MMC and MS is mainly due to abnormal rectosigmoid compliance and rectoanal reflexes, loss of rectoanal sensibility and loss of voluntary control of the external anal sphincter. Constipation in SCI, MMC and MS is probably due to immobilisation, abnormal colonic contractility, tone and rectoanal reflexes or side effects from medication. In PD, dystonia of the external anal sphincter causes difficult rectal evacuation and the loss of dopaminergic neurons in the enteric nervous system probably causes slow-transit constipation. Changes after stroke remain to be studied. Though dietary adjustments, oral laxatives, suppositories and other conservative treatment modalities are commonly used, evidence for their use in patients with central neurological disorders is scarce. For patients with severe symptoms trans-anal irrigation, the Malone appendicostomy or a colostomy can be recommended.

Antegrade continence enema in the treatment of congenital fecal incontinence beyond childhood

PURPOSE

The role of antegrade continence enema for the treatment of congenital fecal incontinence in adult patients remains unclear.

MATERIALS

Twenty-seven patients, median age 19 (range, 17-43) years, with congenital fecal incontinence underwent surgery for antegrade continence enema and were prospectively followed up for functional outcome after a median of 25 (range, 3-117) months.

RESULTS

The diagnoses included myelodysplasia (n = 14), anorectal malformations (n = 6), and others (n = 7). Antegrade continence enema conduits included appendicostomy (n = 22) and cecal (n = 2), ileal (n = 2), and sigmoid (n = 1) tubes. Thirteen (48 percent) patients had complications. Eighteen (66 percent) patients became fully continent, six (23 percent) had minor, and three (11 percent) major soiling. Antegrade continence enema became unnecessary in three patients (11 percent). Treatment with antegrade continence enema failed in three cases. Of the 21 patients who continued with antegrade continence enema, 16 (76 percent) are fully continent, and bowel function and quality of life was improved in 15 (71 percent) and 13 (62 percent) patients, respectively. The scores of convenience (1 = easy, 5 = difficult) and overall satisfaction (1 = poor, 10 = excellent) were median 2 (range, 1-4) and 8 (range, 3-10).

CONCLUSIONS

Despite numerous complications and occasional treatment failures, 90 percent of adult patients with congenital fecal incontinence benefited from antegrade continence enema.

Long-term results of antegrade colonic enema in adult patients: assessment of functional results

PURPOSE

This retrospective study reviewed long-term results in a large group of adult patients treated with antegrade colonic enema and antegrade colonic enema combined with a colostomy.

METHODS

Retrospective chart review identified 80 patients (64 females, mean age 51) surgically treated between 1993 and 2007 for fecal incontinence or constipation. Surgical treatments included 69 appendicostomies, 13 tapered ileum, 3 cecal tube, and 25 appendicostomy/neoappendicostomy combined with a colostomy. A 44-item questionnaire was mailed considering bowel regimen, complications, bowel function, social function, and quality of life.

RESULTS

Sixty-nine patients were available for follow-up (mean follow-up, 75 months). Thirty patients (38 percent) had surgical complications. Forty-three patients (62 percent) were still performing antegrade continence enema and 8 patients (12 percent) no longer needed it. Accordingly, treatment was successful in 51 patients (74 percent). Twenty-seven patients (63 percent) had side effects. Evaluation of bowel function, social function, and quality of life all showed significant improvement. Antegrade continence enema was successful in patients with neurologic disabilities (67 percent), anorectal injury (53 percent), idiopathic fecal incontinence (50 percent), and idiopathic fecal constipation (42 percent). Antegrade continence enema was successful in patients with constipation, incontinence, and mixed symptoms. Results did not differ between appendicostomy, neoappendicostomy, and the combined appendicostomy/neoappendicostomy and colostomy.

CONCLUSION

Long-term results were favorable in most patients treated with antegrade continence enema for fecal incontinence or constipation.

Experimental antegrade enema. Effects on water, electrolyte and acid-base balances with different solutions

PURPOSE

To study the effects on the water, electrolyte, and acid-base balances in rabbits submitted to antegrade enema with different solutions through appendicostomy.

