Percutaneous endoscopic cecostomy for antegrade colonic irrigation in fecally incontinent children

Successful Colonoscopy-assisted Cecostomy Tube Replacement to Salvage Lost Cecostomy Tract Access in Children

OBJECTIVES

Cecostomy tubes are commonly used for antegrade enema delivery in children with spinal defects and anorectal malformations to help address chronic constipation and fecal incontinence. Once surgically or radiologically placed, cecostomy tubes require changes by a percutaneous approach, which may be unsuccessful requiring repeat laparoscopy or open surgery to re-establish the cecostomy tract. The role of colonoscopy assistance to salvage lost cecostomy access in children who fail percutaneous replacement is not well described. The primary aim was to describe the safety and effectiveness of a colonoscopy-assisted approach to re-establish lost cecostomy access in children.

METHODS

This was a retrospective cohort study of the methods, success and complication rates associated with colonoscopy assisted cecostomy tube replacement in children between 2000 and 2017 at a pediatric tertiary care center.

RESULTS

Ninety-five patients with 841 attempted procedures were included with only 1% of procedures requiring endoscopic assistance. These included 7 colonoscopy-assisted cecostomy tube replacement procedures in 6 patients (median age 9.2 years, median weight 26.3 kg, 33% girls). The most common reason for using colonoscopy assistance was a failed percutaneous approach. The colonoscopy-assisted approach was successful in all cases without documented complications.

CONCLUSIONS

Colonoscopy-assisted cecostomy tube replacement is safe and highly successful in re-establishing lost cecostomy access in children after failed attempts with percutaneous or fluoroscopic-guided approaches.

Laparoscopic-assisted percutaneous endoscopic cecostomy in children with defecation disorders (with video)

BACKGROUND

The antegrade continence enema (ACE) procedure has been widely used in the management of children with defecation disorders. The ACE procedure has undergone many technical modifications. We developed a safe and minimally invasive technique, the laparoscopic-assisted percutaneous endoscopic cecostomy (LAPEC).

OBJECTIVE

To compare LAPEC to laparoscopic cecostomy in terms of operative time, hospital length of stay, and procedure-related morbidity.

DESIGN

Retrospective review of children undergoing the ACE procedure.

SETTING

Two tertiary-care centers.

PATIENTS

This study involved children with defecation disorders.

INTERVENTION

The ACE procedure.

MAIN OUTCOME MEASUREMENTS

Procedure complications, length of stay, and operative time.

RESULTS

Fifty patients underwent LAPEC, and 15 underwent laparoscopic cecostomy. Of the LAPEC patients, 70% were male, with mean age 12 ± 4.2 years, mean operative time 100.1 ± 16.6 minutes, and mean length of stay 3.4 ± 1.4 days. Of the laparoscopic cecostomy patients, 56% were male, with mean age 10.5 ± 4 years, mean operative time 100.8 ± 19.1 minutes, and mean length of stay 3.8 ± 1.6 days. There was no statistical difference between the 2 groups. The single intraoperative complication during LAPEC was a cecal hematoma. Postoperative complications after LAPEC included 6 patients with low-grade fever, 3 patients with tube dislodgement (2 treated by repeat LAPEC and the other by open surgery), and 2 patients with skin breakdown. Of the 50 LAPEC patients and their families, 48 were satisfied with the outcome.

LIMITATIONS

Retrospective study.

CONCLUSION

LAPEC is a safe, minimally invasive procedure for cecostomy placement in children with refractory constipation or fecal incontinence.

Is the outcome of the left colon antegrade continence enema better than that of the right colon antegrade continence enema?

BACKGROUND/PURPOSE

The purpose of this report was to review the results of the antegrade continence enema (ACE) procedure and to compare the outcomes of right and left colon ACEs in children.

