Percutaneous colonoscopic cecostomy for management of chronic constipation in children

Percutaneous endoscopic cecostomy for management of Ogilvie's syndrome: a case series and literature review with an update on current guidelines (with video)

INTRODUCTION

Percutaneous endoscopic cecostomy (PEC) is a viable treatment option for patients with persistent or recurrent acute colonic pseudo-obstruction (ACPO; Ogilvie's syndrome). It should be generally considered in patients that are refractory to pharmacologic and endoscopic decompression, especially those not amenable to surgical intervention due to an increased perioperative risk. Physicians are rather unfamiliar with this approach given the limited number of reports in the literature and paucity of guideline resources, although guidelines concerning ACPO and covering the role of endoscopy were recently published by three major expert societies, all within the last 2 years.

PATIENTS AND METHODS

We retrospectively identified three consecutive patients who underwent PEC placement at a Czech tertiary referral center between May 2018 and December 2021: all for recurrent ACPO. In addition, we summarized the current guidelines in order to present the latest knowledge related both to the procedure and management approach in patients with ACPO.

RESULTS

The placement of PEC was successful and resulted in clinical improvement in all cases without any adverse events.

CONCLUSION

The results of our experience are in line with previous reports and suggest that PEC may become a very useful tool in the armamentarium of modalities utilized to treat ACPO. Furthermore, the availability of guideline resources now offers comprehensive guidance for informed decision-making and the procedural aspects.

Therapeutic utility of percutaneous cecostomy in adults: an updated systematic review

Objective

Percutaneous cecostomy is a minimally invasive procedure that provides access to the colon for therapeutic interventions. This review aimed to update and summarize the existing information on the use and application of percutaneous endoscopic cecostomy in the field of therapeutic gastroenterology.

Data Sources

A systematic review of the literature was performed without any restrictions on the year of publication from the date of inception in 1986 to January 2021.

Methods

The review was performed using the medical subject heading keywords in the following search engines: MEDLINE, EMBASE, Cochrane, and Google Scholar.

Results

A total of 29 articles were subjected to final data extraction. The review included a total of 174 patients who underwent percutaneous cecostomy. Most of the included studies were conducted in the United States (n = 14). The most common comorbidity was cancer (n = 10) and the major indication for performing percutaneous cecostomy was colonic pseudo-obstruction or Ogilvie's syndrome (n = 15). The main technique for performing percutaneous cecostomy was endoscopy (17 studies), followed by fluoroscopy- (five studies), computed-tomography- (three studies), laparoscopy- (two studies), and ultrasound- (one study) guided procedures. The procedure was technically successful in 153 (88%) cases. The total cumulative rates of major and minor complications were 47.5%. These complications included tube malfunction, local wound site infections, and bleeding and rare complications of peritonitis and death.

Conclusion

Percutaneous cecostomy is a safe and effective option for managing acute colonic pseudo-obstruction. It leads to durable symptom relief with low to minimal risk.

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.

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.

Colonic transit time and pressure based on Bernoulli's principle

PURPOSE

Variations in the caliber of human large intestinal tract causes changes in pressure and the velocity of its contents, depending on flow volume, gravity, and density, which are all variables of Bernoulli's principle. Therefore, it was hypothesized that constipation and diarrhea can occur due to changes in the colonic transit time (CTT), according to Bernoulli's principle. In addition, it was hypothesized that high amplitude peristaltic contractions (HAPC), which are considered to be involved in defecation in healthy subjects, occur because of cecum pressure based on Bernoulli's principle.

METHODS

A virtual healthy model (VHM), a virtual constipation model and a virtual diarrhea model were set up. For each model, the CTT was decided according to the length of each part of the colon, and then calculating the velocity due to the cecum inflow volume. In the VHM, the pressure change was calculated, then its consistency with HAPC was verified.

RESULTS

The CTT changed according to the difference between the cecum inflow volume and the caliber of the intestinal tract, and was inversely proportional to the cecum inflow volume. Compared with VHM, the CTT was prolonged in the virtual constipation model, and shortened in the virtual diarrhea model. The calculated pressure of the VHM and the gradient of the interlocked graph were similar to that of HAPC.