METHODS

Forty male New Zealand rabbits were submitted to appendicostomy, and distributed in 4 groups, according to the antegrade enema solution: PEG group, polyethylene glycol electrolyte solution (n=10); ISS group, isotonic saline solution (n=10); GS group, glycerin solution (n=10); SPS group, sodium phosphate solution (n=10). After being weighed, arterial blood gas analysis, red blood count, creatinine and electrolytes were measured at 4 times: preoperatively (T1); day 6 postop, before enema (T2); 4h after enema (T3); and 24h after T3 (T4).

RESULTS

In PEG group occurred Na retention after 4h, causing alkalemia, sustained for 24h with HCO3 retention. In ISS group occurred isotonic water retention and hyperchloremic acidosis after 4h, which was partially compensated in 24h. GS group showed metabolic acidosis after 4h, compensated in 24h. In SPS group occurred hypernatremic dehydration, metabolic acidosis in 4h, and hypokalemia, hypocalcemia, hypomagnesemia, and metabolic alkalosis with partially compensated dehydration in 24h.

CONCLUSIONS

All solutions used in this study caused minor alterations on water, electrolyte or acid-base balances. The most intense ones were caused by hypertonic sodium phosphate solution (SPS) and isotonic saline solution (ISS) and the least by polyethyleneglycol electrolyte solution (PEG) and glycerin solution 12% (GS).

Malone antegrade continence enema (MACE) for fecal incontinence in imperforate anus improves quality of life

The MACE procedure has been used in patients with imperforate anus (IA) to improve fecal continence. Our aim was to assess the impact of the MACE on the quality of life (QOL) in children with IA and fecal incontinence. A retrospective review was performed of children with IA that underwent the MACE procedure between 1997 and 2004. Patients and their parents were contacted by telephone survey regarding continence and its psychosocial effects before and after MACE. The same survey was given to the patients' teachers. Responses to 15 questions were compiled and a QOL score calculated and significance evaluated by t-test (P < or = 0.05). IRB approval was obtained. Thirty-two patients were identified with a mean age at operation of 9 years (4-19 years) and mean follow-up of 3.8 years (7 months to 8 years). Four patients had a low malformation, 8 were intermediate, 15 were high, and 5 had a cloacal anomaly. Twenty patients had documented sacral/spinal anomalies, including five with tethered cord. Post-MACE complications included stenosis in 16 (50%), with 11 requiring an operative revision at a mean of 21.7 months (2 months to 6 years), takedown in one at 4 years and volvulus in one at 18 months. Prior to the MACE, 18/25 (72%) had poor QOL scores. Post-MACE QOL results were similar between patients, parents and teachers. Patients' mean QOL score improved from 59.9 to 26.3% (P < 0.001), with parents from 59.7 to 26.4% (P < 0.001). QOL score improved >50% in nine families, 25-50% in ten and <25% in six. All patients and parents interviewed reported an improvement in their QOL following the MACE. This procedure should be offered to children with IA with the expectation of significant improvement in QOL.

Optimal treatment for severe neurogenic bowel dysfunction after chronic spinal cord injury: a decision analysis

BACKGROUND

When conservative management fails in patients with chronic spinal cord injury (SCI) and neurogenic bowel dysfunction, clinicians have to choose from a variety of treatment options which include colostomy, ileostomy, Malone anterograde continence enema (MACE) and sacral anterior root stimulator (SARS) implantation. This study employed a decision analysis to examine the optimal treatment for bowel management of young individuals with chronic refractory constipation in the setting of chronic SCI.

METHODS

A decision analysis was created to compare the four surgical strategies using baseline analysis, one-way and two-way sensitivity analyses, 'worst scenario' and 'best scenario' sensitivity analyses, and probabilistic sensitivity analyses. Quality-adjusted life expectancy (QALE) was the primary outcome.

RESULTS

The baseline analysis indicated that patients who underwent the MACE procedure had the highest QALE value compared with the other interventions. Sensitivity analyses showed that these results were robust.

CONCLUSION

The MACE procedure may provide the best long-term outcome in terms of the probability of improving bowel function, reducing complication rates and the incidence of autonomic dysreflexia, and being congruent with patients' preferences. The analysis was sensitive to changes in assumptions about quality of life/utility, and thus the results could change if more specific estimates of utility became available.

