Long-term results of the antegrade continent enema procedure for constipation in adults

The appendix conduit with a conflict of interests - An alternate strategy

INTRODUCTION

Conventionally the split appendix has been used to address the need for dual conduits such as the Mitrofanoff and the ACE, however limited by its length. We present a video demonstration of an alternate solution.

MATERIAL AND METHODS

Size-12 Nelaton catheter introduced via appendicular stump and skirted along the lateral wall of the caecum. Ethicon Endopath 35 mm Linear Stapler was used to create a caecal tube of about 3 cm based on the appendicular stump.

RESULTS

From September 2019-January 2023, 6-patients, aged 5-18 years with a diagnoses of 4-spinal dysraphisms, 1-cloacal anomaly, and 1-urogenital sinus were included.

FOLLOW UP

5-45 months. Two patients had ACE site infection which resolved with antibiotics. One developed a stomal granuloma treated effectively with silver nitrate. All are clean with no stomal leaks and experience easy intubation.

DISCUSSION

Alternatives to the split appendix include the Monti ACE, and Caecostomy tube/caecal flap when limited by appendicular length. The technique described is easy and quick however care must be taken to keep away from the ileo-caecal junction and to keep the tube length as short as possible or needed to preserve vascularity.

CONCLUSIONS

The stapled caecal tube ACE is easy, quick, and safe especially when limited by appendicular length.

Surgery for chronic idiopathic constipation: pediatric and adult patients - a systematic review

BACKGROUND

Chronic idiopathic constipation (CIC) is a substantial problem in pediatric and adult patients with similar symptoms and workup; however, surgical management of these populations differs. We systematically reviewed the trends and outcomes in the surgical management of CIC in pediatric and adult populations.

METHODS

A literature search was performed using Ovid MEDLINE, Embase, Scopus, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov between January 1, 1995 and June 26, 2020. Clinical trials and retrospective and prospective studies of patients of any age with a diagnosis of CIC with data of at least 1 outcome of interest were selected. The interventions included surgical resection for constipation or antegrade continence enema (ACE) procedures. The outcome measures included bowel movement frequency, abdominal pain, laxative use, satisfaction, complications, and reinterventions.

RESULTS

Adult patients were most likely to undergo resection (94%), whereas pediatric patients were more likely to undergo ACE procedures (96%) as their primary surgery. Both ACE procedures and resections were noted to improve symptoms of CIC; however, ACE procedures were associated with higher complication and reintervention rates.

CONCLUSION

Surgical management of CIC in pediatric and adult patients differs with pediatric patients receiving ACE procedures and adults undergoing resections. The evaluation of resections and long-term ACE data in pediatric patients should be performed to inform patients and physicians whether an ACE is an appropriate procedure despite high complication and reintervention rates or whether resections should be considered as an initial approach for CIC.

Idiopathic Slow Transit Constipation: Pathophysiology, Diagnosis, and Management

Slow transit constipation (STC) has an estimated prevalence of 2-4% of the general population, and although it is the least prevalent of the chronic constipation phenotypes, it more commonly causes refractory symptoms and is associated with significant psychosocial stress, poor quality of life, and high healthcare costs. This review provides an overview of the pathophysiology, diagnosis, and management options in STC. STC occurs due to colonic dysmotility and is thought to be a neuromuscular disorder of the colon. Several pathophysiologic features have been observed in STC, including reduced contractions on manometry, delayed emptying on transit studies, reduced numbers of interstitial cells of Cajal on histology, and reduced amounts of excitatory neurotransmitters within myenteric plexuses. The underlying aetiology is uncertain, but autoimmune and hormonal mechanisms have been hypothesised. Diagnosing STC may be challenging, and there is substantial overlap with the other clinical constipation phenotypes. Prior to making a diagnosis of STC, other primary constipation phenotypes and secondary causes of constipation need to be ruled out. An assessment of colonic transit time is required for the diagnosis and can be performed by a number of different methods. There are several different management options for constipation, including lifestyle, dietary, pharmacologic, interventional, and surgical. The effectiveness of the available therapies in STC differs from that of the other constipation phenotypes, and prokinetics often make up the mainstay for those who fail standard laxatives. There are few available management options for patients with medically refractory STC, but patients may respond well to surgical intervention. STC is a common condition associated with a significant burden of disease. It can present a clinical challenge, but a structured approach to the diagnosis and management can be of great value to the clinician. There are many therapeutic options available, with some having more benefits than others.