CONCLUSION

The CTT and HAPC can be explained by Bernoulli's principle, and constipation and diarrhea may be fundamentally influenced by flow dynamics.

Surgical Management of Idiopathic Constipation in Pediatric Patients

Constipation is a common childhood problem, but an anatomic or physiologic cause is identified in fewer than 5% of children. By definition, idiopathic constipation is a diagnosis of exclusion. Careful clinical evaluation and thoughtful use of imaging and other testing can help exclude specific causes of constipation and guide therapy. Medical management with laxatives is effective for the majority of constipated children. For those patients unresponsive to medications, however, several surgical options can be employed, including anal procedures, antegrade colonic enemas, colorectal resection, and intestinal diversion. Judicious use of these procedures in properly selected patients and based on appropriate preoperative testing can lead to excellent outcomes. This review summarizes the surgical options available for managing refractory constipation in children and provides guidance on how to choose the best procedure for a given patient.

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.

Diagnosis and management of chronic constipation in adults

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

Constipation and Outcomes of Cecostomy

Constipation, defined as delay or difficulty in defecation, present for 2 or more weeks, is a common problem encountered by both primary and specialty medical providers. There are no randomized controlled trials on the use of antegrade enemas in the pediatric population. Most published papers are based on the experience at a particular center. The aim of this article is to describe the pathophysiology of constipation, review the contribution of colonic manometry to the diagnosis of constipation, summarize the advancements in the management of constipation through the use of antegrade enemas, and study the outcomes of cecostomy at different centers. This study is a comprehensive literature review generated by computerized search of literature, supplemented by review of monographs and textbooks in pathology, gastroenterology, and surgery. Literature search was performed using the publications from 1997 to 2012. The search included publications of all types presenting or reviewing data on cecostomy. The antegrade continence enema is a therapeutic option for defecation disorders when maximal conventional therapy is not successful. Symptoms of defecation disorders in children with different underlying etiologies improve significantly after a cecostomy is created. In addition, there is a benefit on the patients' physical activity, healthcare utilization, and general well-being. Based on the review of published literature it seems that antegrade enemas are a successful therapeutic option in children with severe constipation and/or fecal incontinence. With the advent of cecostomy buttons, patient compliance and the overall cosmetic appearance have improved.

Laparoscopic Cecostomy Tube Placement

Fecal incontinence is a debilitating problem for many children, especially those with anorectal malformations. Historically, surgical options have included the Malone antegrade continence enema, using an appendicostomy for antegrade colonic enemas. Since the development of this procedure, multiple alternatives have been developed, including the Chait cecostomy tube. Here, we present our technique for laparoscopic cecostomy tube placement. We find that this approach has several advantages, including mobilization of the cecum to allow the tube to be placed below the waistline for optimal cosmesis and comfort, increased safety provided by direct vision of needle access to the cecum, and increased security of the cecum to the abdominal wall allowing for safer tube replacement should it become dislodged in the early postoperative period.

Ten-year experience using antegrade enemas in children

OBJECTIVE

To describe a single-center, 10-year experience with the use of antegrade enemas.

STUDY DESIGN

Retrospective analysis of 99 patients treated with antegrade enemas at Nationwide Children's Hospital.

RESULTS

Study subjects (median age 8 years) were followed for a mean time of 46 months (range 2-125 months) after cecostomy placement. Seventy-one patients had the cecostomy placed percutaneously and 28 by surgery. Thirty-five patients had functional constipation and 64 patients an organic disease (spinal abnormalities, cerebral palsy, imperforate anus, Hirschsprung's disease). While using antegrade enemas, 71% became symptom-free, in 20 subjects symptoms improved, in 2 subjects symptoms did not change, and in 7 subjects symptoms worsened. Poor outcome was associated with surgical placement of the cecostomy (P < .001), younger age (P = .02), shorter duration of symptoms (P = .01), history of Hirschsprung's disease (P = .05), cerebral palsy (P = .03), previous abdominal surgery (P = .001), and abnormal colonic manometry (P = .004). In 88%, successful irrigation solution included use of a stimulant laxative, and subjects who used a stimulant did significantly better (P < .001) than subjects who started without a stimulant. In 13 patients, the cecostomy was removed 49.7 months after placement without recurrence of symptoms. Major complications occurred in 12 patients and minor complications in 47.

