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James CA, Hogan MJ, Seay RP, James LT, Jensen HK, Kaukis NA, Moore MB, Braswell LE. Percutaneous cecostomy: 25-year two institution experience. Pediatr Radiol 2024; 54:1137-1143. [PMID: 38693250 DOI: 10.1007/s00247-024-05936-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 04/18/2024] [Accepted: 04/19/2024] [Indexed: 05/03/2024]
Abstract
BACKGROUND Reports of technical success, adverse events, and long-term outcome of percutaneous cecostomy in children are limited. OBJECTIVE To characterize technical success, 30-day severe adverse events, and long-term outcome of percutaneous cecostomy at two centers. MATERIALS AND METHODS A retrospective review of hospital course and long-term follow-up (through May 2022) of percutaneous cecostomy tubes placed May 1997 to August 2011 at two children's hospitals was used. Outcomes assessed included technical success (defined as successful tube placement into the colon allowing antegrade colonic enemas), length of stay, 30-day severe adverse events, surgery consults, surgical repair, VP shunt infection, ongoing flushes, tube removal, duration between maintenance tube exchanges, and deaths. RESULTS A total of 215 procedures were performed in 208 patients (90 institution A, 125 institution B). Tubes were placed for neurogenic bowel (72.1%, n = 155) and functional constipation (27.9%, n = 60). Technical success was 98.1% (211/215) and did not differ between centers (p = 0.74). Surgical repair was required for bowel leakage in 5.1% (11/215) and VP shunt infection was managed in 2.1% (2/95). Compared to functional constipation, patients with neurogenic bowel had higher % tube remaining (65.3% [96/147] versus 25.9% [15/58], p < 0.001) and higher ongoing flushes at follow-up (42.2% [62/147] versus 12.1% [7/58], p < 0.001). Tube removal for dissatisfaction occurred in 15.6% [32/205] and did not differ between groups (p = 0.98). Eight deaths due to co-morbidity occurred after a median of 7.4 years (IQR 9.3) of tube access. CONCLUSION Percutaneous cecostomy is technically successful in the vast majority of patients and provided durable access in most. Bowel leakage and VP shunt infection are uncommon, severe adverse events.
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Affiliation(s)
- Charles A James
- Department of Radiology, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Slot 105, 1 Children's Way, Little Rock, 72202, AR, USA.
| | - Mark J Hogan
- Department of Radiology, Nationwide Children's Hospital, Ohio State University, Columbus, OH, USA
| | - Ryan P Seay
- Department of Radiology, Nationwide Children's Hospital, Ohio State University, Columbus, OH, USA
| | - Luke T James
- Department of Radiology, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Slot 105, 1 Children's Way, Little Rock, 72202, AR, USA
| | - Hanna K Jensen
- Department of Radiology, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Slot 105, 1 Children's Way, Little Rock, 72202, AR, USA
| | - Nicholas A Kaukis
- Department of Biostatistics, College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Mary B Moore
- Department of Radiology, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Slot 105, 1 Children's Way, Little Rock, 72202, AR, USA
| | - Leah E Braswell
- Department of Radiology, Nationwide Children's Hospital, Ohio State University, Columbus, OH, USA
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Cull JN, Jacobson DL, Lau GA, Cartwright PC, Wallis MC, Skarda D, Swendiman R, Schaeffer AJ. Internal hernia with volvulus after major abdominal reconstructions in pediatric urology - An infrequently reported and potentially devastating complication. J Pediatr Urol 2023; 19:402.e1-402.e7. [PMID: 37179198 PMCID: PMC10524189 DOI: 10.1016/j.jpurol.2023.04.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 04/02/2023] [Accepted: 04/25/2023] [Indexed: 05/15/2023]
Abstract