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.

Enema-Induced spastic left colon syndrome: An unintended consequence of chronic enema use

BACKGROUND/PURPOSE

Enemas have become a common practice for treating fecal incontinence and severe constipation. Several patients receiving enemas complained of severe, colicky, abdominal pain during enema administration and complained that the duration for fluid to pass was progressively increasing. Contrast studies showed a startling picture of severe right colon dilatation and a spastic, narrow, left colon. An investigation was started to seek the origin and possible management of this condition.

METHODS

Medical and radiologic records were reviewed retrospectively, with emphasis on the type and ingredients of enemas used, the duration the patients had been receiving enemas, and their original diagnosis. A literature review was done on previous reports of this condition and publications related to long-term use of enemas.

RESULTS

This series included 22 patients (average age, 19.6 years; range, 8-54) with fecal incontinence due to anorectal malformations (10 cases), myelomeningocele (5), cloaca (2), severe colonic dysmotility (2), Hirschsprung's disease (2), and sacrococcygeal teratoma (1). The average duration of enema use was 13.7 years (range, 4-45). The composition of the enemas included saline/glycerin (six cases), only saline solution (five), saline/glycerin/soap (four), plain water (three), and one case each of molasses/milk, saline/glycerin/soap/phosphate, saline/phosphate, and only phosphate. The enemas were performed in an antegrade fashion in 21 cases and rectally in 1. All patients had a dilated right colon and a narrow, spastic, left, transverse, and descending colon. Four patients underwent colonoscopy, colonic manometry, and mucosal biopsies, which did not help in explaining the etiology of the problem. In the literature, 43 reports mentioned a "long-term follow-up" for the administration of enemas, but we could not find a description of symptoms, such as in our cases.

CONCLUSIONS

An intriguing and, to our knowledge, previously unreported complication of chronic enema use is presented. We call attention to an overly concerning complication and report our findings in the hope that they will aid and stimulate more investigations into this condition. Several hypotheses to explain the cause are presented, as well as potential treatment options.

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.

Refractory Constipation: What is the Clinician to Do?

Most clinicians will agree that chronic constipation is characterized by abnormal bowel movement consistency and/or frequency plus or minus evacuation symptoms, but patient perception of constipation varies widely and includes symptoms that may or may not meet official defining criteria. Although intermittent constipation is extremely common, only a small minority of patients seek care for their symptoms. Among these patients, dissatisfaction with the currently available laxative options is not uncommon, and many patients will require specialized care for severe or refractory symptoms-especially those with abdominal pain, irritable bowel syndrome overlap, bloating or distention, and psychological comorbidities. This review outlines a physiological assessment of the patient with refractory constipation, exploring treatment options among patients with slow transit, rectal evacuation disorders, and normal transit. In addition, we explore nonlaxative approaches to normal-transit patients bothered by ongoing symptoms, with an emphasis on the biopsychosocial model of functional gastrointestinal disease and treatment of visceral hypersensitivity using neuromodulators. Finally, we propose a comprehensive evaluation algorithm for the management of patients with refractory slow-transit constipation considering surgery and examine surgical options including colectomy and cecostomy using an antegrade continent enema.

Surgical Interventions and the Use of Device-Aided Therapy for the Treatment of Fecal Incontinence and Defecatory Disorders

