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 (χ², 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.     

Fecal incontinence successfully managed by antegrade continence enema in children: A report of two cases

Two children with intractable fecal incontinence after correction of high anorectal malformations were successfully managed by the daily administration of a glycerin enema into the cecum via an appendicocecostomy or tubularized cecostomy, according to the method of Malone's antegrade continence enema (ACE). Fluoroscopic defecography performed during this procedure in each patient disclosed that the glycerin enema promptly evoked cecal peristalsis, which was transmitted to the distal colon and rectum, and squeezed out almost all the fecal matter, evacuating it from the anus. However, two enemas within a short interval were required to achieve a complete washout of feces. Although this report describes only two patients, our experience confirmed that the ACE was very effective and that adding the word continence to antegrade enema was justifiable. Moreover, fluoroscopic defecography was proven to play a significant role in determining the appropriate regimens of this technique to achieve complete washout of the feces.     

Laparoscopic antegrade continence enema procedure for fecal incontinence in a patient with spina bifida

We report a laparoscopic procedure for antegrade continence enema (LACE) that was performed successfully in 39-year-old man patient with spina bifida suffering from severe fecal incontinence. The patient had been receiving regular follow-up at our clinic. He desired the antegrade continence enema procedure to improve his intractable fecal incontinence with a less invasive procedure. Following the placement of the first port at the umbilicus using an open access technique, two additional ports were introduced at the upper and lower abdomen in the midline. The appendix was laparoscopically mobilized to the right lower abdomen and brought out through another port. Next, an in situ appendicocutaneostomy was created. The patient began oral intake the day after surgery. Initial irrigation was performed on the second postoperative day. Convalescence was quick and there were no postoperative complications. Although a minor skin incision was required afterward for superficial stoma stenosis, the patient has been in a satisfactory condition with regular enemas. Laparoscopic appendicocutaneostomy can be a reasonable surgical alternative for antegrade continence stoma procedure. LACE has a clear advantage over conventional open procedures in view of its less invasive nature and better cosmetic results.     

The Malone antegrade continence enema procedure: the Amsterdam experience

Background

The Malone antegrade continence enema (MACE) procedure has been previously described as a safe and effective option for the treatment of children with chronic defecation disorders when maximal medical therapy and conventional treatment have failed.

Purpose

To evaluate clinical success, complications, and quality of life of children with chronic defecation disorders with a MACE stoma.

Methods

A retrospective analysis of 23 patients who underwent the construction of a MACE stoma was performed. Preoperative and postoperative data were evaluated. A specific questionnaire was used to assess patient satisfaction.

Results

A significant increase was found in defecation frequency (1.0 [range, 0-4] pretreatment vs 5.5 [range, 0-28] posttreatment per week; P < .006) and a significant decrease in fecal incontinence frequency (10 [range, 0-14] pretreatment vs 0 [range, 0-14] posttreatment per week; P < .034). Postoperative complications of the MACE procedure were fecal leakage (43%), wound infection (52%), and stomal stenosis (39%). A total of 86% of the patients were satisfied with the results of the Malone stoma (n = 21).

Conclusions

The MACE procedure is an effective treatment in children with intractable defecation disorders. Postoperative complications are, however, not uncommon. Further refinement of the technique focused to reduce the complication rate is necessary to expand the application of this approach.     

The antegrade continence enema successfully treats idiopathic slow-transit constipation

Background

Antegrade continence enemas (ACEs) are successful for constipation and/or fecal incontinence caused by anorectal malformations or spina bifida but have been thought to be less successful in the treatment for patients with colonic dysmotility. We studied the long-term efficacy of ACE in a large group of patients with idiopathic slow-transit constipation (STC).

Methods

We identified 56 children with an appendicostomy for ACE with radiologically proven STC. An independent investigator (SKK) performed confidential telephone interviews.