INTRODUCTION Enterocystoplasty (EC), appendico- or ileovesicostomy (APV), and appendicocecostomy (APC) can facilitate continence and prevent renal damage for patients with congenital urologic or bowel disease. Bowel obstruction is a well-documented complication of these procedures, and the etiology of obstruction is variable. The aim of this study is to determine the incidence and describe the presentation, surgical findings, and outcomes of bowel obstruction from internal herniation due to these reconstructions. METHODS In this single institution retrospective cohort study patients who underwent EC, APV, and/or an APC between 1/2011 and 4/2022 were identified via CPT codes within the institutional billing database. Records for any subsequent exploratory laparotomy during this same timeframe were reviewed. The primary outcome was an internal hernia of bowel into the potential space between the reconstruction and the posterior or anterior abdominal wall. RESULTS Two hundred fifty seven index procedures were performed in 139 patients. These patients were followed for a median of 60 months (IQR 35-104 months). Nineteen patients underwent a subsequent exploratory laparotomy. The primary outcome occurred in 4 patients (including one patient who received their index procedure elsewhere) for a complication rate of 1% (3/257). The complications occurred between 19 months and 9 years after their index procedure (median 5 years). Patients presented with bowel obstruction; two patients also had sudden pain following an ACE flush. One complication was caused by small bowel and cecum passing around the APC and subsequently volvulizing. A second was caused by bowel herniating behind the EC's mesentery and the posterior abdominal wall. A third was caused by bowel herniating behind the APV mesentery and subsequently volvulizing. The exact etiology of fourth internal herniation is unknown. Of the three surviving patients, all required resection of ischemic bowel and 2 required resection of the involved reconstruction. One patient died intraoperatively from cardiac arrest. Only 1 patient required a subsequent procedure to regain lost function. CONCLUSION Internal herniation caused by small or large bowel passing through a defect between the mesentery and abdominal wall or twisting around a channel occurred in 1% of 257 reconstructions performed over 11 years. This complication can arise many years after abdominal reconstruction, resulting in bowel resection and possibly takedown of the reconstruction. When anatomically possible and technically feasible, the surgeon should close any potential spaces created during the initial abdominal reconstruction.
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Affiliation(s)
- Jennison N Cull
- University of Utah, Department of Surgery (Pediatric Urology), Salt Lake City, UT, USA.
| | - Deborah L Jacobson
- University of Utah, Department of Surgery (Pediatric Urology), Salt Lake City, UT, USA
| | - Glen A Lau
- University of Utah, Department of Surgery (Pediatric Urology), Salt Lake City, UT, USA
| | - Patrick C Cartwright
- University of Utah, Department of Surgery (Pediatric Urology), Salt Lake City, UT, USA
| | - M Chad Wallis
- University of Utah, Department of Surgery (Pediatric Urology), Salt Lake City, UT, USA
| | - David Skarda
- University of Utah, Department of Surgery (Pediatric Surgery), Salt Lake City, UT, USA
| | - Robert Swendiman
- University of Utah, Department of Surgery (Pediatric Surgery), Salt Lake City, UT, USA
| | - Anthony J Schaeffer
- University of Utah, Department of Surgery (Pediatric Urology), Salt Lake City, UT, USA