METHODS

Thirty patients who underwent an ACE between 1998 and 2005 were analyzed. Data were obtained based on the following parameters: postoperative soiling, catheter insertion time, colonic washout time, quality of life, and abdominal pain during and after the ACE. Twenty-nine patients were followed for an average of 3.8 years (range, 4 months-7.3 years).

RESULTS

Right colon ACEs were performed in 23 patients, and left colon ACEs were performed in 7 patients. The common complications of the ACE included abdominal pain during and after the ACE (51.7%) and stoma strictures (41.4%). The overall ACE success rate was 24/29 (82.8%; right colon ACE, 18/29; left colon ACE, 6/29). Twenty-three patients (95.8%) believed their quality of life was improved. There were no significant differences in complications or outcomes between the right and left ACEs.

CONCLUSIONS

An ACE is an effective treatment for children with fecal incontinence. A left colon ACE has similar efficacy as a right colon ACE in managing fecal incontinence in children.

Long-term functional assessment of antegrade colonic enema for combined incontinence and constipation using a modified Marsh and Kiff technique

PURPOSE

Constipation and fecal incontinence can severely affect quality of life for patients, particularly when simultaneously present. Malone antegrade colonic enema enables periodic colonic emptying, thus preventing uncontrolled passage of feces and constipation.

METHODS

Eleven patients with fecal incontinence and severe constipation or perineal colostomy after Miles' operation underwent a modified Marsh and Kiff ileostomy for antegrade colonic enema. Before and after surgery, the patients were fully evaluated for gastrointestinal functions, including gallbladder and stomach emptying time, H(2)-breath test, colonic transit time, dynamic defecography, and anorectal manometry. The severity of incontinence and constipation was scored preoperatively and postoperatively by using the American Medical System score and Cleveland Clinic Constipation scale, respectively, whereas the quality of life was measured by the Gastrointestinal Quality of Life Index. The surgical technique involved division of the terminal ileum 10 to 15 cm from the ileocecal valve, anastomosis and intussusception of the ileum with the cecum, narrowing of the ileal conduit with a linear stapler, and a small, introflexed ileostomy with an advanced skin flap.

RESULTS

During the postoperative period, the mean American Medical System score decreased significantly from 77 to 11 (P<0.01) and the mean Cleveland Clinic Constipation score from 23 to 8.5 (P<0.01) with a significant improvement of quality of life. Antegrade colonic enema did not affect gallbladder, gastric, or orocecal transit time, which remained comparable with baseline. Colonic scintigraphy showed that antegrade colonic enema was efficient to clean the whole colon and rectum, leaving only 24 (range, 6-40) percent of the initial radioactivity after 30 minutes. Ileal manometry confirmed the presence of a high-pressure zone, preventing accidental reflux.

CONCLUSIONS

Modified Marsh and Kiff technique is a safe and effective surgical option to treat patients with combined fecal incontinence and severe constipation and those with perineal colostomy after Miles. It should be recommended as a last option before colostomy.

Percutaneous endoscopic cecostomy in adults: a case series

BACKGROUND

Percutaneous cecostomy is used to treat recurrent colonic pseudoobstruction or obstipation in children and adults with multiple medical comorbidities. Percutaneous endoscopic cecostomy is a potentially attractive alternative to surgical or fluoroscopic cecostomy placement. A few reports describe percutaneous endoscopic cecostomy for management of these problems in children, whereas there are no large series of percutaneous endoscopic cecostomy in adult patients describing the indications, complications, and outcomes.

OBJECTIVE

Report our experience with percutaneous endoscopic cecostomy in adults.

DESIGN

Case series.

SETTING

Single tertiary referral center in the United States.

PATIENTS

Five patients with recurrent colonic pseudoobstruction and 2 with chronic refractory constipation.

INTERVENTIONS

Percutaneous endoscopic cecostomy.