Results

We assessed 42 of 56 children (31 boys) of mean age 13.1 years (range, 6.9-25). Mean follow-up was at 48 months (range, 3-118). Mean symptom duration before appendicostomy was 7.5 years (range, 1.4-17.4). Indications for appendicostomy were soiling (29/42), inadequate stool evacuation (7/42), and recurrent hospital admissions for nasogastric washouts (6/42). Both quality of life (Templeton quality of life [P < .0001]) and continence (modified Holschneider continence score [P < .0001]) improved with ACE. Soiling frequency decreased in 32 of 42 (11/32 completely continent). Thirty-seven of 42 children had reduced abdominal pain severity (P < .0001) and frequency (P < .0001). Complications included granulation tissue (33/42), stomal infection (18/42), and washout leakage (16/42). Fifteen of 42 children ceased using the appendicostomy (7/15 symptoms resolved). Thirty-five of 42 families felt that their aspirations had been met.

Conclusions

Antegrade continence enemas were successful in 34 (81%) of 42 children with STC, contradicting views that ACEs are less effective in patients with colonic dysmotility.     

Colonic tubes for the antegrade continence enema: comparison of surgical technique

PURPOSE: The Malone antegrade continence enema has revolutionized the management of intractable fecal incontinence and constipation. When the appendix is absent, surgical options are limited. Small series with short-term followup have demonstrated the feasibility but not the reliability of the continent colonic tube. We present our experience with a lateral based colonic tube. We also compared lateral based colonic tubes to medial based tubes. MATERIALS AND METHODS: The medical records of patients treated with a continent colonic tube for intractable fecal incontinence were reviewed. We identified 8 patients who underwent the procedure between July 2000 and February 2003. The literature was reviewed to compare lateral vs medial based tubes. RESULTS: Average followup was 28 months (range 10 to 41). Stomal stenosis developed in 4 patients (50%) within 3 to 6 months of surgery. Passive dilation at the clinic corrected the problem in 3 patients and 1 required operative stomal revision. All 8 patients reported almost complete relief of rectal incontinence and constipation. A literature review demonstrated a significantly higher rate of stomal stenosis in lateral vs medial based colonic tubes (40% vs 12%). CONCLUSIONS: The continent colonic tube is a safe and effective alternative in patients with refractory fecal incontinence and constipation who do not have an available appendix. These results appear durable during the described period. We believe that this technique is an alternative to the cecostomy button and it should be offered to suitable patients. The lateral based colonic tube appears to have a higher rate of stomal stenosis than medial based colonic tubes, which may be attributed to the local blood supply of the colon.     

Left colonic antegrade continence enema: experience gained from 19 cases

Purpose

As problems have developed with the right colonic antegrade continence enema procedure (Malone's procedure/Monti's retubularized ileocolostomy), left colonic antegrade continence enema (LACE) procedure, in which retubularized ileum or sigmoid colon is anastomosed into the sigmoid colon, has gained popularity. The aim of the study was to describe our experience with the LACE procedure.

Methods

We retrospectively reviewed 19 LACE procedures that were performed at the Yonsei University College of Medicine Hospital (Seoul, Korea) from March 2001 to March 2005.

Results

Male-to-female ratio was 11:8, with median age of 10 years (range, 3-34 years). Most common diagnosis was meningomyelocele (78.9%, 15/19). The median total follow-up period was 23 months (range, 3-37 months); median antegrade continence enema volume used was 600 mL (range, 250-1500 mL); and median transit time was 30 minutes (range, 15-60 minutes). Patients performed antegrade continence enema with an average of once every 2 days (range, 0.3-3 days). Social continence was achieved in 14 patients (73.7%). Regurgitation of fecal material through stoma was not reported at all in 17 patients (89.5%).

Conclusions

We recommend LACE as the procedure of choice for children with congenital malformations or any other condition predisposing to fecal incontinence or constipation intractable to conventional treatment.     

