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Bokova E, Prasade N, Janumpally S, Rosen JM, Lim IIP, Levitt MA, Rentea RM. State of the Art Bowel Management for Pediatric Colorectal Problems: Hirschsprung Disease. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1418. [PMID: 37628417 PMCID: PMC10453740 DOI: 10.3390/children10081418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/12/2023] [Accepted: 08/17/2023] [Indexed: 08/27/2023]
Abstract
After an initial pull-though, patients with Hirschsprung disease (HD) can present with obstructive symptoms, Hirschsprung-associated enterocolitis (HAEC), failure to thrive, or fecal soiling. This current review focuses on algorithms for evaluation and treatment in children with HD as a part of a manuscript series on updates in bowel management. In constipated patients, anatomic causes of obstruction should be excluded. Once anatomy is confirmed to be normal, laxatives, fiber, osmotic laxatives, or mechanical management can be utilized. Botulinum toxin injections are performed in all patients with HD before age five because of the nonrelaxing sphincters that they learn to overcome with increased age. Children with a patulous anus due to iatrogenic damage of the anal sphincters are offered sphincter reconstruction. Hypermotility is managed with antidiarrheals and small-volume enemas. Family education is crucial for the early detection of HAEC and for performing at-home rectal irrigations.
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Affiliation(s)
- Elizaveta Bokova
- Comprehensive Colorectal Center, Department of Surgery, Children’s Mercy Kansas City, Kansas City, MO 64108, USA
| | - Ninad Prasade
- Comprehensive Colorectal Center, Department of Surgery, Children’s Mercy Kansas City, Kansas City, MO 64108, USA
| | - Sanjana Janumpally
- Comprehensive Colorectal Center, Department of Surgery, Children’s Mercy Kansas City, Kansas City, MO 64108, USA
| | - John M. Rosen
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children’s Mercy Kansas City, Kansas City, MO 64108, USA
- Department of Pediatrics, University of Missouri-Kansas City, Kansas City, MO 64108, USA
| | - Irene Isabel P. Lim
- Comprehensive Colorectal Center, Department of Surgery, Children’s Mercy Kansas City, Kansas City, MO 64108, USA
- Department of Surgery, University of Missouri-Kansas City, Kansas City, MO 64108, USA
| | - Marc A. Levitt
- Division of Colorectal and Pelvic Reconstruction, Children’s National Medical Center, Washington, DC 20001, USA
| | - Rebecca M. Rentea
- Comprehensive Colorectal Center, Department of Surgery, Children’s Mercy Kansas City, Kansas City, MO 64108, USA
- Department of Surgery, University of Missouri-Kansas City, Kansas City, MO 64108, USA
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Gould MJ, Marcon MA, Nguyen GC, Benchimol EI, Moineddin R, Swayze S, Kopp A, Ratcliffe EM, Merritt N, Davidson J, Langer JC, Mistry N, Lorenzo AJ, Temple M, Walsh CM. Impact of antegrade enema initiation on healthcare utilization in pediatric patients: A population-based cohort study. Neurogastroenterol Motil 2023; 35:e14495. [PMID: 36377812 DOI: 10.1111/nmo.14495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 10/24/2022] [Accepted: 11/01/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND When constipation is refractory to first-line interventions, antegrade enema use may be considered. We aimed to assess the impact of this intervention on healthcare utilization. METHODS We conducted a population-based, quasi-experimental study with pre-post comparison of the intervention group and a non-equivalent control group using linked clinical and health administrative data from Ontario, Canada. Subjects included children (0-18 years) who underwent antegrade enema initiation from 2007 to 2020 and matched controls (4:1) from the general population. To assess the change in healthcare utilization following antegrade enema initiation, we used negative binomial generalized estimating equations with covariates selected a priori. KEY RESULTS One hundred thirty-eight subjects met eligibility criteria (appendicostomy = 55 (39.9%); cecostomy tube = 83 (60.1%)) and were matched to 550 controls. There was no significant difference in the change in the rate of hospitalizations (rate ratio (RR) 1.05, 95% confidence interval (CI) 0.35-1.75), outpatient visits (RR 1.05, 95% CI 0.91-1.18), or same-day surgical procedures (RR 1.51, 95% CI 0.60-2.43) across cases in 2 years following antegrade enema initiation compared with controls. Cases had an increased rate of emergency department (ED) visits, which was not observed in controls (RR 1.52, 95% CI 1.11-1.79), driven in part by device-related complications. CONCLUSIONS AND INFERENCES Understanding healthcare utilization patterns following antegrade enema initiation allows for effective health system planning and aids medical decision-making. The observed increase in ED visits for device-related complications speaks to the need to improve preventive management to help mitigate emergency care after initiation of antegrade enemas.