CONCLUSIONS

Antegrade enemas represent a successful and relatively safe therapeutic option in children with severe defecatory disorders. Prognostic factors are identified.

Long-term follow-up of patients after antegrade continence enema procedure

BACKGROUND

Antegrade continence enema (ACE) has become an important therapeutic modality in the treatment of intractable constipation and fecal incontinence. There are little data available on the long-term performance of the ACE procedure in children.

METHODS

A retrospective review of patients who underwent the ACE procedure was conducted. Irrigation characteristics and complications were noted. Outcome was assessed for individual encounters based on frequency of bowel movements, incontinence, pain, and predictability.

RESULTS

One hundred seventeen patients underwent an ACE. One hundred five patients had at least 6 months of follow-up, and were included in the analysis. Diagnoses included myelodysplasia (39%), functional intractable constipation (26%), anorectal malformations (21%), nonrelaxing internal anal sphincter (7%), cerebral palsy (3%), and other diagnoses (4%). The average follow-up was 68 months (range 7-178 months). At the last follow-up, 69% of patients had successful bowel management. Of the 31% of patients who did not have successful bowel management, 20% were using the ACE despite suboptimal results, 10% required surgical removal, and 2% were not using the ACE because of behavioral opposition to it. Patients were started on normal saline, but were switched to GoLYTELY (PEG-3350 and electrolyte solution) if there was an inadequate response (61% at final encounter). Additives were needed in 34% of patients. The average irrigation dose was 23 ± 0.7 mL/kg. The average toilet sitting time was 51.7 ± 3.5 minutes, with infusions running for 12.1 ± 1.2 minutes. Stomal complications occurred in 63% (infection, leakage, and stenosis) of patients, 33% required surgical revision and 6% eventually required diverting ostomies.

CONCLUSIONS

Long-term use of the ACE gives successful results in 69% of patients, whereas 63% had a stoma-related complication and 33% required surgical revision of the stoma.

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.

Childhood constipation: evaluation and management

Constipation is a common problem in children. It is also a long-term problem persisting for many months to years in children. Approximately 95% of childhood constipation is functional in nature without any obvious cause. Evaluation of a child with constipation requires a thorough history and physical examination. Hirschsprung's disease is an important cause of constipation arising in infancy and requires a thorough diagnostic evaluation and surgical treatment. Treatment of functional constipation in children requires a well-designed plan and a team approach involving the child, parents, and a health care provider. Treatment involves education of the family about constipation and encopresis, fecal disimpaction, and long-term maintenance therapy of laxatives and behavioral modification. Laxatives such as magnesium hydroxide, lactulose, and mineral oil have been used in children for a long time. A new laxative, polyethylene glycol 3350, has been used successfully in children with constipation and encopresis. Several novel therapeutic interventions have been tried for children presenting with intractable constipation, refractory to conventional treatment.

The experience of finding an effective bowel management program for children with spina bifida: the parent's perspective

Many families who have a child with spina bifida identify establishing an effective bowel program as one of the major challenges they face; yet, we know little about a family's experience with this process. The purpose of this qualitative study was to describe the parent's experience. Seven parents were interviewed by telephone. Content analysis yielded four themes: (a) long complicated journey, (b) the impact of the journey on the child, (c) the family struggle, and (d) the promise of the future. The major contribution of this study is a compelling description of one of the most difficult areas for these children and their families. A better understanding of this issue enhances the health care providers' ability to deliver optimal health care.