Treatment of resistant distal intestinal obstruction syndrome with a modified antegrade continence enema procedure

We report a case of a patient with CF who had a long history of recurrent distal intestinal obstruction syndrome. She had been treated with conventional treatment including gastrografin, n-acetyl cysteine, Klean prep and Picolax. She underwent a modified antegrade continence enema procedure. She currently irrigates her conduit every 2-3 days. She has had no further symptoms of distal intestinal obstruction syndrome.     

Outcomes following Malone antegrade continence enema and their surgical revisions

Background/Purpose

The Malone antegrade continence enema (MACE) channel is an effective means to manage patients with neurogenic bowel; however, complications may occur that may require surgical revision. Specific reports of the outcomes of these interventions are limited. We describe our clinical results following revision of MACE.

Methods

We retrospectively identified patients undergoing MACE revision for at our institution between 1997 and 2009. Type of MACE (in situ appendicocecostomy (AC = 247), ileocecostomy (IC = 25), cecal flap (CF = 10)) performed was recorded, time from creation to revision, site of revision, and need for repeat surgical revision were recorded.

Results

Of a total of 282 patients that underwent creation of MACE during the study period, 49 patients (17%) required surgical revision. Of these 49 patients, 42 had undergone AC, four had IC and three had CF. Mean time from MACE creation to revision was 19 months. Sixty-eight revision procedures were performed in the 49 patients. Skin level or endoscopic procedures accounted for 52/67 (78%) procedures. Sixteen patients (33%) required more than one revision and three patients (6%) required more than two procedures.

Conclusions

Skin level revisions accounted for over three-fourths of MACE revisions. In our series, two thirds of patients requiring revision required only a single procedure, but one third required more than one revision.     

Colpo-wrap: a new continence procedure

OBJECTIVE: To present a new surgical method to increase bladder outlet resistance for the treatment of urinary incontinence in girls and women. PATIENTS AND METHODS: Six patients (mean age 9.6 years), with urinary incontinence were operated using the new technique within the last 3 years. The principle of the procedure is tightening of the bladder neck by mobilizing the anterior vaginal wall and wrapping it around the bladder neck and proximal urethra, in the sense of a vaginoplication (colpoplication). The underlying conditions and causes for urinary incontinence was neurogenic bladder-sphincter dysfunction caused by myelodysplasia in three girls and anorectal malformation combined with a tethered spinal cord in one. In one case incontinence was caused by a cloacal anomaly and one girl had intrinsic sphincter insufficiency after repetitive Otis urethrotomies. The colpo-wrap was combined with a bladder augmentation and Mitrofanoff in three patients, the three other girls undergoing isolated procedures. RESULTS: The result of the method is a constant increase in outlet resistance and coaptation of the urethra, comparable with the effect of a vaginal sling procedure. Five patients are completely dry after surgery, one girl with cloaca needed an additional bladder neck injection with hyaluranon/dextranomer copolymer. Transurethral catheterization was possible after surgery with no problems in all patients who required intermittent catheterization. CONCLUSION: Considering the feasibility of this technique the colpo-wrap is a reasonable alternative for treating urinary incontinence in females.     

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.     

Neoappendicostomy in the management of pediatric fecal incontinence

Purpose

The Malone appendicostomy, for antegrade enemas, has improved the quality of life for many children with fecal incontinence. In patients whose appendix has been removed, a neo-appendix can be created. We describe our approach and experience with this procedure as an option for surgeons managing children with fecal incontinence.

Methods

The procedure involves creating a transverse flap of cecum that receives its blood supply by a transverse mesenteric branch. This flap is then tubularized around a feeding tube. The surrounding colon is plicated around the neo-appendix to prevent leakage of stool. The tip of the flap is then anastomosed to the deepest portion of the umbilicus. We reviewed our experience with this procedure, including results and complications. IRB approval was obtained.