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Affiliation(s)
- Michelle J Gould
- Division of Gastroenterology, Hepatology, and Nutrition, Hospital for Sick Children, Toronto, Canada.,Department of Paediatrics, University of Toronto, Toronto, Canada
| | - Margaret A Marcon
- Division of Gastroenterology, Hepatology, and Nutrition, Hospital for Sick Children, Toronto, Canada.,Department of Paediatrics, University of Toronto, Toronto, Canada
| | - Geoffrey C Nguyen
- Division of Gastroenterology, Mount Sinai Hospital, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada.,ICES, Toronto, Canada
| | - Eric I Benchimol
- Division of Gastroenterology, Hepatology, and Nutrition, Hospital for Sick Children, Toronto, Canada.,Department of Paediatrics, University of Toronto, Toronto, Canada.,ICES, Toronto, Canada
| | - Rahim Moineddin
- Department of Family and Community Medicine, Division of Biostatistics, University of Toronto, Toronto, Canada
| | | | | | - Elyanne M Ratcliffe
- Division of Pediatric Gastroenterology and Nutrition, McMaster Children's Hospital, Hamilton, Canada.,Department of Pediatrics, McMaster University, Hamilton, Canada
| | - Neil Merritt
- Division of Pediatric Surgery, London Health Sciences Center, London, Canada
| | - Jacob Davidson
- Division of Pediatric Surgery, London Health Sciences Center, London, Canada
| | - Jacob C Langer
- Division of General and Thoracic Surgery, Hospital for Sick Children, Toronto, Canada.,Department of Surgery, University of Toronto, Toronto, Canada
| | - Niraj Mistry
- Department of Paediatrics, University of Toronto, Toronto, Canada.,Division of Paediatric Medicine, Hospital for Sick Children, Toronto, Canada
| | - Armando J Lorenzo
- Department of Surgery, University of Toronto, Toronto, Canada.,Division of Urology, Hospital for Sick Children, Toronto, Canada
| | - Michael Temple
- Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, Canada.,Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Catharine M Walsh
- Division of Gastroenterology, Hepatology, and Nutrition, Hospital for Sick Children, Toronto, Canada.,Department of Paediatrics, University of Toronto, Toronto, Canada.,SickKids Research and Learning Institutes, Toronto, Canada
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Esparaz JR, Waters AM, Mathis MS, Mortellaro VE. Reducing Constipation-Related Admissions: The Effectiveness of Antegrade Continence Enema Procedures in Children. Am Surg 2021; 88:2327-2330. [PMID: 34060378 DOI: 10.1177/00031348211023429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Constipation in pediatrics remains a common problem. Antegrade continence enema (ACE) procedures have been shown to decrease the distress of daily therapy. Patients are able to administer more aggressive washouts in the outpatient setting. Therefore, we hypothesize that patients following an ACE procedure would have reduced admissions for constipation. METHODS Patients who underwent an ACE procedure at a large children's hospital from 2015 to 2018 were included. Demographics, diagnosis, procedure, and preoperative/postoperative hospital admissions were analyzed. RESULTS Forty-eight patients were included in the study. Over half were diagnosed with idiopathic constipation. Majority of patients underwent an appendicostomy (88%, n = 42). Preoperatively, 26 patients were admitted for a combined total of 63 times for constipation. Postoperatively, 4 patients were admitted for a total of 5 visits (P = .021). Twenty-eight patients required a nonscheduled appendicostomy tube replacement. CONCLUSION This study demonstrates ACE procedures can improve constipation-related symptoms in children and are associated with decrease hospital admissions.
