Appendicostomy stomas and antegrade colonic irrigation after laparoscopic antegrade continence enema

Medium-term outcomes of antegrade continent enema (ACE): Cairo University Specialized Pediatric Hospital (CUSPH) experience

AIM OF THE STUDY

To assess the medium-term outcomes of ACE in children with fecal incontinence (FI).

METHOD

Eligible children were recruited from the colorectal clinic between December 2016 and January 2020 and were followed prospectively for 2-6 years. A series of questionnaires were used to assess QOL, patients and parent satisfaction, and to assess the outcomes of the ACE.

RESULT

24 children aged 6-12 years (mean age 8.17 ± 1.95), including 18 males (75%) and 6 females (25% were studied. Cases included anorectal malformations (45.83%)., Hirschsprung disease (25%), neural tube defects (16.66%), sacrococcygeal teratoma (4.16%), and intractable pseudoincontinence (8.33%). QOL improved from (3) [3 -3] to (16) [16-16],p < 0.05. Fecal incontinence index showed significant improvement: 20 [20-20] versus 3 [0-4],p < 0.05. Bowel symptoms demonstrated improvement in the ability to decide when to pass stools and a decrease in soiling. Stooling survey showed lower scores representing better outcome. ACE questionnaire showed that the range of irrigation volumes used by parents is wide, and that all families recommend the ACE for children with similar condition. Postoperative complications were stenosis (16.66%), stomal prolapse (12.5%), leakage (4.16%), and false passage (4.16%). Satisfaction questionnaire showed a median score of 9 (range, 5-10).

CONCLUSION

ACE is an effective method to keep the child with FI clean, more socially active, and with a better QOL and FII in the medium-term. The reported complications were stenosis, false passage, and leakage. ACE mucosa prolapse is a novel complication picked up on medium-term follow up.

Antegrade continence enema stoppers: a pilot study on patient preferences

BACKGROUND

Severe constipation can have a major impact on a child's quality of life and that of their families. Forming an antegrade continence enema (ACE) can be a transformational intervention to manage severe symptoms. However, operations can also have unpredictable negative consequences such as stomal stenosis or leaks from the ACE site.

AIM

To investigate whether the choice of an ACE stopper can increase patient satisfaction and compliance.

METHODS

A service evaluation with a standardised questionnaire was completed to assess quality of life and explore factors that have an impact on the preference for which ACE stopper was used.

RESULTS

In total, 17 patients completed the evaluation of all three ACE stopper devices. At least 75% of the children improved their stooling pattern with an overall satisfaction rate of 8.5 out of 10. More patients preferred a flexible stopper but no one device was strongly preferred over the others.

CONCLUSION

The study shows that an ACE has a positive impact on quality of life. With regards to the choice of ACE stopper, results show that different stoppers suit different individuals, highlighting that there is a place for a choice. This is useful information for healthcare providers who wish to improve compliance and reduce the risk of complications in this patient group.

Transumbilical laparoscopy-assisted Malone procedure for fecal incontinence in children

BACKGROUND

Transumbilical laparoscopy-assisted Malone procedure (TULAM) is a single-incision laparoscopic procedure in which the appendicostomy is made at umbilicus. The aim of this study is to evaluate the outcomes of TULAM.

METHODS

With IRB approval, the medical records of the patients who underwent TULAM were retrospectively reviewed between July 2013 and December 2018. The data collected included ages, gender, underlying diseases, operative techniques, complications, stoma continence, parental satisfaction and follow-up duration.

RESULTS

Fifteen patients underwent TULAM at the median age of 5.0 years (2.9-10.7 years). There were 4 girls and 11 boys. Thirteen patients had anorectal malformations or cloaca; the other two patients had spina bifida. All patients presented with fecal incontinence; 9 of them had concomitant constipation. TULAM was successfully accomplished in 14 patients; one patient required conversion to the three-port procedure. The median follow-up period was 1.7 years (0.5-3.2 years). One patient required tube replacement under endoscopy guidance in the operation room. One patient required surgical revision because the appendix was disrupted after an episode of enterocolitis. All patients were socially continent with antegrade enemas. 12 patients were stoma continent, and 3 patients had minor leaking less than once a month. The stoma cosmesis was satisfactory. All parents expressed satisfaction with TULAM.

CONCLUSION

TULAM is effective in the management of fecal incontinence and constipation, and provides a continent stoma with excellent cosmesis.

Neurogenic Bowel Dysfunction in Children and Adolescents

Neurogenic/neuropathic bowel dysfunction (NBD) is common in children who are affected by congenital and acquired neurological disease, and negatively impacts quality of life. In the past, NBD received less attention than neurogenic bladder, generally being considered only in spina bifida (the most common cause of pediatric NBD). Many methods of conservative and medical management of NBD are reported, including relatively recently Transanal Irrigation (TAI). Based on the literature and personal experience, an expert group (pediatric urologists/surgeons/gastroenterologists with specific experience in NBD) focused on NBD in children and adolescents. A statement document was created using a modified Delphi method. The range of causes of pediatric NBD are discussed in this paper. The various therapeutic approaches are presented to improve clinical management. The population of children and adolescents with NBD is increasing, due both to the higher survival rate and better diagnosis. While NBD is relatively predictable in producing either constipation or fecal incontinence, or both, its various effects on each patient will depend on a wide range of underlying causes and accompanying comorbidities. For this reason, management of NBD should be tailored individually with a combined multidisciplinary therapy appropriate for the status of the affected child and caregivers.

