Outcome of antegrade continent enema (ACE) procedures in children and young adults

Single Incision Laparoscopic Surgery for Malone Antegrade Continent Enema: Optimizing Outcomes in Pediatric Bowel Management

BACKGROUND

Malone antegrade continence enemas (MACE) are increasingly being used to manage severe constipation and fecal incontinence in children. Despite advances in minimally invasive pediatric colorectal surgery, single-incision laparoscopic surgery (SILS) for MACE creation remains relatively unexplored. This study, featuring the largest cohort to date, evaluates the feasibility, safety, and clinical outcomes of SILS MACE creation in children.

METHODS

A single-institution, retrospective review of pediatric patients who underwent SILS MACE creation for severe constipation and/or fecal incontinence between March 2022 and July 2024. Patient demographics, operative data, postoperative complications, and stooling patterns were assessed. Quantitative variables were analyzed using descriptive statistical methods.

RESULTS

Eighteen patients (10 males, 56 %) underwent SILS MACE creation at a mean age of 10 years (range 4-18) and a median BMI of 17.6 kg/m2 (IQR 16.8-19.6). Preoperative diagnoses included anorectal malformation (n = 9, 50 %), functional constipation (n = 4, 22 %), neurogenic bowel (n = 3, 17 %), and Hirschsprung Disease (n = 2, 11 %). Median operative time was 51 min (IQR 38-67), Postoperative complications included channel prolapse (n = 3, 17 %) and wound infection (n = 2, 11 %). Two patients (11 %) required interventional radiology owing to Mini-ACE® button dislodgment and one patient (5 %) required operative revision for skin-level stenosis. At a median follow-up of 13 months (IQR 7-18), 16 patients (89 %) were clean for stool with successful management through antegrade flushes.

CONCLUSION

SILS MACE creation is a safe, feasible, and effective minimally invasive approach for managing severe constipation and fecal incontinence in children. The technique demonstrates potential advantages in cosmetic results and comparable surgical outcomes, offering a viable alternative to the traditional multiport laparoscopic approach.

TYPE OF STUDY

Original Research Article.

LEVEL OF EVIDENCE

III.

What Happens Post-Malone? An Investigation of Long-Term Postoperative Management of Antegrade Continence Enemas

BACKGROUND

An option for medically refractory fecal incontinence and/or constipation is the antegrade continence enema (ACE). We investigated ACE usage and its perceptions, including whether patients were able to discontinue use of the appendicostomy/cecostomy tube.

METHODS

Patients who underwent appendicostomy creation or cecostomy tube placement at two institutions between 2012 and 2021 were reviewed. Patients or parents/guardians were contacted for completion of a survey. Summary statistics for clinical data were tabulated and associations were evaluated with chi-square analysis.

RESULTS

A total of 165 patients were included, including 92 (55.8%) males. Eighty-two (49.7%) surveys were completed. Most patients (51.5%) presented with fecal incontinence; 38 (23.3%) presented with constipation. More patients had a primary underlying diagnosis of anorectal malformation (39.4%), followed by functional constipation (21.2%), Hirschsprung disease (18.8%), and spinal malformation (17.6%). Thirty-six (21.8%) patients discontinued flushes by time of contact, with switch to laxatives being the most common reason (19%), followed by appendicostomy stricture/obstruction/closure (17%), switch to ileostomy/colostomy (17%), and patient preference (14%). There was no difference in patients' ability to stop using flushes based on underlying diagnosis (p = 0.31). The majority (84.1%) of respondents were "very likely" to recommend antegrade enemas to other children with similar diagnosis and 76.8% reported being "very satisfied" that the operation was done.

CONCLUSIONS

There remains a high degree of satisfaction with antegrade continence enemas for children with constipation and fecal incontinence; some children may be able to stop using antegrade enemas with varied mechanisms including patient/family weaning versus with assistance and laxative trials.

TYPE OF STUDY

Retrospective cohort study.

LEVEL OF EVIDENCE

III.

Psychosocial factors impacting antegrade continence enema outcomes in pediatric patients

BACKGROUND

Children with constipation and encopresis are often treated with medication and behavioral approaches. When constipation persists, surgical interventions such as antegrade continence enema (ACE) procedures are considered. Many children benefit from these procedures; however, some children continue to have incontinence, experience complications, or discontinue the use of the ACE stoma. There is some evidence in the literature to indicate that psychosocial factors can have an impact on ACE outcomes; however, standardized biopsychosocial guidelines related to ACE candidacy and surgery do not currently exist.