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Lopez JJ, Svetanoff WJ, Bruns N, Lewis WE, Warner CN, Fraser JA, Briggs KB, Carrasco A, Gatti JM, Rosen JM, Rentea RM. Single institution review of Mini-ACE® low-profile appendicostomy button for antegrade continence enema administration. J Pediatr Surg 2022; 57:359-364. [PMID: 35090714 DOI: 10.1016/j.jpedsurg.2021.12.016] [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: 08/06/2021] [Revised: 11/29/2021] [Accepted: 12/14/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE Malone antegrade continence enemas (MACE) provide a conduit in which the patient can achieve improved continence, be clean of stool, and gain independence in maintaining bowel function. The Mini-ACE® is a low-profile balloon button that is used to facilitate the administration of antegrade enemas. We sought to describe our practice and short-term outcomes. METHODS This work is a retrospective review of the Mini-ACE® appendicostomy button from April 2019 to March 2021, with follow-up concluding in October 2021. Patient demographics, colorectal diagnoses, and outcomes were examined. RESULTS Forty-three patients underwent Mini-ACE® placement; 22 (51%) were male. The average age at Mini-ACE® insertion was 9.2 years (range 3-20 years). The most common diagnoses were functional constipation in 19 (44%), anorectal malformation in 15 (35%), and Hirschsprung disease in 3 (7%), spinal differences 3 (7%). There were no intra-operative complications, but 5 (12%) required prolapse resection. The median length of stay was two days (IQR 1, 4). Patients achieved self-catheterization at 4.5 [3,7] months from MACE creation, with 38 children (88%) reporting excellent success in remaining clean of stool. CONCLUSION The Mini-ACE® appears to be a safe and low-profile option for antegrade continence enema access. Further research is needed directly comparing complications and patient satisfaction rates between different MACE devices and overall quality of life. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Joseph J Lopez
- Comprehensive Colorectal Center - Children's Mercy Hospital/Kansas City, Kansas City, MO 64108, USA; Department of Pediatric Surgery - Children's Mercy Hospital/University of Missouri Kansas City, Kansas City, MO 64108, USA.
| | - Wendy J Svetanoff
- Department of Pediatric Surgery - Children's Mercy Hospital/University of Missouri Kansas City, Kansas City, MO 64108, USA
| | - Nicholas Bruns
- Comprehensive Colorectal Center - Children's Mercy Hospital/Kansas City, Kansas City, MO 64108, USA; Department of Pediatric Surgery - Children's Mercy Hospital/University of Missouri Kansas City, Kansas City, MO 64108, USA
| | - Wendy E Lewis
- Comprehensive Colorectal Center - Children's Mercy Hospital/Kansas City, Kansas City, MO 64108, USA; Department of Pediatric Surgery - Children's Mercy Hospital/University of Missouri Kansas City, Kansas City, MO 64108, USA
| | - Christine N Warner
- Comprehensive Colorectal Center - Children's Mercy Hospital/Kansas City, Kansas City, MO 64108, USA; Department of Pediatric Surgery - Children's Mercy Hospital/University of Missouri Kansas City, Kansas City, MO 64108, USA
| | - James A Fraser
- Department of Pediatric Surgery - Children's Mercy Hospital/University of Missouri Kansas City, Kansas City, MO 64108, USA
| | - Kayla B Briggs
- Comprehensive Colorectal Center - Children's Mercy Hospital/Kansas City, Kansas City, MO 64108, USA; Department of Pediatric Surgery - Children's Mercy Hospital/University of Missouri Kansas City, Kansas City, MO 64108, USA
| | - Alonso Carrasco
- Comprehensive Colorectal Center - Children's Mercy Hospital/Kansas City, Kansas City, MO 64108, USA; Department of Pediatric Urology - Children's Mercy Hospital/University of Missouri Kansas City, Kansas City, MO 64108, USA
| | - John M Gatti
- Comprehensive Colorectal Center - Children's Mercy Hospital/Kansas City, Kansas City, MO 64108, USA; Department of Pediatric Urology - Children's Mercy Hospital/University of Missouri Kansas City, Kansas City, MO 64108, USA
| | - John M Rosen
- Comprehensive Colorectal Center - Children's Mercy Hospital/Kansas City, Kansas City, MO 64108, USA; Department of Pediatric Gastroenterology - Children's Mercy Hospital/University of Missouri Kansas City, Kansas City, MO 64108, USA
| | - Rebecca M Rentea
- Comprehensive Colorectal Center - Children's Mercy Hospital/Kansas City, Kansas City, MO 64108, USA; Department of Pediatric Surgery - Children's Mercy Hospital/University of Missouri Kansas City, Kansas City, MO 64108, USA.