The purpose of this clinical practice update expert review is to describe the key principles in the use of surgical interventions and device-aided therapy for managing fecal incontinence (FI) and defecatory disorders. The best practices outlined in this review are based on relevant publications, including systematic reviews and expert opinion (when applicable). Best Practice Advice 1: A stepwise approach should be followed for management of FI. Conservative therapies (diet, fluids, techniques to improve evacuation, a bowel training program, management of diarrhea and constipation with diet and medications if necessary) will benefit approximately 25% of patients and should be tried first. Best Practice Advice 2: Pelvic floor retraining with biofeedback therapy is recommended for patients with FI who do not respond to the conservative measures indicated above. Best Practice Advice 3: Perianal bulking agents such as intra-anal injection of dextranomer may be considered when conservative measures and biofeedback therapy fail. Best Practice Advice 4: Sacral nerve stimulation should be considered for patients with moderate or severe FI in whom symptoms have not responded after a 3-month or longer trial of conservative measures and biofeedback therapy and who do not have contraindications to these procedures. Best Practice Advice 5: Until further evidence is available, percutaneous tibial nerve stimulation should not be used for managing FI in clinical practice. Best Practice Advice 6: Barrier devices should be offered to patients who have failed conservative or surgical therapy, or in those who have failed conservative therapy who do not want or are not eligible for more invasive interventions. Best Practice Advice 7: Anal sphincter repair (sphincteroplasty) should be considered in postpartum women with FI and in patients with recent sphincter injuries. In patients who present later with symptoms of FI unresponsive to conservative and biofeedback therapy and evidence of sphincter damage, sphincteroplasty may be considered when perianal bulking injection and sacral nerve stimulation are not available or have proven unsuccessful. Best Practice Advice 8: The artificial anal sphincter, dynamic graciloplasty, may be considered for patients with medically refractory severe FI who have failed treatment or are not candidates for barrier devices, sacral nerve stimulation, perianal bulking injection, sphincteroplasty and a colostomy. Best Practice Advice 9: Major anatomic defects (eg, rectovaginal fistula, full-thickness rectal prolapse, fistula in ano, or cloaca-like deformity) should be rectified with surgery. Best Practice Advice 10: A colostomy should be considered in patients with severe FI who have failed conservative treatment and have failed or are not candidates for barrier devices, minimally invasive surgical interventions, and sphincteroplasty. Best Practice Advice 11: A magnetic anal sphincter device may be considered for patients with medically refractory severe FI who have failed or are not candidates for barrier devices, perianal bulking injection, sacral nerve stimulation, sphincteroplasty, or a colostomy. Data regarding efficacy are limited and 40% of patients had moderate or severe complications. Best Practice Advice 12: For defecatory disorders, biofeedback therapy is the treatment of choice. Best Practice Advice 13: Based on limited evidence, sacral nerve stimulation should not be used for managing defecatory disorders in clinical practice. Best Practice Advice 14: Anterograde colonic enemas are not effective in the long term for management of defecatory disorders. Best Practice Advice 15: The stapled transanal rectal resection and related procedures should not be routinely performed for correction of structural abnormalities in patients with defecatory disorders.

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.

Constipation: Pathophysiology and Current Therapeutic Approaches

Chronic constipation is a common, persistent condition affecting many patients worldwide, presenting significant economic burden and resulting in substantial healthcare utilization. In addition to infrequent bowel movements, the definition of constipation includes excessive straining, a sense of incomplete evacuation, failed or lengthy attempts to defecate, use of digital manoeuvres for evacuation of stool, abdominal bloating, and hard consistency of stools. After excluding secondary causes of constipation, chronic idiopathic or primary constipation can be classified as functional defecation disorder, slow-transit constipation (STC), and constipation-predominant irritable bowel syndrome (IBS-C). These classifications are not mutually exclusive and significant overlap exists. Initial therapeutic approach to primary constipation, regardless of aetiology, consists of diet and lifestyle changes such as encouraging adequate fluid and fibre intake, regular exercise, and dietary modification. Laxatives are the mainstay of pharmacologic treatment for potential long-term therapy in patients who do not respond to lifestyle or dietary modification. After a failed empiric trial of laxatives, diagnostic testing is necessary to understand underlying anorectal and/or colonic pathophysiology. No single test provides a comprehensive assessment for primary constipation; therefore, multiple tests are used to provide complementary information to one another. Dyssynergic defecation, a functional defecation disorder, is an acquired behavioural disorder of defecation present in two-thirds of adult patients, where an inability to coordinate the abdominal, recto-anal, and pelvic floor muscles during attempted defecation exists. Biofeedback therapy is the mainstay treatment for dyssynergic defecation aimed at improving coordination of abdominal and anorectal muscles. A large percentage of patients with dyssynergic defecation also exhibit rectal hyposensitivity and may benefit from the addition of sensory retraining. Our understanding of the pathophysiology of STC is evolving. The advent of high-resolution colonic manometry allows for the improved identification of colonic motor patterns and may provide further insight into pathophysiological mechanisms. In a minority of cases of STC, identification of colonic neuropathy suggests a medically refractory condition, warranting consideration of colectomy. The pathophysiology of IBS-C is poorly understood with multiple etiological factors implicated. Pharmacological advances in the treatment of primary constipation have added therapeutic options to the armamentarium of this disorder. Drug development in the secretagogue, serotonergic prokinetic, and ileal bile acid transporter inhibition pathways has yielded current and future medical treatment options for primary chronic constipation.