PURPOSE

The purpose of this review is to summarize the research to date on psychosocial factors related to ACE treatment outcomes and complications. Identifying what is known and what limitations remain can support future research to inform development of guidelines for pre-procedure evaluations. Psychosocial pre-procedure evaluations could help to inform eligibility for the procedure as well as interventions to enhance outcomes for children at increased risk for poor outcomes or complications from ACE. Age, psychiatric symptoms, and adherence to the ACE flush regimen were some of the factors identified in the literature as impacting ACE outcomes; however, there is limited research in this area.

Long term outcome of antegrade colonic enema (ACE) stoma for treatment of constipation and fecal incontinence in children

AIM

To determine the long term outcome of antegrade colonic enema (ACE) stoma for treatment of chronic constipation and soiling in children.

METHOD

We reviewed patients prospectively who underwent formation of ACE stoma after failure of maximum medical treatment of chronic constipation and soiling from September 2008 to October 2020. All patients had anorectal manometry, endosonography and colonic transit study. A validated symptom severity (SS) score questionnaire was used pre operatively and during follow up. The sum of SS score ranged between 0 (best) and 65 (worst). Data was expressed as median(range) and Wilcoxon rank sum test was used and p value < 0.05 was considered significant.

RESULTS

58 patients had formation of ACE stoma, laparoscopic appendicostomy 56, cecostomy 1, and open procedure 1. The main indications for the ACE stoma were chronic functional constipation (FC) 50(86%), anorectal malformations (ARM) 6(11%) and Hirschsprung disease (HD) 2(3%). 41(71%) of patients had previous intrasphincteric botulinum toxin (BT) treatment. Age at operation was 11(range 4-15) years and follow up was 36(3-84) months. 47(81%) patients were continent of stool within three months postoperatively. The preoperative SS score improved from 34/65 (26-47) to 8/65 (4-12) at 12 months and 5/65 (2-11) at 24 months follow up, p ≤ 0.05. OVERALL: complication rate was 15(26%), wound infection 5, granulation tissue 4, stoma prolapse 4, retraction 1, abscess formation and fistula 1. 15 (26%) adolescents had transition of their care to adult services.

CONCLUSION

There is a significant improvement of constipation, soiling and general health of patients following formation of ACE stoma. Adolescents benefits an orderly transition of their care to adult services.

LEVEL OF EVIDENCE

Level 2, Therapeutic study.

Transition and reversal: long-term experience of the MACE procedure in children

PURPOSE

Analysis of outcomes and follow-up of children who underwent the Malone antegrade continence enema (MACE) procedure in a UK tertiary paediatric surgery unit.

METHODS

Children who underwent a MACE procedure from 1998 to 2020 were identified. Demographic and clinical data were obtained from contemporaneous records. Outcomes were categorised as full (success), partial or failure.

RESULTS

Ninety-five children were identified for inclusion (chronic idiopathic constipation (CIC, 59), anorectal malformations (ARM, 23) and Hirschsprung's disease (HD, 13)). Mean age at surgery was 9.4 years (3-19 years) and mean follow-up time was 6 years (0.3-16.8 years). Outcomes were successful in 69% of CIC patients, 78% in ARM and 69% in HD. Twenty (21%) underwent MACE reversal after developing independent continence, with a significant difference between groups (CIC 19%, ARM 9%, HD 54%, p = 0.0047). 50% of patients > 16 years old were transitioned to adult services.

CONCLUSION

We report a success rate of 72% for MACE procedures in our unit, with a significant difference in reversal rate between diagnostic groups. Long term, a fifth of patients no longer required their MACE. When these patients reach adolescence, those who require ongoing support outside of the paediatric surgery setting should be safely transitioned to adult services.

Antegrade Colonic Enema Channels in Pediatric Patients Using Appendix or Cecal Flap: A Comparative Robotic versus Open series