Slow-transit constipation: evaluation and treatment

Slow-transit constipation is characterized by delay in transit of stool through the colon, caused by either myopathy or neuropathy. The severity of constipation is highly variable, but may be severe enough to result in complete cessation of spontaneous bowel motions. Diagnostic tests to assess colonic transit include radiopaque marker or radioisotope studies, and intraluminal tests (colonic and small bowel manometry). Most patients with functional constipation respond to laxatives, but a small proportion are resistant to this treatment. In some patients biofeedback is helpful although the mechanism by which this works is still uncertain. Other patients are resistant to all conservative modes of therapy and require surgical intervention. Extensive clinical and physiological preoperative assessment of patients with slow colonic transit is essential before considering surgery, including an assessment of small bowel motility and identification of coexistent obstructed defecation. The psychological state of the patient should always be taken into account. When surgery is indicated, subtotal colectomy and ileorectal anastomosis is the operation of choice. Segmental colonic resection has been reported in a few patients, but methods of identifying the affected segment need to be developed further. Less invasive and reversible surgical options include laparoscopic ileostomy, antegrade colonic enema and sacral nerve stimulation.

Long-term functional assessment of antegrade colonic enema for combined incontinence and constipation using a modified Marsh and Kiff technique

PURPOSE

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.

Endoscopically placed caecostomy buttons: a trial ACE procedure

The use of the antegrade continence enema (ACE) is becoming more widespread. Preliminary studies have been promising, but the procedure is not universally successful. A colonoscopic insertion of a caecostomy button is a relatively minor procedure. This allows the ACE to be used for a trial period to assess whether a permanent procedure would be beneficial. If successful, enemas can be continued by the caecostomy, or a formal ACE can be performed. We report a series of five patients who underwent staged endoscopic insertion of a MIC-KEY caecostomy button, and we discuss the technical aspects of the procedure.

Surgery for slow transit constipation: are we helping patients?

INTRODUCTION

Long-term outcome after surgery for slow transit constipation is conflicting. The aim of this study was to assess long-term quality of life after surgery.

METHODS

The medical records of all patients undergoing colectomy with ileorectal anastomosis between 1983 and 1998 were evaluated. Preoperative, operative, and postoperative details were recorded. A survey was conducted to evaluate current symptoms and health. Quality of life was assessed using the short-form (SF)-36 survey.

RESULTS

Sixty-nine (2 male) patients were identified. Five were deceased. Mean age at surgery was 38.6 years (range, 19.7-78.8 years). Median follow-up after surgery was 10.8 years (range, 5.1-18.6 years). Forty-one percent had a family history of constipation. Eleven (16%) had an ileus postoperatively, which responded to medical therapy. One patient had a leak that required temporary diversion. Long-term complications occurred in 32 (46%) patients, which included hernias (3 patients; 4%), pelvic abscess (1 patient; 1.5%), rectal pain (1 patient; 1.5%), small-bowel obstruction (14 patients; 20%, with eight requiring surgery), diarrhea (5 patients; 7%), incontinence (1 patient, 1.5%), and persistent constipation (6 patients; 9%). Fifty-five percent (35/64) responded to a questionnaire. Overall, 25 of 35 (77% of the respondents) stated that surgery was beneficial. Sixty-four percent of patients have semisolid stools, 35% have liquid stools, and 4% reported hard stool. Results of the SF-36 showed the physical component score was comparable with healthy individuals. However, the mental component score was low especially in the areas of vitality (median, 45) and social functioning (median, 37).

CONCLUSION

Surgery for constipation is not perfect, and preoperative symptoms may persist after surgery. When assessing long-term quality of life, the mental component of the SF-36 was low compared with the general population, and the physical component was similar. Moreover, because 77% report long-term improvement, surgery is beneficial for appropriate patients.

Surgery for constipation

Patients with intractable chronic constipation should be evaluated with physiologic tests after structural disorders and extracolonic causes have been excluded. Conservative treatment options should be tried excessively. If surgery is indicated subtotal colectomy with IRA is the treatment method of choice. However, segmental resection may be a good option for isolated megasigmoid, sigmoidocele or recurrent sigmoid volvulus. In general patients with GID should not be offered any surgical options because of their anticipated poor results. Moreover, patients with psychiatric disorders should be actively discouraged from resection as they tend to have poorer prognosis. Patients must be counseled that preoperative pain and/or bloating will likely persist even if surgery normalizes bowel frequency. Patients with associated problems may be better served by having a stoma without resection as both a therapeutic maneuver and a diagnostic trial. Colectomy is no option to treat pain and/or abdominal bloating.

