Laparoscopic antegrade continence enema using a two-port technique

BACKGROUND: The antegrade continence enema is an effective method of treatment of fecal incontinence. We report our experience of a laparoscopic antegrade continence enema procedure and describe a simple approach to this procedure using a two-port technique. MATERIALS AND METHODS: Over a 3-year period, 12 children with intractable constipation and fecal soiling underwent the antegrade continence enema procedure laparoscopically. All cases had full bowel preparation the day before surgery. This procedure was done through one 5-mm camera port and two 5-mm working ports in 8 cases, and using the camera port and only one additional 5-mm working port in 4 cases. The appendix was used in 5 cases and the cecum in 3 cases with the threeport technique while the appendix was used in all 4 cases with the two-port technique. The appendix or cecum was delivered extracorporeally through the 5-mm port site in the right lower quadrant. The mucocutaneous anastomosis was stented using a gastrostomy button. RESULTS: Between 2001 and 2004, 12 children (10 male, 2 female) underwent a laparoscopic antegrade continence enema procedure at a median age of 10.5 years (range, 7-14 years). This procedure was easy to perform and no case required conversion to an open procedure. The wash-outs via the MIC-KEY gastrostomy button (MIC-KEY, Kimberly-Clark) were commenced at a median of 3.5 days (range, 1-5 days). Median postoperative hospital stay was 2 days (range, 1-5 days). This procedure was effective in completely resolving fecal incontinence in 9 cases and partially resolving it in 3 cases. There were no episodes of stomal stenosis, leakage, or herniation. However, one case required a revision of antegrade continence enema due to wound breakdown and leakage of irrigation fluid around the stoma. The median follow-up period was 15.5 months (range, 5-32 months). CONCLUSION: The laparoscopic technique is a simple and effective approach in creating an antegrade continence enema. The use of a gastrostomy button can potentially reduce some of the complications commonly associated with an antegrade continence enema. We describe a procedure that incorporates the advantages of both laparoscopy and a button device, which is simple and easy to perform using just two ports.     

Modified cecal flap neoappendix for the Malone antegrade continence enema procedure: a novel technique

PURPOSE: We report our experience with the creation of a tubularized cecal flap to construct a neoappendix. This flap effectively serves as an alternative means of creating a conduit for antegrade continence enemas in patients who have either an absent or an unusable appendix. MATERIALS AND METHODS: We reviewed our results from our initial 4 patients in whom we used this technique. A neoappendix is created from a medially based flap of distal cecum that is tubularized over a catheter and then buried in a seromuscular tunnel to create an antireflux mechanism. A skin stoma is then created. RESULTS: All stomas are continent, functional and without any evidence of stenosis or necrosis of the cecal flap with followup ranging from 3 months to 8 years. CONCLUSIONS: A medially based cecal flap neoappendix is an easily created and reliable conduit for antegrade enemas. This procedure should be considered within the surgical armamentarium of urologists and pediatric surgeons when the appendix is absent, atretic or fibrotic.     

Y-appendicoplasty: a technique to minimize stomal complications in antegrade continence enema

PURPOSE: The antegrade continence enema (ACE) is an effective method of treatment of fecal incontinence and constipation. However, the original procedure described is not easy to perform and is associated with a high complication rate, especially stomal stenosis-necrosis (55%). Even with introduction of orthotopic appendicostomy, composite series still report an incidence of 30% with stomal problems. The authors report a virtually complication-free simple modification, the Y-appendicoplasty. METHODS: The base of the appendix is imbricated into cecum by 2 successive rows of interrupted seromuscular stitches. A small Y-shaped incision is made on the abdominal wall at McBurney's point, and 3 triangular skin flaps are raised. The appendix is brought out of the skin incision. The tip is excised, and 3 vertical cuts are made 120 degrees apart. The 3 appendiceal flaps thus created are interdigitated with the skin flaps using interrupted sutures. RESULTS: Twelve children underwent Y-appendicoplasty and orthotopic appendicostomy. Mean operating time was 1 hour. None experienced stomal complications that required intervention. Control of fecal continence with ACE ranged from excellent to good. CONCLUSION: Y-appendicoplasty and orthotopic appendicostomy minimizes complications for ACE and is easy to perform.     

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.     

The colon flap/extension Malone antegrade continence enema: an alternative to the Monti-Malone antegrade continence enema

PURPOSE: In situations where the appendix is not available for the Malone antegrade continence enema (MACE) procedure a Yang-Monti channel or a colon flap conduit can be created. We report our experience with colonic flap conduits used for the MACE. MATERIALS AND METHODS: A total of 169 MACE procedures were performed between February 1997 and March 2003. In 11 patients 12 colon flaps or cecal extensions were used to construct the MACE conduit. Diagnoses included myelomeningocele (8 patients), caudal regression (1), sacral agenesis (1) and gunshot wound (1). Mean age at creation of MACE was 11.3 years (range 4.4 to 16.9). Seven cecal flaps, 1 descending colon flap and 4 cecal extension flaps were created. RESULTS: Average followup was 22.8 months (range 2.6 to 34.6). Indications for colon flap MACE were appendicovesicostomy (6 patients), short appendix (2), shortened mesentery (1), retrocecal appendix (1), prior appendectomy (1) and right hemicolectomy (1). Initially all patients easily catheterized and flushed the MACE once daily. All 11 patients achieved fecal continence. Complications occurred in 3 cases. One obese patient could not visualize the umbilical stoma and it stenosed, requiring conversion to a spiral Monti-MACE. One patient with a cecal extension had development of a false passage, resulting in complete channel stenosis. One patient had development of stomal leakage, which was successfully treated with dextranomer/hyaluronic acid copolymer injection. CONCLUSIONS: A colon flap MACE conduit is a simple technique to provide access to the colon for irrigation. When faced with situations were the appendix is not available for the MACE procedure the colon flap can be a good option.     