Introduction We present perioperative outcomes of a single center experience with robotic assisted ACE channel creation for the treatment of chronic constipation refractory to medical therapy and compare it to the traditional open surgical approach. We also demonstrate a step-by-step video presentation of the robotic approach for cecal flap ACE performed as part of a dual continence procedure in patients with short length of appendix. Methods A retrospective chart review of pediatric patients who underwent ACE channel creation between 2008-2020 was performed. We compared demographics, intraoperative, and postoperative variables of the open versus robotic approach. Results Among 28 patients, 15 were open and 13 robotic. In order to construct the ACE channel, a cecal flap was utilized in 36%, split appendix in 50%, full length appendix in 11%, and sigmoid colon in 3% of patients. Both approaches showed equivalent estimated blood loss (50 ml [IQR=20-100]), median length of hospital stay (7 vs. 8 days, p=0.7) and median time to return to regular diet (4 vs. 5 days, p=0.5) (table 1). Patients in the open group were more likely to have a history of prior abdominal surgeries than those in the robotic group (80% vs. 38.5%, p=0.02). The risk of Clavien-Dindo grade 3 or more complications (40% vs. 23.1%, p=0.04) and the rate of ACE channel stenosis (46.7% vs. 7.7%, p=0.02) were significantly higher in the open approach. Channel stenosis was significantly higher in patients with an appendix ACE channel (87.5% vs. 12.5%, p<0.05) compared to those with cecal flap ACE. Conclusions Robotic assisted ACE channel creation is a safe and acceptable alternative with a significantly lower rate of channel stenosis and other Clavien grade 3 complications compared to the traditional open approach. Cecal flaps are also at a lower risk of stomal stenosis than appendix.

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.

In-hospital resource utilization, outcome analysis and radiation exposure in children undergoing appendicostomy vs cecostomy tube placement

INTRODUCTION AND OBJECTIVES

Continence enemas for the purpose of bowel management may be delivered via trans-anal retrograde irrigations, and via antegrade conduits including surgical appendicostomy or placement of cecostomy tube (CT). An appreciation of the relative advantages and disadvantages of each antegrade continence enema (ACE) procedure allows clinicians, parents and children to make an informed decision regarding which procedure is most appropriate in individual cases. The objective of this study was to evaluate the differences in in-hospital resource utilization, surgical outcomes and radiation exposure between children undergoing appendicostomy creation and CT placement at our institution.

METHODS

We conducted a retrospective chart review of children undergoing these procedures at our institution over a 10-year period. All patients 0-18 years of age undergoing either procedure for any indication were included. Data on demographics, length of stay (LOS), radiation exposure events (REE), and surgical outcomes were collected.

RESULTS

One hundred fifteen (63 appendicostomy/52 CT) patients were included. Those undergoing CT placement had significantly increased post-procedural LOS, catheter exchanges and REE compared to those undergoing appendicostomy (see Table). Reported rates of bowel control were similar between the two groups, and there was no significant difference in rates of surgical complications, although each group had unique, procedure-specific complications.

DISCUSSION AND CONCLUSION

In our study, appendicostomy holds a clear advantage over CT in terms of post-procedural LOS, as well as REE. In general, children with CTs require more planned and unplanned device maintenance procedures than those with appendicostomy. These findings aside, the rates of success for bowel control between the two groups are similar, and the incidence of complications does not differ significantly between the two groups. CT remains a safe and effective conduit for delivery of ACEs, and is a particularly good option in patients whose appendix has been lost or used for another conduit. However, patients wishing to avoid repeated procedures and radiation exposure may find the option of appendicostomy more attractive.

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

The antegrade continence enema (ACE) procedures are successful surgical options to achieve bowel cleaning in children with faecal incontinence due to a neuropathy or an anorectal malformation and an intractable constipation. The reversed and orthotopic appendicocecostomy, tubularized ileal conduit and the tubularized cecal flap are frequently applied procedures in the treatment of faecal incontinence (FI). The most common complications are the stoma stenosis, leakage, prolapse, adhesive obstruction and the difficulty in catheterization. Each procedure has its own advantages and disadvantages with different complication rates. The postoperative complications of ACE procedures may reduce patient compliance and quality of life. Most of these complications can be preventable and are easy to manage. This review aimed to discuss the prevention and management strategies for various ACE procedure complications.

Optimization of Pediatric Bowel Management Using an Antegrade Enema Troubleshooting Algorithm

BACKGROUND

A successful flush is the ability to flush through the appendicostomy or cecostomy channel, empty the flush through the colon, and achieve fecal cleanliness. We evaluated our experience with patients who were having flush difficulties based on a designed algorithm.

METHODS

Eight patients with flush difficulties were initially evaluated. Based on the need for additional surgery versus changes in bowel management therapy (BMT), we developed an algorithm to guide future management. The algorithm divided flush issues into before, during, and after flushing. Children aged <20 y who presented with flush issues from September 2018 to August 2019 were evaluated to determine our algorithm's efficacy. Specific outcomes analyzed included changes in BMT versus need for additional surgery.