Associated Factors for Antegrade Continence Enemas for Refractory Constipation and Fecal Incontinence

OBJECTIVE

Determine clinical and manometric parameters associated with success of antegrade continence enemas (ACEs) administered via cecostomy in the treatment of constipation and fecal overflow incontinence.

METHODS

We performed a retrospective review of clinical symptoms and manometry (colonic and anorectal) before cecostomy in 40 pediatric patients (20 males, 20 females). The mean age at time of follow-up was 9.5 ± 4.4 years with a mean follow-up time of 12.2 ± 10.9 months. Clinical outcomes were defined as good, if subjects had >3 bowel movements per week, <2 episodes of soiling per week, and absence of pain at the time of follow-up after cecostomy.

RESULTS

Before cecostomy, the mean duration of constipation and/or fecal incontinence was 7.7 ± 4.4 years, mean number of BMs was 1.5 ± 0.9 per week, and soiling episodes 4.12 ± 3.5 per week; 24 (60%) patients had abdominal pain. At follow-up 30 out of 40 patients had a good outcome, and 10 had a poor outcome; with a difference in the number of weekly BM of 5.7 ± 2.2 versus 1.5 ± 0.9, P < 0.001, and soiling episodes (0.4 ± 1.5 vs 4 ± 3.1, P < 0.001). There was no difference in the duration of symptoms between groups. Obesity was more common in the poor-outcome group, 60% versus 21% (P = 0.01). Abdominal pain was more common in the poor-outcome group, 100% versus 47% (P = 0.003). Normal colonic manometry was associated with good outcome, whereas absence of high-amplitude propagating contraction (HAPC) in any part of the colon was associated with poor outcome. No other differences in colonic manometry were observed between the good- and poor-outcome groups with the exception of a trend toward decreased number of sigmoid HAPCs in the poor-outcome group (P = 0.07). No differences were observed in anorectal manometry measurements between good- and poor-outcome groups with the exception of an observable increased baseline resting pressure in the poor outcome (P = 0.05).

CONCLUSIONS

Obesity and abdominal pain tend to be associated with poor outcomes after cecostomy for refractory constipation. Normal colonic and anorectal manometry were associated with good outcome. Absence of HAPC in any part of the colon, and increased baseline resting pressure of the anal canal were more associated with poor outcome. No other specific differences in either colonic or anorectal manometric parameters were observed in patients with good versus poor outcomes with cecostomy. Large prospective studies potentially combining other diagnostic modalities such as colonic transit studies are needed to determine the optimal tests to predict successful outcomes from cecostomy.

Diagnosis and management of chronic constipation in adults

Constipation is a heterogeneous, polysymptomatic, multifactorial disease. Acute or transient constipation can be due to changes in diet, travel or stress, and secondary constipation can result from drug treatment, neurological or metabolic conditions or, rarely, colon cancer. A diagnosis of primary chronic constipation is made after exclusion of secondary causes of constipation and encompasses several overlapping subtypes. Slow-transit constipation is characterized by prolonged colonic transit in the absence of pelvic floor dysfunction. This subtype of constipation can be identified using either the radio-opaque marker test or wireless motility capsule test, and is best treated with laxatives such as polyethylene glycol or newer agents such as linaclotide or lubiprostone. If unsuccessful, subspecialist referral should be considered. Dyssynergic defecation results from impaired coordination of rectoanal and pelvic floor muscles, and causes difficulty with defecation. The condition can be identified using anorectal manometry and balloon expulsion tests and is best managed with biofeedback therapy. Opioid-induced constipation is an emerging entity, and several drugs including naloxegol, methylnaltrexone and lubiprostone are approved for its treatment. In this Review, we provide an overview of the burden and pathophysiology of chronic constipation, as well as a detailed discussion of the available diagnostic tools and treatment options.

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.

The antegrade continence enema procedure and total anorectal reconstruction

Patients may present with anal incontinence (AI) following repair of a congenital anorectal anomaly years previously, or require total anorectal reconstruction (TAR) following radical rectal extirpation, most commonly for rectal cancer. Others may require removal of their colostomy following sphincter excision for Fournier's gangrene, or in cases of severe perineal trauma. Most of the data pertaining to antegrade continence enema (the ACE or Malone procedure) comes from the pediatric literature in the management of children with AI, but also with supervening chronic constipation, where the quality of life and compliance with this technique appears superior to retrograde colonic washouts. Total anorectal reconstruction requires an anatomical or physical supplement to the performance of a perineal colostomy, which may include an extrinsic muscle interposition (which may or may not be 'dynamized'), construction of a neorectal reservoir, implantation of an incremental artificial bowel sphincter or creation of a terminal, smooth-muscle neosphincter. The advantages and disadvantages of these techniques and their outcome are presented here.