Outcome of antegrade continence enema procedures for faecal incontinence in adults

BACKGROUND

Faecal incontinence has major consequences. Colostomy has been the mainstay of therapy when other options fail. Operations such as the Malone procedure have been proposed as an alternative. The aim of this study was to evaluate the outcomes and quality of life of patients having a Malone procedure for the treatment of faecal incontinence.

METHODS

Charts of patients who had had a Malone procedure or equivalent between 1998 and 2004 were reviewed. The patients completed a Short Form (SF) 36 quality of life questionnaire.

RESULTS

The study included 25 patients (17 female; median age 47 years). In seven, the appendix was used; an ileoneoappendicostomy was performed in the other 18. Three patients were lost to follow-up; the remaining 22 were followed for a median (range) of 21 (1-61) months. Five patients had a cutaneous stenosis; another had the appendicostomy removed and replaced by a colostomy. Four patients no longer used the stoma for irrigation. All other patients were completely clean except one, who reported occasional night-time seepage. The mean SF-36 showed a good physical recovery (43.9) but persisting psychological distress (36.0).

CONCLUSION

The Malone procedure or equivalent achieves good results in the management of faecal incontinence, although psychological distress persists after surgery.

Malone antegrade colonic irrigation: ileal neoappendicostomy is the preferred procedure in adults

BACKGROUND

Antegrade colonic enema, via a caecal access [Malone antegrade continence enema (MACE)], is proposed to selected patients suffering from incontinence and/or constipation when other therapeutic modalities have failed.

METHODS

We compared complication rates after three MACE techniques: appendicostomy, caecal neoappendicostomy, and ileal neoappendicostomy in 28 adult patients having 31 MACE operations.

RESULTS

Stenoses and leakages occurred more frequently after appendicostomy and caecal flap than after ileal neoappendicostomy. This latter technique appears to reduce morbidity for adult patients.

Investigation and treatment of faecal incontinence

Faecal incontinence is a debilitating condition affecting people of all ages, and significantly impairs quality of life. Proper clinical assessment followed by conservative medical therapy leads to improvement in more than 50% of cases, including patients with severe symptoms. Patients with advanced incontinence or those resistant to initial treatment should be evaluated by anorectal physiology testing to establish the severity and type of incontinence. Several treatment options with promising results exist. Patients with gross sphincter defects should undergo surgical repair. Those who fail to respond to sphincteroplasty and those with no anatomical defects have the option of either sacral nerve stimulation or other advanced procedures. Stoma formation should be reserved for patients who do not respond to any of the above procedures.

Introducer method of percutaneous endoscopic cecostomy and antegrade continence enema by use of the Chait Trapdoor cecostomy catheter in patients with adult neurogenic bowel

BACKGROUND

Previous reports on percutaneous endoscopic cecostomy (PEC) for the delivery of antegrade continence enema (ACE) in adults have been presented in the form of case reports. Heretofore the tubes used in the pull method of PEC have been thick bolster catheters. The author performed PEC by using the introducer method (IM) with 10 F Chait Trapdoor cecostomy catheters (CTCC) in adult cases.

OBJECTIVE

Report author experience with a new method of PEC in adults.

DESIGN

Case series.

SETTING

Single institution in Japan.

PATIENTS

Five patients with bowel obstruction and 15 patients with chronic severe constipation.

INTERVENTIONS

The interventions were the pull method or IM of PEC and drainage or ACE. In 5 cases, PEC was performed by the pull method with the use of an 18 F to 24 F bolster catheter for decompression of dilated intestine. In 15 patients with chronic constipation, PEC was performed with the IM method using a balloon catheter (11 F or 15 F) and CTCC. ACE was performed every other day.

RESULTS

PEC was successful and effective (decompression and evacuation) in all patients. In patients with IM of PEC, 5 patients were placed with a 15 F balloon catheter and 10 patients were placed with an 11 F balloon catheter. Immediate bleeding occurred in 1 case. Balloon rupture occurred during the first month or on average at the 1 month period. Nine of 10 patients who had the 11 F catheters were changed to CTCC. The advantages of CTCC were prevention of accidental balloon rupture, decreased leakage and granulation tissue, and ease of exchange compared with bolster catheter.