RESULTS

After algorithm creation, 29 patients were evaluated for flush issues. The median age was 8.4 y (interquartile range: 6, 14); 66% (n = 19) were men. Underlying diagnoses included anorectal malformations (n = 17), functional constipation (n = 7), Hirschsprung's disease (n = 2), spina bifida (n = 2), and prune belly (n = 1). A total of 35 flush issues/complaints were noted: 29% before the flush, 9% during the flush, and 63% after the flush. Eighty percent of issues before the flush required surgical intervention, wherease 92% of issues during or after the flush were managed with changes in BMT.

CONCLUSIONS

Most flush issues respond to changes in BMT. This algorithm can help delineate which types of flush issues would benefit from surgical intervention and what problems might be present if patients are not responding to changes in their flush regimen.

Injectable bulking treatment of persistent fecal incontinence in adult patients after anorectal malformations

BACKGROUND/PURPOSE

Injectable bulking therapy has emerged as a treatment for fecal incontinence (FI), however there are no studies including adult patients with anorectal malformations (ARM). This study aimed to evaluate non-animal stabilized hyaluronic acid with dextranomer (NASHA/Dx) for the treatment of adult ARM patients with persistent FI.

METHODS

Seven adults with ARM and incontinence to loose stool at least once weekly and without rectal or mucosal prolapse were treated with anal NASHA/Dx injection. They were evaluated preoperatively, at 6 and 18 months with a bowel function questionnaire and a 2-week bowel diary as well as FIQL and SF-36 quality of life questionnaires.

RESULTS

Before treatment, the mean number of incontinence episodes over 2 weeks was 20.7 (median 16, range 8-52). At 6 months, the corresponding figures were 5.3 (median 4, range 0-19, p = 0.018), and at 18 months the figures were 4.3 (median 2, range 1-20, p = 0.018). An improved physical function in SF-36 from 74.3 at baseline to 86.4 at 6 months was noted (p = 0.04). No serious adverse events occurred.

CONCLUSIONS

NASHA/Dx is a promising treatment option for selected adult patients with persistent FI after ARM. Longer follow up of larger patient series and studies on patients in adolescence is needed.

TYPE OF STUDY

Treatment Study.

LEVEL OF EVIDENCE

Level IV.

Pediatric Neurogenic Bladder and Bowel Dysfunction: Will My Child Ever Be out of Diapers?

CONTEXT

Managing patient and parent expectations regarding urinary and fecal continence is important with congenital conditions that produce neurogenic bladder and bowel dysfunction. Physicians need to be aware of common treatment algorithms and expected outcomes to best counsel these families.

OBJECTIVE

To systematically evaluate evidence regarding the utilization and success of various modalities in achieving continence, as well as related outcomes, in children with neurogenic bladder and bowel dysfunction.

EVIDENCE ACQUISITION

We performed a systematic review of the literature in PubMed/Medline in August 2019. A total of 114 publications were included in the analysis, including 49 for bladder management and 65 for bowel management.

EVIDENCE SYNTHESIS

Children with neurogenic bladder conditions achieved urinary continence 50% of the time, including 44% of children treated with nonsurgical methods and 64% with surgical interventions. Patients with neurogenic bowel problems achieved fecal continence 75% of the time, including 78% of patients treated with nonsurgical methods and 73% with surgical treatment. Surgical complications and need for revisions were high in both categories.

CONCLUSIONS

Approximately half of children with neurogenic bladder dysfunction will achieve urinary continence and about three-quarters of children with neurogenic bowel dysfunction will become fecally continent. Surgical intervention can be successful in patients refractory to nonsurgical management, but the high complication and revision rates support their use as second-line therapy. This is consistent with guidelines issued by the International Children's Continence Society.

PATIENT SUMMARY

Approximately half of children with neurogenic bladder dysfunction will achieve urinary continence, and about three-quarters of children with neurogenic bowel dysfunction will become fecally continent. Most children can be managed without surgery. Patients who do not achieve continence with nonsurgical methods frequently have success with operative procedures, but complications and requirements for additional procedures must be expected.

Malone Antegrade Continence Enemas vs. Cecostomy vs. Transanal Irrigation-What Is New and How Do We Counsel Our Patients?

PURPOSE OF REVIEW

No gold standard exists for managing neurogenic bowel dysfunction, specifically in individuals with spina bifida. Since the International Children's Continence Society published its consensus document on neurogenic bowel treatment in 2012, an increased focus on why we must manage bowels and how to improve our management has occurred. This review provides updated information for clinicians.

RECENT FINDINGS

A surge in research, mostly retrospective, has been conducted on the success and satisfaction of three types of management for neurogenic bowel. All three management techniques have relatively high success rates for fecal continence and satisfaction rates. Selection of which treatment to carry out still is debated among clinicians. Transanal irrigation is a safe and effective management option for neurogenic bowel that does not require surgery. Antegrade enemas can be carried out via cecostomy tube or Malone antegrade continence enema with similar fecal continence outcomes.