Prevention and management of complications in various antegrade enema procedures in children: a review of the literature

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.

Laparoscopic Appendicostomy Low-Profile Balloon Button for Antegrade Enemas in Children

INTRODUCTION

The Malone appendicostomy is a continent channel used for antegrade enemas. It requires daily cannulation and is susceptible to stenosis. We use an indwelling low-profile balloon button tube inserted through the appendix into the cecum for antegrade enemas. We hypothesized that this method is effective at managing constipation or fecal incontinence and is associated with a low rate of stenosis.

METHODS

Children who underwent laparoscopic appendicostomy balloon button placement at our institution from January 2011 to April 2017 were identified. The primary outcome was success in managing constipation or fecal continence as measured by the Malone continence scale. Postoperative complications were analyzed.

RESULTS

Thirty-six children underwent the procedure, 35 of which met the inclusion criteria. Thirty-one patients (88.5%) underwent the operation for idiopathic constipation, 3 patients (8.6%) for anorectal malformation, and 1 patient (2.9%) for hypermobility. Rate of open conversion was 3%. A full response was obtained in 24 patients (68.6%), partial response in 9 patients (25.7%), and 2 patients failed (5.7%). One patient developed an internal hernia requiring laparotomy and later developed mucosal prolapse. One patient developed a stricture noted at button change. Seven patients (20%) underwent reversal of their appendicostomy tube: 5 due to return of normal bowel function and 2 due to discomfort with flushes.

CONCLUSION

A laparoscopic appendicostomy with a balloon button tube is an effective means of addressing chronic constipation or fecal incontinence. The stenosis rate associated with tube appendicostomy may be lower than those reported for Malone antegrade continence enema procedures.

Laparoscopic-Assisted Percutaneous Endoscopic Cecostomy (LAPEC) in Children and Young Adults

OBJECTIVE

We evaluated the safety and efficacy of the laparoscopic-assisted percutaneous endoscopic cecostomy (LAPEC) procedure both in children and young adults, along with review of their pre-operative motility profiles, antegrade continence enema (ACE) regimen, and postoperative complications.

METHODS

This retrospective review investigated 38 patients (32 children and 6 young adults) that underwent the LAPEC procedure. Primary outcomes evaluated were success versus failure of the procedure and post-operative complications. Success was defined as daily stool evacuation with minimal to no fecal incontinence per week.

RESULTS

Mean follow up time was 25.8 ± 22.4 months. Indications for LAPEC included slow transit constipation or colonic neuropathy (n = 22), other types of constipation (n = 5), and a variety of congenital disorders (n = 11). The overall success rate was 95% (36/38 patients) with the two failures in children, both attributed to inability to use the tube due to underlying behavioral disorders or severe anxiety. Five patients above age 18 had leakage compared to 6 in the under age 18 group (83% vs. 19, P = 0.003). There were no other significant complications.

CONCLUSION

LAPEC is a safe and effective means of addressing refractory constipation and fecal incontinence in children and young adults who have failed medical management with minimal post-operative complications.

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.

Appendicostomy in preschool children with anorectal malformation: successful early bowel management with a high frequency of minor complications

Aim. The aim of this study is to evaluate postoperatively bowel symptoms of antegrade colon enema through appendicostomies in preschool children with anorectal malformation (ARM). Method. 164 children with ARM operated on with posterior sagittal anorectal plasty were included. The malformations were classified according to Krickenbeck classification. Seventeen children in preschool age had an appendicostomy. The bowel symptoms according to the Krickenbeck follow-up were analysed pre- and postoperatively. All complications were registered. A questionnaire on the use of the appendicostomy was answered. Results. The median age (range) at the time of the appendicostomy was 4 (1–6) years. The observation time was 5 (0.5–14) years. The main indications for appendicostomy were incontinence and noncompliance to rectal enemas. Postoperatively there was a significant decrease in soiling and constipation (P < 0.001). The total complication rate was 43% with infections (29%), stenosis (12%), and retrograde leakage (0). The median time required for giving enema in the appendicostomy was 45 minutes (range: 15–120) once a day varying from 2 times/week to 3 times/day. And: complications are less frequent than in older children. Conclusion. Appendicostomy in preschool children with ARM is a way to achieve fecal cleanness before school start. The infection rate was high, but other complications are less frequent than in older children.

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.