[Antegrade colonic enemas for intractable constipation in non-mentally retarded children]

A descriptive review of 12 patients who underwent appendicocecostomy or caecostomy for antegrade colonic lavage from January 2002 to February 2008. There were 9 appendicocecostomies performed patients from 3 to 13 years suffering from myelomeningocele, of which 8 of them had a very good outcome, with one case withdrawn due to poor use by the family. Three caecostomies were performed in non-mentally retarded constipated children. One was an otherwise healthy 7 year-old boy with hard stools since he was 10 months old, in spite of multiple laxative treatments, with normal morphology and function. He had a percutaneous caecostomy five years ago, with some improvement and a good quality of life, but still some occasional partial impactions. Another healthy 12 year-old boy with daily constipation associated faecal incontinence since he was 3 years old (normal manometry and rectal biopsy with signs of mild neuronal dysplasia) had a percutaneous caecostomy performed three years ago, with improvement in the faecal incontinence and better psychological outcome. The last caecostomy patient was an 8-year-old boy, with a similar clinical history and good progress in last three years after placing a Chait's button using an endoscopic procedure. Stubborn constipation continuing into adult life has a negative impact on the social and emotional adaptation of the paediatric patient, affecting family interactions. Antegrade colonic lavage allows independence and improves the quality of life in patients affected by recurrent faecal impactions. This technique needs to be performed on more patients to find out its true effectiveness.

Cecostomy button for antegrade enemas: survey of 29 patients

OBJECTIVE

This study evaluated the Trap-door button use (Cook Medical, Bloomington, IL) for antegrade enemas in children.

METHODS

Since 2002, patients with fecal incontinence or encopresis and constipation underwent percutaneous cecostomy under laparoscopy using a button. Technical details are described. Age at surgery, operative time, hospital stay, diagnosis, indications for cecostomy, and duration of follow-up were recorded. A survey was proposed via a questionnaire that was sent to the patients. Patients wearing the button for less than 1 month were excluded from this evaluation. The survey concerned volume and frequency of enemas, difficulties encountered, benefits and disadvantages of this method, and assessment of the antegrade enemas in continence.

RESULTS

Twenty-nine patients, 18 males and 11 females, aged 3 to 21 years (mean, 8.5 years) underwent laparoscopic Trap-door button placement. The indications for all the patients were intractable fecal incontinence in 24 cases and constipation with encopresis in 5 cases. Incontinence was because of myelomeningocele (n = 10), anorectal malformations (n = 11), caudal regression syndrome (n = 1), 22q11 syndrome (n= 1), and Hirschsprung disease with encephalopathy with convulsions (n = 1). Constipation with encopresis was because of sacrococcygeal teratoma (n = 1), cerebral palsy (n = 1), and acquired megarectum with psychiatric and social disorders (n = 3). A total of 26 cecostomy button placements and 3 sigmoidostomy button placements were successful with no intraoperative complication. The mean operative time was 25 minutes (10-40 minutes), and the hospital stay was 2.5 days (1-4 days). Twenty-two parents or patients answered the questionnaire. At the time of this survey, 2 patients had improved their fecal continence and had had the button removed. A mean of 4 weekly enemas was enough to improve fecal continence troubles (range, 1 daily to 1 for 2 weeks). The volume for enemas was 250 to 1000 mL (mean, 700 mL). The time required for the irrigation of the bowel by gravity took from 5 to 60 minutes (mean, 25 minutes) for 20 patients. Before surgery, 14 patients needed a diaper, day and night, and 6 needed sanitary protection. Soiling was a very significant inconvenience for all the patients. After surgery, only 5 patients needed a diaper (cerebral palsy, 22q11, cloacal malformation, myelomeningocele, bladder exstrophy) because of moderate results or urinary incontinence and continued soiling. Patients were asked to give an assessment (null = 0, bad = 1, fair = 2, good = 3, very good = 4). None of the patients felt there had been no changes or a bad result. There were 5 patients who felt they had an average result, 5 a good result, and 12 a very good result. The mean grade was 3.44 (17.2/20). A total of 3 patients had hypertrophic granulation tissue formation around the cecostomy button, and 12 had tiny leakage.