Long-term outcomes of antegrade continence enema in children with chronic encopresis and incontinence: what is the optimal flush to use?

PURPOSE

Severe constipation and encopresis are significant problems in the pediatric population. Medical management succeeds in 50-70%; however, surgical considerations are necessary for the remainder such as the antegrade continence enema (ACE). The purpose of this study is to assess the long-term outcomes following the ACE procedure.

METHODS

All patients undergoing an ACE over a 14-year period were included. Data on clinical conditions, treatments, and outcomes were collected. A successful outcome was defined as remaining clean with ≤ 1 accident per week. Comparative data were analyzed using the Fisher's exact test, Mann-Whitney U test, or Student's t test.

RESULTS

There were 42 ACE patients, and overall, 79% had improvement in their bowel regimens. Encopresis rates decreased from 79 to 5% (P < 0.001). Admissions for cleanouts decreased from 52 to 19% (P = 0.003). All cases of Hirschsprung's, functional constipation and spina bifida were successful. Rates of success varied for other diseases such as slow-transit constipation (60%) and cerebral palsy (33%). A majority (85%) required a change in the enema composition for improvement.

CONCLUSION

In our study, ACE reduced soiling, constipation, and need for fecal disimpaction. Higher volume saline flushes used once a day was the optimal solution and most preferred option.

LEVEL OF EVIDENCE

Level 4 (retrospective case series or cohort).

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.

METHODS

We reviewed all patients in our Center who received an appendicostomy or cecostomy from 2014 to 2017 who were participants in our bowel management program.

RESULTS

204 patients underwent an antegrade access procedure (150 appendicostomies and 54 cecostomies). Skin-level leakage (3% vs. 22%) and wound infections (7% vs. 28%) occurred less frequently in patients with appendicostomy compared to cecostomy. Nineteen (13%) appendicostomies required revision for stenosis, 4 (3%) for mucosal prolapse, and 1 (1%) for leakage. The rates of stenosis (33 vs. 12%) and wound infection (13 vs. 6%) were higher in patients who received a neoappendicostomy compared to an in situ appendicostomy. Intervention was needed in 19 (35%) cecostomy patients, 15 (28%) for an inability to flush or a dislodged tube, and 5 for major complications including intraperitoneal spillage in 4 (7%) and 1 (2%) for a tube misplaced in the ileum, all occurring in patients with a percutaneously placed cecostomy. One appendicostomy (1%) patient required laparoscopic revision after the appendicostomy detached from the skin.

CONCLUSION

Patients had a lower rate of minor and major complications after appendicostomy compared to cecostomy. The unique complication profile of each technique should be considered for patients needing these procedures as an adjunct to their care for constipation or fecal incontinence.

TYPE OF STUDY

Retrospective comparative study.

LEVEL OF EVIDENCE

Level III.

Bowel management in children with spina bifida

Spina bifida is a birth defect that commonly causes bowel and bladder dysfunction in children with a significant negative impact on quality of life and emotional wellbeing. Fecal continence improves satisfaction and the quality of life of both children and their caretakers. Bowel management in children with spina bifida is hampered by limited controlled studies and variable practice within different institutions and subspecialists. The goals of a successful bowel management program in children with spina bifida consist of predictable bowel movements, social continence, and eventual independence. Treatment options range from conservative interventions such as diets and oral laxatives that modify stool consistency and transit, to trans-anal irrigations and antegrade continence enemas that facilitate predictable recto-sigmoid emptying and provide a greater degree of independence. In children, the treatment approach should be implemented in the context of the child's developmental age in order to allow for optimum social integration with their age-appropriate peers. We present a review of a stepwise approach to bowel management in children with spina bifida and the challenges related to the proposed treatment options.

Bowel management in children with spina bifida

Spina bifida is a birth defect that commonly causes bowel and bladder dysfunction in children with a significant negative impact on quality of life and emotional wellbeing. Fecal continence improves satisfaction and the quality of life of both children and their caretakers. Bowel management in children with spina bifida is hampered by limited controlled studies and variable practice within different institutions and subspecialists. The goals of a successful bowel management program in children with spina bifida consist of predictable bowel movements, social continence, and eventual independence. Treatment options range from conservative interventions such as diets and oral laxatives that modify stool consistency and transit, to trans-anal irrigations and antegrade continence enemas that facilitate predictable recto-sigmoid emptying and provide a greater degree of independence. In children, the treatment approach should be implemented in the context of the child's developmental age in order to allow for optimum social integration with their age-appropriate peers. We present a review of a stepwise approach to bowel management in children with spina bifida and the challenges related to the proposed treatment options.