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Affiliation(s)
- Joseph R Esparaz
- Division of Pediatric Surgery, 22078Children's of Alabama, Birmingham, AL, USA
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Alicia M Waters
- Division of Pediatric Surgery, 22078Children's of Alabama, Birmingham, AL, USA
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Michelle S Mathis
- Division of Pediatric Surgery, 22078Children's of Alabama, Birmingham, AL, USA
| | - Vincent E Mortellaro
- Division of Pediatric Surgery, 22078Children's of Alabama, Birmingham, AL, USA
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
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Rajindrajith S, Devanarayana NM, Thapar N, Benninga MA. Functional Fecal Incontinence in Children: Epidemiology, Pathophysiology, Evaluation, and Management. J Pediatr Gastroenterol Nutr 2021; 72:794-801. [PMID: 33534361 DOI: 10.1097/mpg.0000000000003056] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
ABSTRACT Functional fecal incontinence (FI) is a worldwide problem in children and comprises constipation-associated FI and nonretentive FI. Irrespective of pathophysiology, both disorders impact negatively on the psychological well-being and quality of life of affected children. A thorough clinical history and physical examination using the Rome IV criteria are usually sufficient to diagnose these conditions in most children. Evolving investigations such as high-resolution anorectal and colonic manometry have shed new light on the pathophysiology of functional FI. Although conventional interventions such as toilet training and laxatives successfully treat most children with constipation-associated FI, children with nonretentive FI need more psychologically based therapeutic options. Intrasphincteric injection of botulinum toxin, transanal irrigation and, in select cases, surgical interventions have been used in more resistant children with constipation-associated FI.
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Affiliation(s)
- Shaman Rajindrajith
- Department of Pediatrics, Faculty of Medicine, University of Colombo, Colombo 8
| | | | - Nikhil Thapar
- Department of Gastroenterology, Hepatology and Liver Transplant, Queensland Children's Hospital, Brisbane, Australia
| | - Marc Alexander Benninga
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Vilanova-Sanchez A, Levitt MA. Surgical Interventions for Functional Constipation: An Update. Eur J Pediatr Surg 2020; 30:413-419. [PMID: 32987436 DOI: 10.1055/s-0040-1716729] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Chronic idiopathic constipation, also known as functional constipation, is defined as difficult and infrequent defecation without an identifiable organic cause. Medical management with laxatives is effective for the majority of constipated children. However there is a subset of patients who may need evaluation by a surgeon. As constipation progresses, it can lead to fecal retention and rectal and sigmoid distension, which impairs normal colorectal motility. Surgical interventions are influenced by the results of: a rectal biopsy, transit studies, the presence of megacolon/megarectum on contrast enema, the degree of soiling/incontinence, anorectal manometry findings, and colonic motility evaluation. In this review, we describe the different surgical options available (intestinal diversion, antegrade enemas, sacral nerve stimulation, colonic resections, and Botulinum toxin injection) and provide guidance on how to choose the best procedure for a given patient.
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Affiliation(s)
- Alejandra Vilanova-Sanchez
- Deparment of Pediatric Surgery, Urogenital and Colorectal Unit, La Paz University Hospital Children Hospital, Madrid, Comunidad de Madrid, Spain
| | - Marc A Levitt
- Department of Pediatric Surgery, Children's National Medical Center, Washington, District of Columbia, United States
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Soyer T. Prevention and management of complications in various antegrade enema procedures in children: a review of the literature. Pediatr Surg Int 2020; 36:657-668. [PMID: 32185458 DOI: 10.1007/s00383-020-04635-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/06/2020] [Indexed: 12/26/2022]
Abstract
The antegrade continence enema (ACE) procedures are successful surgical options to achieve bowel cleaning in children with faecal incontinence due to a neuropathy or an anorectal malformation and an intractable constipation. The reversed and orthotopic appendicocecostomy, tubularized ileal conduit and the tubularized cecal flap are frequently applied procedures in the treatment of faecal incontinence (FI). The most common complications are the stoma stenosis, leakage, prolapse, adhesive obstruction and the difficulty in catheterization. Each procedure has its own advantages and disadvantages with different complication rates. The postoperative complications of ACE procedures may reduce patient compliance and quality of life. Most of these complications can be preventable and are easy to manage. This review aimed to discuss the prevention and management strategies for various ACE procedure complications.
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Affiliation(s)
- Tutku Soyer
- Department of Paediatric Surgery, Faculty of Medicine, Hacettepe University, Ankara, Turkey.