CONCLUSION

Percutaneous placement of a cecostomy button under laparoscopic control is an easy and major complication-free procedure. The use of the Trap-door device by the patients or with the help of the parents for antegrade enemas is effective and satisfactory. It improves the quality of life and is reversible.

Adynamic ileus and acute colonic pseudo-obstruction

Ileus and colonic pseudo-obstruction cause functional obstruction of intestinal transit, without mechanical obstruction, because of uncoordinated or attenuated intestinal muscle contractions. Ileus usually arises from an exaggerated intestinal reaction to abdominal surgery that is often exacerbated by numerous other conditions. Colonic pseudo-obstruction is induced by numerous metabolic disorders, drugs that inhibit intestinal motility, severe illnesses, and extensive surgery. It presents with massive colonic dilatation with variable, moderate small bowel dilatation. Both conditions are initially treated with supportive measures that include intravenous rehydration, correction of electrolyte abnormalities, discontinuation of antikinetic drugs, and treatment of other contributing disorders. Specific therapies for colonic pseudo-obstruction include neostigmine (an anticholinesterase) for pharmacologic colonic decompression and colonoscopic decompression.

Percutaneous Cecostomy for Management of Fecal Incontinence in Pediatric Patients

PURPOSE

To report the authors' experience with percutaneous cecostomy and demonstrate its effectiveness in the management of pediatric patients with fecal incontinence.

MATERIALS AND METHODS

Between March 2002 and November 2006, 21 percutaneous cecostomy procedures were performed in 20 patients in whom classical therapeutic approaches for the management of fecal incontinence had failed. Eighteen patients had anorectal malformations, one had myelomeningocele, and one had chronic constipation. All procedures were performed under general anesthesia and fluoroscopic guidance. In all cases, an 8.5-F Dawson-Mueller catheter was placed in the cecum and exchanged after 45 days with a cecostomy button (ie, Trapdoor catheter). Data regarding complications, effectiveness of treatment, satisfaction, and quality of life were obtained by interviewing the patients' parents at follow-up consultation.

RESULTS

Nineteen of 20 procedures were technically successful. There were no major complications. All patients' symptoms of incontinence improved. Ninety percent of patients in our series (n = 18) reported satisfaction with the procedure, mainly related to their independence and quality of life.

CONCLUSIONS

Percutaneous cecostomy is a safe and effective procedure for the management of pediatric patients with fecal incontinence. Percutaneous cecostomy allows antegrade and more physiologic colon irrigation, avoiding the need for multiple retrograde enemas, achieving more patient independence, and improving quality of life.

Novel and alternative therapies for childhood constipation

Constipation is a worldwide problem that affects many children. Treatment of constipation is largely based on clinical experience rather than on evidence-based controlled clinical trials. Stool softeners and cathartic agents in combination with behavioral interventions constitute the programs most commonly used to facilitate painless and frequent defecation. Long-term treatment is needed for most patients, and approximately 30% of children beyond puberty continue to struggle with symptoms of constipation, such as infrequent, painful evacuation of stools and fecal incontinence. Not surprisingly, chronicity of these bowel complaints may cause significant interference with the child's emotional growth and development. Development of new therapeutic strategies is necessary in order to treat these challenging patients more effectively. This review provides an overview of novel and alternative therapies, such as new drugs, surgery, and probiotics, that are being proposed for the treatment of childhood chronic constipation.