Robotic conversion of cecostomy tube to catheterizable antegrade continence enema (ACE): Surgical technique

INTRODUCTION

Antegrade continence enema (ACE) is a well described treatment for pediatric patients with neurogenic bowel refractory to medical and retrograde management. ACE can be carried out either by catheterizable channel with enteric conduit or a cecostomy tube appliance. For those patients who have issues with pain or leakage around the cecostomy appliance or wish to be appliance free, we present our initial results and description of a novel technique of laparoscopic conversion of cecostomy to catheterizable ACE which uses the existing tract and requires no enteric conduit.

METHODS

A single institution, retrospective chart review was carried out for 2014-2017 to identify patients undergoing ACE conversion. Preoperative parameters included age, sex, weight, neurogenic bowel etiology and time from initial cecostomy. Perioperative data included length of surgery, length of hospitalization and postoperative complications (via Clavien-Dindo scale). Postoperative follow up, ancillary procedures pertinent to the ACE and status at time of submission are also presented.

RESULTS

Six patients were identified (mean age 14.1 +/- 4.3 years) with median follow up of 36 months (range 18-65). Neurogenic bowel etiology was spina bifida in five and spinal cord injury in one; all patients had concurrent neurogenic bladder with preexisting appendicovesicostomy. Mean operative time was 168 +/- 37 min (range 122-228) and mean length of hospital stay was 2 days (range 1-4). Success rate is 83% (5/6 continue to catheterize ACE channel), with one patient opting back for appliance through same tract. One patient has required operative revision for stomal stenosis.

CONCLUSION

To our knowledge, this is the first report describing robotic-assisted laparoscopic conversion of cecostomy tube to a catheterizable ACE. The surgical technique we describe is simple and safe with minimal morbidity to the patient. It does not require an enteral conduit, and may represent a valid treatment in patients without the option of using the appendix.

Malone appendicostomy versus cecostomy tube insertion for children with intractable constipation: A systematic review and meta-analysis

PURPOSE

Children with intractable constipation are often treated with antegrade continence enemas. This requires the creation of a Malone appendicostomy in the operating room or insertion of a cecostomy tube using endoscopic, radiologic, or surgical techniques. The purpose of this study was to assess the evidence regarding these procedures.

METHODS

We conducted a search of Embase, Medline, CINAHL, and Web of Science up to October 2016. We included comparative studies of children treated with Malone appendicostomy or cecostomy tube insertion. Two reviewers screened abstracts, reviewed studies, and extracted data.

RESULTS

We identified 166 children from three retrospective studies who underwent Malone appendicostomy (n=82) or cecostomy tube insertion (n=84). There were no differences in the number of patients who achieved continence (80% versus 70%, p=0.76), but the need for additional surgery was higher in children treated with Malone appendicostomy (30% versus 12%, p=0.01). Studies reported a variety of tube and stoma-related complications, but quality of life was not assessed using validated measures.

CONCLUSION

Malone appendicostomy and cecostomy tube insertion are comparable in terms of achieving continence. Children treated with Malone appendicostomy appear to be more likely to require additional surgery due to early or late complications.

LEVEL OF EVIDENCE

Therapeutic, 1c.

How long will I have my ACE? The natural history of the antegrade continence enema stoma in idiopathic constipation

PURPOSE

We aim to determine the natural history of the ACE in idiopathic constipation and factors predictive of closure.

METHODS

A retrospective case-note review of all patients undergo ACE formation for idiopathic constipation Jan 2003-Mar 2016. Kaplan-Meier analysis was used to determine ACE survival and Cox's proportional hazard models to examine potential predictors of closure.

RESULTS

29/84 (35%) ACEs were closed: 21/84 due to success and 8/84 due to failure. Median age of closure was 15.5 years (3.5-23.6). Median ACE survival was 77.0 months (95% CI 58.0-96.0). An ACE survival curve was derived from which we estimate that 5-year post-ACE, one-third of patients can expect to have had their ACE closed. Younger age at ACE was predictive of earlier closure (p = 0.023) and closure for success (p < 0.001). Neither patient sex (p = 0.546) nor presence of psychological comorbidities (p = 0.769) predicted likelihood of closure. Incontinence 6-week post-ACE was also associated with increased likelihood of closure (p = 0.042).