Review of sacral neuromodulation for management of constipation

BACKGROUND

Sacral neuromodulation (SN) is an emerging treatment for constipation. This review evaluates the mechanism of action, techniques, efficacy, and adverse effects of SN in the management of constipation.

METHODS

Electronic searches for studies describing the use of SN were performed in PubMed, MEDLINE and Embase. Abstracts were reviewed and full text copies of all relevant articles obtained.

RESULTS

Fifty-nine results were obtained on the initial searches. Ten studies discussed the results of SN in patients with constipation. A total of 225 temporary neuromodulations and 125 permanent implants were performed. Bowel diaries showed improvement in assessment criteria in more than 50% of patients on temporary neuromodulation and the results were maintained in approximately 90% of patients who underwent permanent implantation over medium to long-term follow-up. The rate of adverse effects was high, but the majority of them were related to electrode position. Improvements in transit studies and anorectal physiology after neuromodulation were noted in some studies. The recognized limitations included a lack of randomized studies and an inability to perform meta-analysis.

CONCLUSION

Sacral neuromodulation may be an effective treatment in selected patients with constipation and should be a part of the management repertoire. Improvement in defecatory frequency with temporary wire placement is a good predictor of subsequent response following permanent implant. Further research into predictive factors for success would improve patient selection.

Tissue engineering for neuromuscular disorders of the gastrointestinal tract

The digestive tract is designed for the optimal processing of food that nourishes all organ systems. The esophagus, stomach, small bowel, and colon are sophisticated neuromuscular tubes with specialized sphincters that transport ingested food-stuffs from one region to another. Peristaltic contractions move ingested solids and liquids from the esophagus into the stomach; the stomach mixes the ingested nutrients into chyme and empties chyme from the stomach into the duodenum. The to-and-fro movement of the small bowel maximizes absorption of fat, protein, and carbohydrates. Peristaltic contractions are necessary for colon function and defecation.

The impact of transcutaneous electrical stimulation therapy on appendicostomy operation rates for children with chronic constipation--a single-institution experience

PURPOSE

Appendicostomy for antegrade continence enema is a minimally invasive surgical intervention that has helped many children with chronic constipation. At our institution, since 2006, transcutaneous electrical stimulation (TES) has been trialed to treat slow-transit constipation (STC) in children. This retrospective audit aimed to determine if TES use affected appendicostomy-formation rates and to monitor changes in practice. We hypothesized that appendicostomy rates have decreased for STC but not for other indications.

METHODS

Appendicostomy-formation rate was determined for the 5 years before and after 2006. Children were identified as STC or non-STC from nuclear transit scintigraphy and patient records.

RESULTS

Since 1999, 317 children were diagnosed with STC using nuclear transit scintigraphy with 121 during 2001 to 2005 (24.2/year) and 147 during 2006 to 2010 (29.4/year). Seventy-four children had appendicostomy formation. For 2001 to 2005, appendicostomy-formation rates for STC and non-STC children were similar: 5.4 per year (n = 27) and 4.8 per year (n = 24), respectively. For 2006 to 2010, appendicostomy-formation rates were 1.2 per year (n = 6) for STC and 3.2 per year (n = 16) for non-STC (χ(2), P = .04).

CONCLUSION

Since 2006, appendicostomy-formation rates have significantly reduced in STC but not in non-STC children at our institute, coinciding with the introduction of TES as an alternative treatment for STC. Transcutaneous electrical stimulation has not been tested on non-STC children in this period.

Sacral neuromodulation for the management of severe constipation: development of a constipation treatment protocol

BACKGROUND

Constipation is a common multifactorial gastrointestinal symptom with quality of life implications. Sacral neuromodulation has been used in the management of severe constipation with mixed results. The aim of this study was to review our experience of sacral neuromodulation as a treatment for chronic constipation and develop a chronic constipation management protocol.