Severe delayed complication after percutaneous endoscopic colostomy for chronic intestinal pseudo-obstruction: A case report and review of the literature

Percutaneous endoscopic colostomy (PEC) is increasingly proposed as an alternative to surgery to treat various disorders, including acute colonic pseudo-obstruction, chronic intestinal pseudo-obstruction and relapsing sigmoid volvulus. We report on a severe complication that occurred two months after PEC placement. A 74-year-old man with a history of chronic intestinal pseudo-obstruction evolving since 8 years was readmitted to our hospital and received PEC to provide long-standing relief. The procedure was uneventful and greatly improved the patient’s quality of life. Two months later, the patient developed acute stercoral peritonitis. At laparotomy, the colostomy flange was embedded in the abdominal wall but no pressure necrosis was found at the level of the colonic wall. This complication was likely related to inadvertent traction of the colostomy tube. Subtotal colectomy with terminal ileostomy was performed. We review the major features of 60 cases of PEC reported to date, including indications and complications.

Motility disorders of the gastrointestinal tract

Over the past decades our knowledge of normal and abnormal gastrointestinal motility has increased tremendously. The availability of manometry to study bowel contraction patterns, laparoscopy to perform full thickness bowel biopsies for histological examination, have added to the investigative armamentarium and helped better diagnose motility disorders. However, the development of newer therapies for bowel motility disorders has been disappointingly slow. Newer modalities such as gastric and bowel pacing provides some hope for the future. In this article we have provided an overview of some of the common motility disorders in children and discussed their management.

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.

Introducer method of percutaneous endoscopic cecostomy and antegrade continence enema by use of the Chait Trapdoor cecostomy catheter in patients with adult neurogenic bowel

BACKGROUND

Previous reports on percutaneous endoscopic cecostomy (PEC) for the delivery of antegrade continence enema (ACE) in adults have been presented in the form of case reports. Heretofore the tubes used in the pull method of PEC have been thick bolster catheters. The author performed PEC by using the introducer method (IM) with 10 F Chait Trapdoor cecostomy catheters (CTCC) in adult cases.

OBJECTIVE

Report author experience with a new method of PEC in adults.

DESIGN

Case series.

SETTING

Single institution in Japan.

PATIENTS

Five patients with bowel obstruction and 15 patients with chronic severe constipation.

INTERVENTIONS

The interventions were the pull method or IM of PEC and drainage or ACE. In 5 cases, PEC was performed by the pull method with the use of an 18 F to 24 F bolster catheter for decompression of dilated intestine. In 15 patients with chronic constipation, PEC was performed with the IM method using a balloon catheter (11 F or 15 F) and CTCC. ACE was performed every other day.

RESULTS

PEC was successful and effective (decompression and evacuation) in all patients. In patients with IM of PEC, 5 patients were placed with a 15 F balloon catheter and 10 patients were placed with an 11 F balloon catheter. Immediate bleeding occurred in 1 case. Balloon rupture occurred during the first month or on average at the 1 month period. Nine of 10 patients who had the 11 F catheters were changed to CTCC. The advantages of CTCC were prevention of accidental balloon rupture, decreased leakage and granulation tissue, and ease of exchange compared with bolster catheter.

LIMITATIONS

Retrospective, single-institution.

CONCLUSIONS

PEC with IM is a safe and useful method. CTCC is advantageous on a long-term basis for ACE.

Laparoscopic cecostomy button placement for the management of fecal incontinence in children with Hirschsprung’s disease and anorectal anomalies

BACKGROUND

Antegrade colonic enemas offer a surgical solution for many children with chronic constipation and encopresis associated with Hirschsprung's disease and anorectal malformations. This study demonstrated the feasibility of a new laparoscopic technique for cecostomy button placement (LCBP) to allow antegrade enema treatment.

METHODS

Charts of children with encopresis who underwent LCBP between 1999 and 2001 were reviewed. The age, weight, primary diagnosis, operative time, hospital stay, associated complications, follow-up duration, and outcome of the patients were recorded. The surgical technique used a "U-stitch" method and a chait tube or a standard gastrostomy button. A follow-up telephone survey was conducted to assess parental satisfaction and overall success in continence.