CONCLUSION

The ACE survival curve estimates the proportion of patients with idiopathic constipation who can expect closure (either due to success or failure) at certain timepoints. This may be useful for patient counseling. Younger age at ACE was associated with earlier closure (for success).

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.

Managing fecal incontinence in patients with myelomeningocele in Sub-Saharan Africa: Role of antegrade continence enema (ACE)

BACKGROUND

Neural tube defects (NTDs) are among the major causes of sphincter dysfunctions. Fecal incontinence (FI) because of myelomeningocele (MMC) leads to problems with social acceptability and decreased quality of life (QOL), life satisfaction in addition to other morbidities. This is a report of experience with antegrade continence enema (ACE) in the management of FI in patients with MMC in an African set-up.

MATERIALS AND METHOD

A retrospective review of 23 children and young adults with FI because of MMC managed with ACE from October 2008 to September 2015 from African Specialist Hospital. The clinical outcomes have been analyzed.

RESULTS

From October 2008 to September 2015, a total of thirty-two n=32 patients underwent ACE procedure after repair of MMC associated with FI. Available data of 23 (71.87%) patients were reviewed retrospectively. Mean age at which ACE was created was 6.43±3.83years, range (3.5-17.8) years, median 5years. Follow-up after ACE creation was (0.5-6.9) years, median 2.6years. There were full continence in 13 (56.52%), partial continence in 8 (34.78%) and failure in 2 (8.69%). There were 16 (69.56%) complications and 4 (17.39%) minor post ACE surgery revisions. Mean PedQOL⁽™⁾ score before ACE and then 5, 10, and 15months after ACE were 47.86±13.83, range (20.4-66.0) vs 88.34±7.11, range (77.9-98.6); p=0.000, 88.9±6.44 range (76.9-98.5); p=0.000, 89.01±6.50, range (76.9-98.88) p=0.000 respectively. Mean parental/caregiver satisfaction score for 15 (65.21%) patients aged 6years and below using modified visual analogue scale (VAS) 1 to 10 before ACE and after were 3.06±0.79, range (2-4), median 3 vs 8.0±1.30, range (5-10), median 8; (p=0.000) while 8 (34.78%) patients aged above 6years were able to assess their satisfactions score before and after ACE creation with mean of 1.75±0.70, range (1-3), median 2 vs 7.75±1.03, range (6-9) median 8; (p=0.000).

CONCLUSION

ACE has satisfactory outcomes in an African set-up in patients with MMC associated with FI. Multidisciplinary approach to neurogenic FI should be encouraged in such set-ups.

Assessment of pediatric Malone antegrade continence enema (MACE) complications: Effects of variations in technique

OBJECTIVE

The Malone antegrade continence enema (MACE) procedure is performed for patients with fecal incontinence and constipation who do not respond to medical therapy. The MACE procedure provides antegrade catheter access to the right colon and allows administration of enemas to help evacuate the bowel regularly. The objective of this study was to identify risk factors for surgical complications in children who undergo the MACE procedure.

METHOD

Records from 97 pediatric patients who underwent MACE procedure were reviewed retrospectively. Data collected included age, sex, weight (obese/not obese), stomal location, presence of a permanent button/catheter in the stoma, open vs. laparoscopic surgery, and etiology of fecal incontinence/constipation. The complications reviewed included stomal stenosis, leakage, and stomal site infection. The relationships between the independent variables and complications were assessed using chi-square tests and Fisher's exact test. Statistical significance was set at p < 0.05.

RESULTS

Overall, 66 (68%) patients had at least one complication. Twenty-three (23.7%) patients developed stomal stenosis, and 27 (27.8%) patients had significant stomal leakage. Insertion of a stomal button/catheter device was associated with an increased risk of developing stomal leakage and stomal infection. The presence of a stomal button/catheter was also associated with a decreased risk of stomal stenosis (Figure). The non-intubated, imbricated sub-population, preteen patients (<12 years old) experienced more stomal leakage than teenage patients. In this subgroup, patients with umbilical stomas also experienced more leakage than patients with right lower quadrant (RLQ) stomas.

CONCLUSION

The prevalence rates of stomal complications in our study were consistent with previously reported series. In our study, however, stomal leakage had a higher prevalence in comparison with stomal stenosis. This seems to be related to the heterogeneity of the study group, which contained two variants of the MACE procedure; non-imbricated, intubated MACE and imbricated, non-intubated MACE. The use of stomal buttons in conjunction with MACE has previously been reported without changes in complication rates. We found the use of stomal buttons/catheters to be associated with changes in the prevalence of stomal complications. Stomal complications are common in the MACE procedure. The use of a permanent stomal button/catheter is associated with changes in the rates of stomal complications. While many find an umbilical stomal site is more cosmetically appealing, there is an increased risk of leakage with imbricated, non-intubated stomas. In the non-intubated, imbricated sub-population, the MACE procedure results in a higher risk of stomal leakage in preteen patients in comparison with teenage patients.