LIMITATIONS

Retrospective, single-institution.

CONCLUSIONS

PEC with IM is a safe and useful method. CTCC is advantageous on a long-term basis for ACE.

Use of Malone antegrade continence enema in patients with perineal colostomy after rectal resection

PURPOSE

Abdominoperineal resection, with iliac colostomy, remains the gold standard treatment for very low-lying rectal cancer, but it alters patients' quality of life. Alternatives to iliac colostomy need to be experimented. Antegrade enemas via a cecal access (Malone operation) obtains a colonic emptying and improves continence for incontinent patients. Continence and quality of life after abdominoperineal resection and perineal colostomy associated to a Malone antegrade continence enema were studied.

METHODS

After abdominoperineal resection for cancer, 18 patients had a digestive reconstruction by perineal colostomy and Malone antegrade continence enema. Patients performed antegrade enemas every 24 to 48 hours with tap water. After six months, continence (Cleveland Clinic score) and quality of life (Fecal Incontinence Quality of Life scale) were recorded.

RESULTS

Morbidity was 5 percent (1 appendix necrosis). All patients could perform antegrade enemas by themselves. Mean continence score was 6.41/20 (standard error, 2.31). Fecal Incontinence Quality of Life scores were: lifestyle 3.18/4 (standard error, 0.83); coping/ behavior 2.99/4 (standard error, 0.83); depression/self-perception 3.11/4 (standard error, 0.83); embarrassment 2.84/4 (standard error, 0.63).

CONCLUSIONS

After abdominoperineal resection, Malone antegrade continence enema associated to perineal colostomy provided an acceptable continence. It preserved patients' body image and resulted in a satisfying quality of life. It could become an alternative to iliac colostomy in selected patients.

Review article: the management of pelvic floor disorders

Anorectal disorders, such as faecal incontinence, defecation difficulty and conditions associated with anorectal pain, are commonly encountered in the practices of gastroenterologists, urogynaecologists and colorectal surgeons. The evaluation of these disorders has been very much improved by the development and wider availability of diagnostic tests, such as manometry, endo-anal ultrasound, static and dynamic pelvic magnetic resonance imaging and electromyography. After briefly reviewing the normal anatomy and physiology of the anorectum, the pathophysiology and diagnostic approaches to faecal incontinence, defecation disorders and functional anorectal pain are discussed. Until recently, the management of these disorders has been largely anecdotal. However, our therapeutic armamentarium has been expanded by pharmacological agents, such as nitrates, calcium channel blockers and botulinum toxin, as well as the development of novel techniques, such as sacral nerve stimulation. These and other pharmacological, behavioural and surgical approaches are reviewed with respect to the robustness of evidence to support their efficacy in patients with these disorders.

Left-colon antegrade continence enema (LACE) procedure for fecal incontinence

PURPOSE

Antegrade continence enemas (ACE) are an efficacious therapeutic option for patients with fecal incontinence. The authors review their institution's experience with a variation of the Monti-Malone ACE procedure using the left colon as a source of an intestinal conduit and enema reservoir.

METHODS

From 2000 to 2002, 18 patients with fecal incontinence or intractable constipation underwent left-colon ACE (LACE) procedure. Concomitant Mitrofanoff appendicovesicostomy was performed in 15 patients and bladder augmentation in 9. The majority of patients had neural tube defects. A segment of left colon was tubularized, tunneled into the muscular wall of the distal colon, and exteriorized through the left upper quadrant or midabdomen. Stomal catherization and enema installation were started one month postoperatively.

RESULTS

Fifteen patients (83%) achieved fecal continence, 2 remain incontinent of stool, and 1 experienced stomal closure (mean follow-up was 24 +/- 9 months). Two patients had stomal stenosis that required revision. The mean enema volume in patient's achieving continence was 360 +/- 216 mL, and the mean transit time was 18 +/- 12 minutes.

CONCLUSIONS

LACE is an efficacious procedure for fecal incontinence that can be performed safely at the time of major urologic reconstruction. Administration of enemas into the left colon has several physiologic advantages that result in predictable bowel evacuation.