RESULTS

Seven patients ages 4 to 12 years (mean, 7.3 +/- 1.3 years) and weighing 15 to 44 kg (mean, 24.5 +/- 4 kg) underwent LCBP over a 2-year period. The mean follow-up period was 15 +/- 4 months (range, 6-33 months). Four patients had anorectal malformations, and three patients had Hirschsprung's disease. For all the patients, LCBP was accomplished without any intraoperative complications. The mean operative time was 33 +/- 2 min, and the hospital stay was 2 to 5 days (mean, 3.8 +/- 0.5 days). The patients received one or two daily antegrade enemas, and none had accidental bowel movements. Episodes of soiling at night once or twice a week were observed with two children. Two patients had hypertrophic granulation tissue formation, which responded to topical therapy. The button was uneventfully changed twice in one patient because of mechanical malfunction.

CONCLUSION

To manage overflow incontinence of children with anorectal malformations and Hirschsprung's disease, LCBP is a technically straightforward, effective, and reversible method for the placement of a cecostomy button.

Cecostomy in children with defecation disorders

Administration of antegrade enemas through a cecostomy is a therapeutic option for children with severe defecation disorders. The purpose of this study is to report our 4-year experience with the cecostomy procedure in 31 children with functional constipation (n = 9), Hirschsprung's disease (n = 2), imperforate anus (n = 5), spinal abnormalities (n = 8), and imperforate anus in combination with tethered spinal cord (n = 7). Data regarding complications, antegrade enemas used, symptoms, and quality of life were retrospectively obtained. Placement of cecostomy tubes was successful in 30 of 31 patients. Soiling episodes decreased significantly in children with functional constipation (P = 0.01), imperforate anus (P < 0.01), and spinal abnormalities (P = 0.04). Quality of life improved in patients with functional constipation and imperforate anus. No difference in complications was found between percutaneous and surgical placement. Use of antegrade enemas via cecostomy improved symptoms and quality of life in children with a variety of defecation disorders.

Management of Fecal Incontinence in Children Without Functional Fecal Retention

The management of the fecal incontinence in children is difficult, and its social consequences are usually devastating. The general objectives of any bowel program are to produce social continence, predictability, and eventually independence. How to achieve those goals depends in part on the underlying condition. In children, fecal incontinence can occur from a variety of conditions. The most common is overflow incontinence from functional fecal retention, but it can also occur in otherwise healthy children with functional nonretentive fecal soiling or in children with organic causes of fecal incontinence, such as congenital malformations, or any other condition affecting the anorectum, anal sphincters, or the spinal cord. The therapeutic regimen that is recommended in patients with nonretentive fecal soiling consists of explanation and support for the child and parents, a nonaccusatory approach, and a toilet training program with a rewarding system. Biofeedback does not play an important role, and laxatives need to be used with caution, as they may exacerbate the incontinence. For those patients with congenital/neuropathic incontinence a combination of maneuvers to change stool consistency, colonic transit, anorectal function, and rectosigmoid evacuation is used. Stool consistency can be changed with the use of dietary interventions or medications. Stool transit can be slowed (antimotility agents) or accelerated (laxatives) with the use of medications. Anorectal function can be improved with the use of biofeedback or procedures to alter sphincter pressure, and the production of a bowel movement can be induced with maneuvers to empty the sigmoid (suppositories, enemas). With the recent advent of the Antegrade Colonic Enema (ACE), the patient is then able to be predictable and independent. This procedure creates a continent conduit from the skin to the cecum that can be catheterized or accessed for self-administration of enemas. The ACE has revolutionized the treatment of children with fecal incontinence.

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

OBJECTIVE

The aim of this study was to evaluate the long-term results of the Antegrade Continent Enema (ACE) procedure for treating severe constipation in adults.

METHODS

Over 10 years 37 ACE conduits were created in 32 patients (median age 35 years, 26 women) with constipation caused by slow transit, obstructed defaecation or both. Conduits were created from the appendix (n = 20, 54%), ileum (n = 10, 27%), neoappendix caecostomy (n = 5, 14%) or colon (n = 2, 5%). Clinical records were retrospectively reviewed to determine outcome.