The association of the severity of anorectal malformations and intestinal malrotation

INTRODUCTION

Intestinal malrotation is a known association of anorectal malformations (ARM). Exact incidence, prognosis and surgical implications related to ARM are unknown. The aim of this study was to identify relevant associations between ARM and the presence of malrotation.

METHODS

Records of patients from two referral centers were retrospectively analyzed looking for malrotation associated to ARM and its management, as well as factors for functional prognosis.

RESULTS

40 patients out of 2572 with ARM (1.6%) were found to have malrotation. Females were more commonly affected, and severe malformations were more frequent (cloaca, covered cloacal exstrophy in females and rectoprostatic and rectobladder neck fistula in males). Factors significantly associated with malrotation included Müllerian or Wolffian duct anomalies (P<0.05), while fecal continence status, presence of constipation, and use of laxatives or enemas were not. Detecting and correcting malrotation early on or at the time of colostomy creation represented a protective factor against additional surgeries for bowel obstruction and volvulus (P<0.001). Removal of the appendix during malrotation treatment required constructing a neoappendicostomy using a cecal flap in 9 out of 14 patients needing antegrade enema administration.

CONCLUSIONS

Malrotation presence in patients with ARM has the same frequency as in the general population, but it is more common in severe malformations. Surgeons treating these patients should address the malrotation at the time of colostomy opening if detected. The appendix should be preserved for potential future use as an appendicostomy for antegrade administration of enemas.

5 years after an ACE: what happens then?

PURPOSE

Antegrade continence enema (ACE) revolutionised the lives of children with chronic constipation and soiling. Parents often ask how long the ACE will be required. We looked at our patients 5 years after ACE formation to answer the question.

METHODS

We reviewed clinical notes of all patients undergoing ACE procedure during January 1990 to December 2010. Only patients with >5 years follow-up were included. Data are given as median (range).

RESULTS

133 patients were included with >5 years of follow-up. Primary pathology was anorectal anomaly (ARA) 64 (48%); spinal dysraphism (SD) 40 (30%); functional constipation (FC) 14 (10%); Hirschsprung's Disease (HD) 10 (8%) and others 5 (4%). Median follow-up was 7 years (5-17 years). Overall 74% still use their ACE; whilst 26% no longer access their stoma, of whom 47% recovered normal colonic function. 50% of HD patient recover colonic function. FC has the highest failure rate at 21%.

CONCLUSIONS

Overall 86% achieved excellent clinical outcome with 74% of patient still using their ACE at 5 years. HD has the highest recovery rate of 50%. FC has a more unreliable clinical outcome with 21% recovered colonic function and 21% failed. Outcome varied dependent on the background diagnosis.

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.

Antegrade continence enema (ACE): predictors of outcome in 111 patients

PURPOSE

The antegrade continence enema (ACE) is used as a means of managing faecal incontinence and constipation with varying outcomes. We aim to evaluate our outcomes of ACEs and identify predictors of outcome.

METHODS

A retrospective case-note review of patients ≤16 years of age undergoing an ACE (March 2000-September 2013) was carried out. Data collected included: patient demographics, functional outcomes and complications. Data are quoted as median (range) and compared using Mann-Whitney and Fisher's exact test. Univariate analysis was performed to identify predictors of successful outcomes. P < 0.05 is significant. Successful outcome = total continence/occasional leakage and failed outcome = regular soiling and/or constipation.

RESULTS

111 patients with complete data sets underwent an ACE [59% male, median age = 9.5 years (3.4-16 years)] and median follow-up = 48 months (4 months-11 years 4 months). Underlying diagnoses were idiopathic constipation (n = 68), anorectal malformation (n = 27), neuropathic bowel (n = 7), Hirschsprung disease (n = 5) and gastrointestinal dysmotility (n = 4). Social continence was achieved in 87/111 (78%). Fifteen percent of patients underwent reversal of ACE due to resolution of symptoms. There was no difference in outcomes related to diagnosis, gender, age or follow-up duration. Complication rate was 20.7% (23/111).

CONCLUSIONS

The ACE is safe and effective in the management of intractable constipation and soiling. No predictors of outcome were identified.