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Svetanoff WJ, Dekonenko C, Dorman RM, Osuchukwu O, Carrasco A, Gatti JM, Rentea RM. Optimization of Pediatric Bowel Management Using an Antegrade Enema Troubleshooting Algorithm. J Surg Res 2020; 254:247-254. [PMID: 32480068 DOI: 10.1016/j.jss.2020.04.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/17/2020] [Accepted: 04/18/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND A successful flush is the ability to flush through the appendicostomy or cecostomy channel, empty the flush through the colon, and achieve fecal cleanliness. We evaluated our experience with patients who were having flush difficulties based on a designed algorithm. METHODS Eight patients with flush difficulties were initially evaluated. Based on the need for additional surgery versus changes in bowel management therapy (BMT), we developed an algorithm to guide future management. The algorithm divided flush issues into before, during, and after flushing. Children aged <20 y who presented with flush issues from September 2018 to August 2019 were evaluated to determine our algorithm's efficacy. Specific outcomes analyzed included changes in BMT versus need for additional surgery. RESULTS After algorithm creation, 29 patients were evaluated for flush issues. The median age was 8.4 y (interquartile range: 6, 14); 66% (n = 19) were men. Underlying diagnoses included anorectal malformations (n = 17), functional constipation (n = 7), Hirschsprung's disease (n = 2), spina bifida (n = 2), and prune belly (n = 1). A total of 35 flush issues/complaints were noted: 29% before the flush, 9% during the flush, and 63% after the flush. Eighty percent of issues before the flush required surgical intervention, wherease 92% of issues during or after the flush were managed with changes in BMT. CONCLUSIONS Most flush issues respond to changes in BMT. This algorithm can help delineate which types of flush issues would benefit from surgical intervention and what problems might be present if patients are not responding to changes in their flush regimen.
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Affiliation(s)
| | | | - Robert M Dorman
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO
| | - Obiyo Osuchukwu
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO
| | - Alonso Carrasco
- Department of Urology, Children's Mercy Hospital, Kansas City, MO
| | - John M Gatti
- Department of Urology, Children's Mercy Hospital, Kansas City, MO
| | - Rebecca M Rentea
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO.
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Woodhouse F. Creating awareness of the antegrade continence enema procedure and why nurses need to know about it. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2020; 29:S16-S18. [PMID: 32207650 DOI: 10.12968/bjon.2020.29.6.s16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The antegrade continence enema (ACE) procedure is mostly associated with children. Many children who underwent this are now entering adulthood and require expert advice and support from nursing and medical services. This article describes how a poster was created to make health professionals aware of this procedure and provide advice for troubleshooting. The type of flushing solution used for irrigation still seems to be selected by trial and error, depending on what suits each individual. There is little evidence in the literature on skin management for patients practising ACE, so it is pertinent to apply the best evidence available. Adult stoma care nurses will need a detailed understanding of this technique and management in the future, as it is likely that they will be called upon for support and advice.
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Affiliation(s)
- Fran Woodhouse
- Senior Specialist Nurse, Colorectal Nursing, Oxford University Hospitals NHS Foundation Trust
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Pediatric Neurogenic Bladder and Bowel Dysfunction: Will My Child Ever Be out of Diapers? Eur Urol Focus 2020; 6:838-867. [PMID: 31982364 DOI: 10.1016/j.euf.2020.01.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 12/02/2019] [Accepted: 01/13/2020] [Indexed: 02/07/2023]
Abstract
CONTEXT Managing patient and parent expectations regarding urinary and fecal continence is important with congenital conditions that produce neurogenic bladder and bowel dysfunction. Physicians need to be aware of common treatment algorithms and expected outcomes to best counsel these families. OBJECTIVE To systematically evaluate evidence regarding the utilization and success of various modalities in achieving continence, as well as related outcomes, in children with neurogenic bladder and bowel dysfunction. EVIDENCE ACQUISITION We performed a systematic review of the literature in PubMed/Medline in August 2019. A total of 114 publications were included in the analysis, including 49 for bladder management and 65 for bowel management. EVIDENCE SYNTHESIS Children with neurogenic bladder conditions achieved urinary continence 50% of the time, including 44% of children treated with nonsurgical methods and 64% with surgical interventions. Patients with neurogenic bowel problems achieved fecal continence 75% of the time, including 78% of patients treated with nonsurgical methods and 73% with surgical treatment. Surgical complications and need for revisions were high in both categories. CONCLUSIONS Approximately half of children with neurogenic bladder dysfunction will achieve urinary continence and about three-quarters of children with neurogenic bowel dysfunction will become fecally continent. Surgical intervention can be successful in patients refractory to nonsurgical management, but the high complication and revision rates support their use as second-line therapy. This is consistent with guidelines issued by the International Children's Continence Society. PATIENT SUMMARY Approximately half of children with neurogenic bladder dysfunction will achieve urinary continence, and about three-quarters of children with neurogenic bowel dysfunction will become fecally continent. Most children can be managed without surgery. Patients who do not achieve continence with nonsurgical methods frequently have success with operative procedures, but complications and requirements for additional procedures must be expected.
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