Results

Eighty patients required a neo-appendicostomy. Sixty-six patients (82%) had an anorectal malformation, four had spina bifida, and ten had other diagnoses. The reasons for not having an appendix available included: “incidental” appendectomy (34, 42.5%), use of the appendix for a Mitrofanoff procedure (20, 25%), and Ladd's procedure (5, 6%). In fifteen patients (19%) we could find no appendix and assume that it was removed previously. Following neoappendicostomy, nine patients (11%) developed a stricture, and seven patients had leakage (9%). In 2004, we modified the appendiceal-umbilical anastomosis and among these patients, only one patient (3%) developed a stricture, compared with eight patients (18%) without the modification. All seven patients with leakage were within the first forty cases. No patient in the last forty cases had a leakage.

Conclusions

In patients with the potential for fecal incontinence, the appendix should be preserved. In patients without an appendix, the neo-appendicostomy is a valuable tool for fecally incontinent patients. We have found that the V-V anastomosis had a reduced rate of stricture, and the rate of leakage seems to be related to surgical experience.     

Impact of cecostomy and antegrade colonic enemas on management of fecal incontinence and constipation: ten years of experience in pediatric population

Background

In childhood and adolescence, fecal soiling represents a psychologically devastating problem. Physical and emotional distress associated with daily rectal enemas is minimized by the introduction of a cecostomy tube for colonic cleansing with antegrade colonic enemas (ACEs).

Patients and Methods

Over a period of 10 years (1997-2007), we performed “button” cecostomies in 69 pediatric patients with fecal soiling secondary to a variety of disorders; laparoscopic procedures were performed in 40 and open procedures in 29. Mean postoperative follow-up was 4.03 SD ± 1.76 years. Cleansing protocols differed between patients.

Results

We adopted a standardized questionnaire concerning management of incontinence/intractable constipation before and after button cecostomy insertion to assess the long-term impact of ACE on symptom severity and quality of life. Complications included tube dislodgement (n = 9), development of granulation tissue (n = 11), decubitus ulcer (n = 5), and infection (n = 3). Patient/parents satisfaction (appraisal scale 1-3) and improvement of quality of life achieved statistical significance for both (P < .001).

Conclusions

Since button cecostomy and ACE were introduced in our institution as a management option, the treatment of fecal incontinence and intractable constipation significantly improved in terms of efficacy and patient compliance and also resulted in greater patient and parent satisfaction.     

High imperforate anus--quantitative results of long-term fecal continence

In a 22-year period, 120 patients were admitted for treatment of a high imperforate anus. Sixty-one patients were available for long-term assessment following a pull-through procedure. These patients were evaluated by written questionnaire and personal interview. Both a qualitative and quantitative fecal continence score were established to provide a system for long-term follow-up that was both reproducible and easy to use. These results were grouped according to the length of time following repair and type of repair performed. Three follow-up time periods were used: 2.5 to 9 years; 10 to 16 years; and 17 to 24 years. During this study, three different procedures were used: sacroperineal (SP), sacroabdominoperineal (SAP), and abdominoperineal (AP). Grouping all three procedures together, the percentage of patients with "good" fecal continence increased in time from 33% to 58% to 64%. Patients undergoing an SP repair uniformly had good results by 10 or more years following repair. In contrast, all patients undergoing an SAP or AP repair had only fair quantitative results 10 to 16 years following repair. Females generally had much better results than males but females also tended to have a lower rectal pouch than males. A comparison of this survey with the results of Swenson, Kiesewetter, Stephens, and Rehbein supports the following conclusions: the anatomic level of rectal pouch at birth predicts fecal continence better than the sex of the patient or type of procedure used; patients in whom the full thickness, terminal rectal wall is used in performing the pull-through procedure have the best fecal continence results.(ABSTRACT TRUNCATED AT 250 WORDS)     

A comparison of Malone appendicostomy and cecostomy for antegrade access as adjuncts to a bowel management program for patients with functional constipation or fecal incontinence

Background

Appendicostomy and cecostomy are two approaches for antegrade enema access for children with severe constipation or fecal incontinence as adjuncts to a mechanical bowel management program. Each technique is associated with a unique set of complications. The purpose of our study was to report the rates of various complications associated with antegrade enema access techniques to help guide which option a clinician offers to their patients.

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.