Robot-assisted Mitrofanoff and Malone antegrade continence enema reconstruction using divided appendix

Fecal soiling or intractable constipation frequently occurs in association with urinary incontinence in children with varying pathologic conditions. To manage double incontinence or the combination of wetting and severe constipation, a Mitrofanoff conduit and a channel for antegrade continence enema is constructed using the appendix by open surgery. We present a video of the first case of robot-assisted laparoscopy for simultaneous reconstruction of a continent urinary diversion using the Mitrofanoff principle and a Malone antegrade continent enema using the divided appendix.     

Appendicostomy stomas and antegrade colonic irrigation after laparoscopic antegrade continence enema

BACKGROUND: Children with spina bifida, high anorectal anomalies, or neuronal intestinal dysplasia who are treated with a laparoscopic antegrade continence enema to achieve a socially acceptable level of fecal continence sometimes have problems with the stoma and its catheterization. The goal of this study was to determine the nature and incidence of these problems, and their relationship to the underlying condition. MATERIALS AND METHODS: A retrospective review of the hospital case notes of 74 consecutive patients who had a laparoscopic antegrade continence enema was undertaken. RESULTS: The laparoscopic antegrade continence enema procedure is well tolerated but is associated with a variety of usually minor complications including stomal stenosis, leakage, peristomal infection, granulation tissue overgrowth, mucosal prolapse, abdominal discomfort during irrigation, appendiceal false passage, and ineffective irrigation. Surgical revision of the stoma was required in 19% of the cases in this study, usually because of stenosis and skin overgrowth. Ongoing problems achieving colonic emptying were most likely to occur in patients with an anorectal malformation. CONCLUSION: Overall, the laparoscopic antegrade continence enema provides an effective method of facilitating emptying of the bowel. However, it has a high incidence of minor troublesome problems, with stenosis and skin overgrowth of the stoma being the most common. Younger children tend to have more complications and difficulty performing effective irrigation. Children with anorectal malformations were more likely to require surgical revision of the stoma, and often needed ongoing manual evacuation and bowel washouts despite the laparoscopic antegrade continence enema.     

A new complication of the Malone antegrade continence enema

The Malone antegrade continence enema now commonly known as the ACE procedure was described originally for the treatment of intractable fecal incontinence in 1990. Since this time it has been used widely in many centers for the treatment of constipation and faecal soiling in both adult and pediatric practice. This case report describes a previously unreported complication of an ACE that developed in a disused appendicocecostomy in a child. J Pediatr Surg 37:1216.     

Durability of the Malone antegrade continence enema in pregnancy

The Malone antegrade continence enema (MACE) is a therapeutic option to treat chronic constipation and fecal incontinence in patients with neurogenic bowel. Previous reports have described the short-term success of this procedure, but no report has described the durability of the procedure during pregnancy. We present the case of a spinal cord injury patient who underwent an uncomplicated pregnancy after a MACE procedure with no stomal catheterization difficulties or leakage during or after the pregnancy.     

Laparoscopic antegrade continence enema (Malone) procedure: description and illustration of technique

The antegrade continence enema (ACE Malone) procedure has improved the lives of many patients who struggle with intractable forms of constipation. We describe a laparoscopic approach to this technique and review the literature.     

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.     

The Macedo-Malone antegrade continence enema procedure: early experience

PURPOSE: The successful treatment of fecal incontinence can dramatically improve the quality of life of affected children. The introduction of the Malone antegrade continence enema provides the opportunity to manage previously resistant cases. However, using the to create this catheterizable channel is not always possible, and the duration of these antegrade enemas is a source of concern for the patients. We describe a new approach to create left continent colonic access to shorten the duration of these enemas, and report the experience gained from the first 9 cases managed at our institution. MATERIALS AND METHODS: During a 5-year period 9 patients underwent a Macedo-Malone antegrade continence enema at our institution. Incontinence was associated with myelomeningocele in 7 patients and anorectal malformation in 2. The antegrade continence enema procedure is begun by isolating a 2 cm flap in a tenia on the left colon (spleen flexure). A 12Fr silicone Foley catheter is placed on the mucosal surface of the flap to allow tubularization of the plate with interrupted polyglycolic acid 3-zero transverse sutures, creating an efferent tubular conduit. Antegrade colonic washouts were started 2 weeks after surgery with saline solution or tap water in all patients. RESULTS: Followup of our 9 cases ranged from 8 to 33 months (average 20.7). Enema volume varied from 250 to 800 ml, with administration taking from 45 to 60 minutes, and colonic evacuation occurred within 30 to 60 minutes of enema administration. Of the 9 patients 8 were completely continent and 1 was partially continent. Four patients experienced difficulty with catheterization initially because of stenosis of the stomal track. The affected stomas were dilated, which was successful in 1 case. Three patients subsequently required stomal revision. CONCLUSIONS: The Macedo-Malone procedure is a relatively straightforward operative approach providing an effective washout technique that is acceptable to parents and children.     

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.     

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.