METHODS

In patients with severe constipation, failure of conservative management including biofeedback and rectal irrigation were considered for neuromodulation. Temporary stimulation lead was placed in the sacral foramen of eligible patients and pre and post stimulation bowel diaries were compared. Patients with ≥50% improvement in bowel diaries had permanent implant. Patients were followed up at 2 and 4 weeks, 3, 6, and 12 months, and then yearly with bowel diaries.

RESULTS

Temporary neuromodulation wires were implanted in 21 patients (20 female). Significant bowel diary improvement was seen in 12 (57%) patients (p < 0.01). Eleven permanent implants have been performed. Improvement in symptoms was lost in one patient. No major side effects were observed. Three patients have had reoperations (one wire fracture, one reposition of battery, and one poor initial lead placement). Improvements in bowel diaries have been maintained over a median follow-up period of 38 months (18-62 months).

CONCLUSION

Sacral neuromodulation can provide long-term symptom relief in selected patients with severe constipation. Sacral neuromodulation should be incorporated into the treatment algorithm for chronic constipation.

Surgical treatment for constipation in children and adults

Functional constipation is one of the most common gastrointestinal disorders. In both children and adults, most patients are managed conservatively with good results. In this review, we focus on the surgical approach to constipation. Patients who lack the capacity to consistently have voluntary bowel movements may need mechanical emptying of the colon through an enema program; for them, surgery to allow for antegrade enemas, (via the appendix or using a button device) is useful. Those patients with severe constipation not responsive to intense medical treatment may be candidates for other surgical interventions, such as resection of the dysfunctional colonic segment (rectosigmoid or whole colon), or plication, -pexy, and STARR techniques for evacuatory disorders secondary to obstructive anatomical features. Permanent stomas are an option of last resort.

Constipation and obstructed defecation

Difficulties with bowel function are common and may be due to several causes including slow colonic transit and obstructed defecation. The anatomical and pathophysiological changes associated with these conditions are varying, often incompletely understood, and in many cases have limited treatment outcomes. Patients present with variable complaints and have previously tried a plethora of over-the-counter medications in an effort to relieve their symptoms. Physicians need an organized approach to manage these patients optimally. Improvements over the past few years in our understanding of the complex process of defecation, along with the increasing use of radiological and anorectal physiology studies, have led to improved treatment results.

Surgical management of constipation

This review addresses the range of operations suggested to be of contemporary value in the treatment of constipation with critical evaluation of efficacy data, complications, patient selection, controversies and areas for future research.

Constipation in old age

The prevalence of constipation increases with age. However, constipation is not a physiological consequence of normal ageing. Indeed, the aetiology of constipation in older people is often multifactorial with co-morbid diseases, impaired mobility, reduced dietary fibre intake and prescription medications contributing significantly to constipation in many instances. A detailed clinical history and physical examination including digital rectal examination is usually sufficient to uncover the causes of constipation in older people; more specialized tests of anorectal physiology and colonic transit are rarely required. The scientific evidence base from which to develop specific treatment recommendations for constipation in older people is, for the most part, slim. Constipation can be complicated by faecal impaction and incontinence, particularly in frail older people with reduced mobility and cognitive impairment; preventative strategies are important in those at risk.

After the honeymoon comes divorce: long-term use of the antegrade continence enema procedure

BACKGROUND

Having reported that 18% of children discontinue use of the antegrade continence enema (ACE) after 5 years, we aimed to determine long-term use after an ACE procedure.

METHODS

A postal/telephone questionnaire was conducted. Subjects were consecutive children undergoing an ACE between 1993 and 1999. Outcome measures were use of ACE, reasons for nonuse, complications, and overall satisfaction.

RESULTS

Of 84 eligible subjects, data were available on 61 (73%) aged 22.4 years (15.5-35.1 years). Underlying diagnoses included spina bifida (n = 27), anorectal malformations (n = 18), constipation (n = 11), Hirschsprung's disease (n = 1), sacral agenesis (n = 2), and trauma/tumor (n = 2). Follow-up was 11.02 years (8.34-14.39 years). Thirty-six (59%) of 61 patients were still using their ACE. Reasons for nonuse were lack of effectiveness (n = 14), complications (n = 5), psychologic issues (n = 2), and poor compliance (n = 2). There was no association between diagnosis and nonuse (chi(2), P = .63). In those still using ACE, the overall satisfaction score was 4.1 (1-5). Several individuals reported feeling abandoned on becoming adults and losing the support they had in childhood.

CONCLUSION

There is a late "failure" rate for the ACE procedure. However, satisfaction was high among those still using the ACE. This study further emphasizes the need for robust transitional care arrangements.