RESULTS

Eight cases of percutaneous endoscopic cecostomy were performed from May 2001 through October 2005: 6 for colonic pseudoobstruction and 2 for chronic constipation. Seven of 8 cases were successful and resulted in clinical improvement. One patient required surgical removal of the percutaneous endoscopic cecostomy tube at 4 days for fecal spillage resulting in peritonitis despite successful tube placement for chronic constipation. Removal of the cecostomy tube occurred in 3 of 6 cases of pseudoobstruction (the other 3 remain in place). In the other patient with chronic constipation, clinical improvement occurred, but the patient died of underlying illness 21 days after placement. No other serious complications occurred.

LIMITATIONS

Retrospective, single-center study.

CONCLUSIONS

Percutaneous endoscopic cecostomy is a viable alternative to surgically or fluoroscopically placed cecostomy in a select group of patients with recurrent colonic pseudoobstruction or chronic intractable constipation.

A multicentre study of the management of disorders of defecation in patients with spina bifida

Patients with spinal dysraphism may have severe constipation and faecal incontinence. The impact of antegrade colonic enema (ACE) in the management of patients with spina bifida (SB) is analysed. In a multicentre cross-sectional study, constipation, faecal incontinence and faecal management were described. Cases surgically treated were identified. Data were collected from 423 patients, of whom 230 did not use any manoeuvre or laxatives to assist evacuation. Conventional treatment was used in 193 patients, including digital extraction in 39%, retrograde enema in 21% and oral laxatives in 52%. For intractable constipation and overflow of faecal incontinence, 47 patients were treated with ACE, of whom 41 used the method at a mean time of interview of 4.1 +/- 1.9 years after ACE operation; six abandoned ACE for conventional management. With ACE, faecal continence was significantly improved compared with conventional management, and neither retrograde rectal enema nor digital extraction were required. The conduit was fashioned to the right colon in 32 cases and to the left colon in nine cases. This study provides information on a multicentre experience in bowel management in SB patients. Whatever the technique used, ACE has improved faecal status compared with conventional therapy.

Gastrointestinal symptoms related to autonomic dysfunction following spinal cord injury

The impact of spinal cord injury on an individual's gastrointestinal tract function is often poorly understood by the general public and also by those involved with persons with spinal cord injury. This chapter reviews the anatomy, physiology and function of the gastrointestinal tract, with particular emphasis on neurological control mechanisms. In turn, it relates the effect that spinal cord injury has on the neurological control of the gastrointestinal tract. The symptoms that are encountered by patients in the acute phase following injury, and by individuals in the months/years after injury, with particular reference to the effect of altered autonomic nervous system control of the gastrointestinal tract, are discussed. Together with a following summary of current bowel management regimens and techniques, this chapter aims to provide an overall view of the effect that autonomic dysfunction due to spinal cord injury has on gastrointestinal function.

Gastrointestinal interventions--emphasis on children

Although the fundamental principles of interventional and minimally invasive image-guided techniques are the same in children as in adults, nonetheless the spectrum of diseases, the pediatric approach, and the devices used differ significantly from those in adults. The following is a general overview of image-guided gastrointestinal interventions in children and neonates, with emphasis on those aspects peculiar to children. Many of the facets and tips have been learned the hard way over the years, in a busy pediatric practice. Although there are several potential ways to do some of these procedures, the description below reflects our practice and experience. In general terms, minimizing radiation dose is a significant responsibility for the pediatric interventionalist. Reducing the number of exposures, reliance on last image hold, low-dose pulse fluoroscopy, and tight coning are all important. Protection for the radiologist is equally important, but sometimes difficult to achieve, given the small size of many of the patients.

Percutaneous endoscopic colostomy of the left colon: a new technique for management of intractable constipation in children

BACKGROUND

The antegrade colonic enema is accepted as effective for management of intractable constipation in children when conventional bowel management has failed. This study describes experience with a new, minimally invasive technique, the distal antegrade colonic enema, which involves percutaneous endoscopic colostomy of the left colon.