Review of organic causes of fecal incontinence in children: evaluation and treatment

Even though fecal incontinence (FI) in children is most commonly the result of functional constipation, there are organic conditions that can be associated with incontinence. FI has a major impact on the quality of life of those children who experience it. The general objectives of any bowel program are to achieve predictability and independence. This is achieved by manipulating colonic transit and stool consistency and by producing more controlled evacuations, usually with the use of rectal interventions. Dietary interventions and medications can be used to change stool consistency or to manipulate transit by accelerating or slowing it down. Biofeedback or other interventions that increase sphincter pressure can also be used to improve anorectal function. Enemas or suppositories can be used to empty the sigmoid colon in a more controlled manner. With the recent advent of the antegrade colonic enemas, the patient can have predictable bowel movements and become independent.

Quality of life in pediatric patients with unremitting constipation pre and post Malone Antegrade Continence Enema (MACE) procedure

OBJECTIVE

The primary aim of this study was to determine if there is a change in the quality of life in pediatric patients with unremitting functional constipation and/or encopresis after undergoing a MACE procedure.

METHODS

Patients, ages 5 to 18 years with unremitting constipation and a normal evaluation, including anorectal manometry and colonic manometry, who opted to undergo a MACE procedure were contacted to participate in the study. Patients with congenital anorectal malformations as well as spinal cord disorders were excluded from the study. The patient's parent/guardian completed the PedsQL(TM) Generic Core Scales QOL survey prior to the operation, 6 months, and 12 months after the procedure.

RESULTS

A total of 15 consecutive patients meeting protocol criteria were recruited within a period of 20 months. The mean age at the MACE procedure was 9.8 years (range 7.0-11.1). 5 patients were female. The mean QOL score pre-MACE was 64.1. At 6 months post-MACE the mean overall QOL score was 90.2, and it was 92.0 at 12 months. All 15 patients at the 6 month follow up had significant improvement in their QOL (p=1.9 × 10(-7)) and all subcategories of QOL were significantly improved as well.

CONCLUSIONS

A MACE procedure is of benefit to otherwise normal pediatric patients who have unremitting functional constipation with failure of medical treatment. Our patients had a significant improvement in all QOL categories and overall QOL.

The appendix as a conduit for antegrade continence enemas in patients with anorectal malformations: lessons learned from 163 cases treated over 18 years

INTRODUCTION

The antegrade continence enema (ACE) has been shown to be a safe and effective method for managing fecal incontinence in the pediatric population. The purpose of this study was to examine our experience with the ACE procedure using the appendix as a catheterizable conduit in children with anorectal malformations (ARMs).

METHODS

We reviewed the charts of all patients who underwent an ACE procedure using the appendix as a catheterizable conduit between January 1992 and January 2010. Preoperative diagnosis (ARM type), operative details, functional outcomes, and postoperative complications were assessed. Technical modifications over time included selective cecoplication, implementation of the umbilical V-V appendicoplasty technique, and laparoscopy for cecal mobilization.

RESULTS

Mean age was 9.9 ± 0.6 years, and 67% were male. The most common preoperative diagnosis was rectourethral fistula in boys (39%) and persistent cloaca in girls (61%). Forty-five complications occurred in 41 patients with an overall incidence of 25.6% (stricture, 18%; leakage, 6%; prolapse, 4%; intestinal obstruction, 0.6%). The incidence of stomal leakage was lower in patients when a cecoplication was performed (2.9% [4/138] vs 29.4% [5/17]; P < .01), and the incidence of stricture was lower in patients when the umbilical anastomosis was created using the V-V appendicoplasty technique (11% [11/100] vs 30% [18/60]; P < .01). Successful management of incontinence was reported by 96% of all patients.

CONCLUSIONS

The ACE procedure using the umbilical V-V appendicoplasty provides an effective and cosmetically superior means for bowel management in children with ARMs. The rate of late complications is not insignificant however, and preventative strategies should focus on careful operative technique and ensuring compliance with catheterization protocols well past the initial postoperative period.

Antegrade continence enema (ACE): current practice

The purpose of this study was to assess current status of antegrade continence enema (ACE) procedure taking into account the recent improvement in the technique and outcome. Reviewing our record of 48 patients with ACE procedure performed between January 2002 and May 2007, we found that the underlying diagnoses were idiopathic constipation in 56%, anorectal malformation in 31%, spina bifida in 8% and Hirschsprung's disease in 4%. Mean age of operation was 10.7 years. Appendix was used as stoma in 73% of cases. Stomal stenosis requiring revision was seen in 6% of cases and continence was achieved in 92% of cases. A systematic search of database was performed for the same period. Twenty-four studies describing 676 patients were found. The mean age was 10 years and various sites used for ACE were, right side of abdomen in 71%, umbilicus in 15% and left side of abdomen in 14%. The incidence of open and laparoscopic procedures were 87 and 13%, respectively. Appendix was used for stoma in 76% procedures. Other operative modalities were retubularised colon, retubularised ileum, caecal button and caecostomy tube, etc. The mean volume of enema fluid used was 516 ml. The mean evacuation time was 42 min. Stomal stenosis requiring revision was seen in 13% of cases. Continence was achieved in 93% of cases. There has been significant improvement in the outcome during last 5 years in comparison to the outcome published in late 1990s. Advancements in techniques, better-trained stoma care nurses and better stoma appliances could have played major role in this success.