RESULTS

After a median follow up of 36 (range 13-140) months, 28 (88%) required at least one further procedure on a primary conduit, including reversal in 19 (59%). Five patients had a second conduit fashioned, two successfully. Conduit type and constipation cause did not significantly influence the rates of ACE reversal or major revision. Ileal conduits were associated with fewer minor revision procedures for stenosis (1 in 7 patients) than appendix conduits (21 in 20 patients). There was one (3%) serious complication. Satisfactory ACE function was ultimately achieved in 47% of patients, at last follow up. After ACE reversal, 9 (28%) patients underwent formation of an end stoma and 3 patients had a colectomy.

CONCLUSIONS

Revision procedures are common, but approximately half of patients can expect satisfactory long-term ACE function. ACE conduit reversal does not preclude subsequent alternative surgical strategies to treat this difficult condition.

Palliation of malignant bowel obstruction using a percutaneous cecostomy

Bowel obstruction is a common complication of metastatic gastrointestinal and ovarian cancers, and can cause distressing symptoms. Along with medical options, surgical options should be considered in all patients with bowel obstruction, including percutaneous gastrostomy. We report the case of a patient with metastatic colon cancer with an obstructing recurrence at the primary site who was not eligible for major surgery or percutaneous gastrostomy and was managed with a percutaneous cecostomy for symptom control.

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.

Management of intractable constipation with antegrade enemas in neurologically intact children

OBJECTIVES

To assess the benefit of antegrade enemas in children with severe constipation who were referred to a tertiary care center.

METHODS

From 1997 to 1999, 12 children (9 male, aged 8.7 +/- 4.4 years) underwent cecostomy placement. All children were neurologically normal and had been extensively examined to rule out organic causes of constipation. Follow-up included a questionnaire to interview caregivers 13.1 +/- 8.5 months after cecostomy placement.

RESULTS

For all children, antegrade enemas led to improvement in the number of bowel movements / week (7.1 versus 1.4, P < 0.005), number of soiling accidents / week (1.0 versus 4.7, P < 0.01), abdominal pain score (0.9 versus 2.9, P < 0.005), emotional health score (3.6 versus 1.9, P < 0.005), overall health score (3.6 versus 1.7, P < 0.005), number of medications used for constipation (0.8 versus 4.0, P < 0.005), number of missed school days / month (1.5 versus 7.5, P < 0.02), and number of physician office visits / year (9.2 versus 24.0, P < 0.05). Irrigation solutions used for the antegrade enemas included polyethylene glycol (67%), saline and glycerin solution (25%), and phosphate enema (8%), administered everyday in seven children and every other day in five children. Adverse events included skin breakdown and granulation tissue in one patient, leakage of irrigation solution in one patient, and dislodging of the tube in two patients. Five patients discontinued the use of antegrade enemas within a mean of 14.6 +/- 9.1 months after beginning treatment.

CONCLUSION

Antegrade enemas through a cecostomy are a safe and satisfactory option for children who are neurologically intact and who have severe constipation that does not respond to medical treatment.

Gastrointestinal problems in the handicapped child

Gastrointestinal issues are a major chronic problem in 80 to 90% of children with cerebral palsy and in children with neurodevelopmental disabilities who are at special risk of developing malnutrition because of uncoordinated swallowing, gastroesophageal reflux, and constipation. In addition to poor linear growth, there is a decrease in muscle strength and coordination, impaired cerebral function leading to decreased motivation and energy. Significant neurodevelopmental progress can be achieved with improved nutritional status. A multidisciplinary approach, with input from neurologists, gastroenterologists, nurses, occupational therapists, and dieticians, can make a major contribution to the medical wellbeing and quality of life of these children. Different neurological diseases ( eg, spinal dysraphism, syringomyelia, tethered cord syndromes) can give rise to gastrointestinal dysfunction and symptoms that may need different gastrointestinal or surgical management. The introduction of new drugs, including proton pump inhibitors and innovative endoscopic and surgical techniques in the management of gastroesophageal reflux disease and constipation also may have an impact on the treatment of neurologically handicapped children in the future.