Management of chronic constipation in the elderly

Constipation is a significant healthcare problem in the elderly. However, while undoubtedly common in the elderly, data on the prevalence of constipation in general and of its subtypes vary considerably, depending on the nature of the study population and their location. Furthermore, the complexity of the pathophysiology of constipation in this age group is little appreciated. Assumptions regarding 'age-related changes in colorectal physiology' are, for the most part, not supported by scientific evidence and may serve to distract the clinician from uncovering the contributions of co-morbid diseases and the impact of iatrogenic factors. The evidence base from which one can develop recommendations on the management of constipation in the elderly is, for the most part, slim. This becomes most starkly apparent when one attempts to critically assess specific approaches to management. There is insufficient evidence to support the use of many commonly used laxatives both in the general population and in the elderly. Lifestyle interventions have value for some patients but data are lacking on the benefits of these interventions for patients with chronic constipation. Data in the elderly do not exist for most new pharmacological approaches to constipation. Pending the availability of good data, management of constipation in the elderly should be tailored to each individual's needs and expectations, regardless of age or place of residence. In certain situations, constipation may be complicated by the development of impaction; preventive strategies are important in this context. We urge enrolment of many more elderly individuals with chronic constipation in clinical trials designed to address their particular needs.

Surgery and sacral nerve stimulation for constipation and fecal incontinence

Fecal continence is a complex bodily function, which requires the interplay of sensation, rectal capacity, and anal neuromuscular function. Fecal incontinence affects approximately 2% of the population and has a prevalence of 15% in elderly patients. Constipation is one of the most common gastrointestinal disorders. The variety of symptoms and risk factors suggest a multifactorial origin. Before any invasive intervention, the surgeon should have a thorough understanding of the etiology of these conditions. Appropriate medical management can improve symptoms in the majority of patients. Surgery is indicated when all medical possibilities are exhausted. This review discusses the most used surgical procedures emphasizing the latest experiences. Sacral nerve stimulation (SNS) is a promising option for patients with fecal incontinence and constipation. The procedure affords patients improved continence and quality of life. The mechanism of action is still poorly understood. This treatment has been used before in other more invasive surgical procedures or even after their failure to improve patients' symptoms and avoid a definitive stoma. Before any invasive intervention, the surgeon should have a thorough understanding of the etiology of these conditions. Appropriate medical management can improve symptoms in the majority of patients. Surgery is indicated when all medical possibilities are exhausted. This review discusses the most used surgical procedures emphasizing the latest experiences. Sacral nerve stimulation (SNS) is a promising option for patients with fecal incontinence and constipation. The procedure affords patients improved continence and quality of life. The mechanism of action is still poorly understood. This treatment has been used before in other more invasive surgical procedures or even after their failure to improve patients' symptoms and avoid a definitive stoma.

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.

Surgical treatment of patients with constipation and fecal incontinence

Patients with constipation and fecal incontinence usually come to the attention of the surgeon when conservative measures have failed to alleviate sufficiently severe symptoms. Following detailed clinical and physiologic assessment, the surgeon should tailor the procedure to specific underlying physiologic abnormalities to restore function. This article describes the rationale, indications (including patient selection), results, and current position controversies of surgical procedures for constipation and fecal incontinence, dividing these into those regarded as historical, contemporary, or evolving. Reported surgical outcome data must be interpreted with caution because for most studies the evidence is of low quality, making comparison of different procedures problematic and emphasizing the need for better designed and conducted clinical trials.

Slow transit constipation: a review of a colonic functional disorder

Constipation is a common gastrointestinal complaint that can cause significant physical and psychosocial problems. It has been categorized as slow transit constipation, normal transit constipation, and obstructed defecation. Both the definition and pathophysiology of constipation are unclear, but attempts to describe each of the three types have been made. Slow transit constipation, a functional colonic disorder represents approximately 15 to 30% of constipated patients. The theorized etiologies are disorders of the autonomic and enteric nervous system and/or a dysfunctional neuroendocrine system. Slow transit constipation can be diagnosed with a complete history, physical exam, and a battery of specific diagnostic studies. Once the diagnosis is affirmed and medical management has failed, there are several treatment options. Biofeedback, sacral nerve stimulation, segmental colectomy, and subtotal colectomy with various anastomoses have all been used. Of those treatment options, a subtotal colectomy with ileorectal anastomosis is the most efficacious with the data to support its use.