METHODS

Fifteen children with refractory constipation and soiling who had radiographic evidence of megarectum and/or distal colonic delay were selected for the procedure. The junction of the descending and the sigmoid colon was identified colonoscopically, and the percutaneous endoscopic colostomy tube, through which antegrade distal colonic enema are administered, was inserted.

RESULTS

Fourteen children underwent distal percutaneous endoscopic colostomy insertion. The median time required for the procedure was 30 minutes (20-50 minutes). Excluding one child (technical difficulties with percutaneous endoscopic colostomy placement), median post-procedural hospital stay was 4 days (2-27 days). Thirteen children were no longer soiling, and improvement in quality of life was reported at 2 months' follow-up. At 6 months' follow-up, 90% of children were clean during intervals between enemas. All children evaluated at 12 months' follow-up remained clean. Median duration of follow-up was 12.5 months (2-51 months).

CONCLUSIONS

The distal percutaneous endoscopic colostomy is a simple alternative to established methods for delivery of antegrade enemas. It is less invasive and on reversal leaves only minor scarring.

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.

Percutaneous endoscopic cecostomy: a case series

BACKGROUND

There are few reports of percutaneous endoscopic cecostomy in adult patients.

METHODS

All cases of acute colonic pseudo-obstruction (n = 2) and neurogenic bowel (n = 3) in adults in which percutaneous endoscopic cecostomy was performed were reviewed retrospectively.

OBSERVATIONS

Percutaneous endoscopic cecostomy was a definitive treatment. In 1 of the 2 patients with acute colonic pseudo-obstruction, the percutaneous endoscopic cecostomy tube was clamped and subsequently removed 10 weeks after placement; in the other patient with acute colonic pseudo-obstruction, the percutaneous endoscopic cecostomy tube remains in place. In 2 of the 3 patients with neurogenic bowel, the percutaneous endoscopic cecostomy tube continues to function well; the third patient did well for 6 months and then died of underlying comorbid disease. There was no mortality or need for surgical intervention for any patient. Complications occurred in 2 patients; 1 developed transient fever and leukocytosis and 1 had self-limited bleeding during anticoagulation.

CONCLUSIONS

Percutaneous endoscopic cecostomy is a safe and effective treatment for both acute colonic pseudo-obstruction and neurogenic bowel when aggressive albeit conservative treatment is unsuccessful.

Appendiceal versus ileal segment for antegrade continence enema

PURPOSE

To assess outcomes after the antegrade continence enema procedure, we present our results with an ileal segment or the appendix in children with severe bowel dysfunction.

MATERIALS AND METHODS

A retrospective review of 45 children who had undergone the creation of a continent cecostomy for severe chronic constipation and fecal incontinence was performed.

RESULTS

The appendix was used to create the continent cecostomy in 28 patients (group 1) and ileum 17 (group 2). Of 16 patients who underwent simultaneous construction of appendiceal Mitrofanoff neourethra, including continent catheterizable stoma, the appendix was split and used for the cecostomy and neourethra in 11. Overall, acceptable continence was achieved in 39 (87%) patients and total continence 31 (69%). No significant difference was noted in the rate of continence between groups 1 and 2. Nonstomal postoperative complications occurred in 5 patients in group 1 and 3 group 2. Complications that required reoperation related to the continent cecostomy occurred in 10 patients, including stomal stenosis in 8, with 6 group 1 and 2 group 2 (p >0.05), and stricture in 2, with 1 group 1 and 1 group 2. There were 2 patients who had previously undergone colostomy for intractable constipation who were undiverted at the time of the creation of continent cecostomy. Both were continent postoperatively. There were 3 patients, including those 2 who presented with chronic severe constipation of unclear etiology, who underwent colostomy for unrecoverable colonic dys-motility, of whom 1 subsequently required total colectomy.

CONCLUSIONS

The creation of a continent cecostomy for antegrade continence enema is a successful management option in children with debilitating fecal incontinence, and may enable undiversion of an existing colostomy. The appendix and ileal segment are viable options for the procedure, with no significant difference noted in continence or complication rates.