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Hooker E, Martin B, Gee O, Jester I. Antegrade continence enema stoppers: a pilot study on patient preferences. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2022; 31:770-774. [PMID: 35980916 DOI: 10.12968/bjon.2022.31.15.770] [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: 06/15/2023]
Abstract
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.
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Affiliation(s)
- Emily Hooker
- Colorectal Nurse Specialist, Birmingham Children's Hospital, Birmingham Women's and Children's NHS Foundation Trust
| | - Benjamin Martin
- Paediatric Surgery Trainee, Birmingham Children's Hospital, Birmingham Women's and Children's NHS Foundation Trust
| | - Oliver Gee
- Paediatric Surgeon, Birmingham Children's Hospital, Birmingham Women's and Children's NHS Foundation Trust
| | - Ingo Jester
- Paediatric Surgeon, Birmingham Children's Hospital, Birmingham Women's and Children's NHS Foundation Trust
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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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Sierralta Born MC, Milford K, Rickard M, Shkumat N, Amaral JG, Koyle MA, Lorenzo AJ. In-hospital resource utilization, outcome analysis and radiation exposure in children undergoing appendicostomy vs cecostomy tube placement. J Pediatr Urol 2020; 16:648.e1-648.e8. [PMID: 32830062 DOI: 10.1016/j.jpurol.2020.07.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 07/09/2020] [Accepted: 07/15/2020] [Indexed: 11/17/2022]
Abstract
INTRODUCTION AND OBJECTIVES Continence enemas for the purpose of bowel management may be delivered via trans-anal retrograde irrigations, and via antegrade conduits including surgical appendicostomy or placement of cecostomy tube (CT). An appreciation of the relative advantages and disadvantages of each antegrade continence enema (ACE) procedure allows clinicians, parents and children to make an informed decision regarding which procedure is most appropriate in individual cases. The objective of this study was to evaluate the differences in in-hospital resource utilization, surgical outcomes and radiation exposure between children undergoing appendicostomy creation and CT placement at our institution. METHODS We conducted a retrospective chart review of children undergoing these procedures at our institution over a 10-year period. All patients 0-18 years of age undergoing either procedure for any indication were included. Data on demographics, length of stay (LOS), radiation exposure events (REE), and surgical outcomes were collected. RESULTS One hundred fifteen (63 appendicostomy/52 CT) patients were included. Those undergoing CT placement had significantly increased post-procedural LOS, catheter exchanges and REE compared to those undergoing appendicostomy (see Table). Reported rates of bowel control were similar between the two groups, and there was no significant difference in rates of surgical complications, although each group had unique, procedure-specific complications. DISCUSSION AND CONCLUSION In our study, appendicostomy holds a clear advantage over CT in terms of post-procedural LOS, as well as REE. In general, children with CTs require more planned and unplanned device maintenance procedures than those with appendicostomy. These findings aside, the rates of success for bowel control between the two groups are similar, and the incidence of complications does not differ significantly between the two groups. CT remains a safe and effective conduit for delivery of ACEs, and is a particularly good option in patients whose appendix has been lost or used for another conduit. However, patients wishing to avoid repeated procedures and radiation exposure may find the option of appendicostomy more attractive.
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Affiliation(s)
- María Consuelo Sierralta Born
- The Division of Urology, The Hospital for Sick Children, University of Toronto, Toronto, Canada; The Division of Urology, Dr Luis Calvo Mackenna Children's Hospital, Santiago, Chile
| | - Karen Milford
- The Division of Urology, The Hospital for Sick Children, University of Toronto, Toronto, Canada.
| | - Mandy Rickard
- The Division of Urology, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Nicholas Shkumat
- Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Joao G Amaral
- Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Martin A Koyle
- The Division of Urology, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Armando J Lorenzo
- The Division of Urology, The Hospital for Sick Children, University of Toronto, Toronto, Canada.
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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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