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.

Anorectal manovolumetry in the decision making before surgery for slow transit constipation

BACKGROUND

Colectomy with ileorectal anastomosis for slow transit constipation (STC) is being challenged by other operations, such as segmental resections. The importance of preoperative anorectal physiology testing may therefore be increased. The aim of this study was to identify anorectal abnormalities in patients with STC, which may influence the surgical approach.

METHODS

Fifty consecutive patients with STC (43 women; median age, 49 years) and 28 controls (23 women; median age, 50 years) were examined with anorectal manovolumetry. Anal pressures and rectal volumes were recorded, at stepwise rectal distension.

RESULTS

Anal resting pressure was lower in patients (median, 54 cm H(2)O; range, 22-130) than in controls (median, 68 cm H(2)O; range, 35-100) (p<0.05). Squeeze pressure tended to be lower in patients (median, 147 cm H(2)O; range, 53-382) than in controls (median, 177 cm H(2)O; range, 65-423) (p=0.09). Rectal sensory thresholds did not differ significantly between patients and controls, although 10 patients had a threshold for filling above the 95(th) percentile of controls. Rectal compliance was increased in patients in the pressure interval 5-35 cm H(2)O (p<0.05-0.01). The threshold and amplitude of the recto-anal inhibitory reflex did not differ significantly, but the recovery of resting pressure after eliciting the reflex was lower in patients than in controls in the pressure interval 10-50 cm H(2)O (p<0.05-0.001).

CONCLUSIONS

More than half of the patients with STC deviated in some parameter. An impaired internal sphincter function and increased rectal compliance were seen. One fifth of the patients had impaired rectal sensation.

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.

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.

Malone antegrade continent enema: an alternative to resection in severe defecation disorders

PURPOSE

This study was designed to evaluate patient self-reported outcome of the Malone antegrade continent enema at a single institution in patients suffering from severe defecatory disorders.

METHODS

A total of 18 patients (15 females; median age, 31 (range, 12-63) years) underwent a Malone antegrade continent enema (August 1999 to September 2004). The Malone antegrade continent enema technique has been previously described; however, in this series emphasis was placed on method appendix tunneling. Patients' charts were reviewed and follow-up telephone interviews were conducted. Indications for Malone antegrade continent enema were chronic constipation (n = 12), intractable fecal incontinence (n = 5), or both (n = 1). The underlying pathology included neurogenic (n = 2), congenital (n = 4), postsurgery-related (n = 4), irritable bowel syndrome (n = 6), and megarectum (n = 2). The appendix (n = 17) or cecum (n = 1) was used as a conduit.

RESULTS

The mean follow-up was 18.5 (range, 3-67) months. Fourteen patients (78 percent) still use the Malone antegrade continent enema routinely and report good functional outcome. Three patients (20 percent) required stoma creation as subsequent alternate treatment. A total of 10 patients experienced 12 complications: 3 perioperative (infections) and 9 postoperative Malone antegrade continent enema use/nonuse complications (4 stomal orifice strictures, 2 fecal impactions, 2 appendiceal perforations, and 1 irrigation catheter knot). No patient experienced leakage from the appendiceal stoma. During the follow-up interval, one patient underwent proctectomy for megarectum. No failures occurred in patients with congenital or neurogenic disorders.

CONCLUSIONS

Malone antegrade continent enema is a reasonable option for the treatment of select patients with severe defecation disorders. Good functional patient self-reported outcome was achieved by 78 percent of patients. The social inconvenience of stoma leakage is avoided with appropriate surgical technique. Malone antegrade continent enema is one option that provides a less invasive surgical alternative than colectomy or ileostomy for severe defecation disorders.

Tratamiento del estreñimiento crónico grave mediante la técnica del enema anterógrado continente

The antegrade continent enema procedure was first described in 1990 by Malone for the treatment of severe fecal neurogenic incontinence in children. Since then, this technique has been successfully carried out in adults, as well as in patients with refractory constipation. The procedure provides a continent and catheterizable channel, generally an appendicostomy, through which antegrade washouts are given to produce colonic emptying. We describe the case of a 23-year-old man with severe constipation and overflow fecal incontinence who underwent an appendicostomy. There were no immediate postoperative complications and saline washouts were started on the fourth day. Since then, the patient has had a bowel movement between 1 and 3 hours after each washout, has recovered continence, and no longer wears an absorbent pad.