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Srinivas S, Halaweish I, Knaus ME, Ahmad H, Griffin KL, Stephenson KG, Yossef L, Trimble C, Jimenez ALN, Lu A, Gasior A, Wood RJ, Williams KC. Outcomes of children with constipation and autism spectrum disorder treated with antegrade continence enemas. J Pediatr Gastroenterol Nutr 2024; 78:810-816. [PMID: 38284650 DOI: 10.1002/jpn3.12130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 11/01/2023] [Accepted: 11/16/2023] [Indexed: 01/30/2024]
Abstract
BACKGROUND Treatment of functional constipation (FC) in children with autism spectrum disorder (ASD) is challenging due to sensory and behavioral issues. We aimed to understand whether antegrade continence enemas (ACEs) are successful in the treatment of FC in children with ASD. METHODS A single-institution retrospective review was performed in children diagnosed with ASD and FC who underwent appendicostomy or cecostomy placement from 2007 to 2019. Descriptive statistics regarding soiling and complications were calculated. RESULTS There were 33 patients included, with a median age of 9.7 years at the time of ACE initiation. The average intelligence quotient was 63.6 (SD = 18.0, n = 12), the average behavioral adaptive score was 59.9 (SD = 11.1, n = 13), and the average total Child Behavioral Checklist score was 72.5 (SD = 7.1, n = 10). Soiling rates were significantly lower following ACE initiation (42.3% vs. 14.8%, p = 0.04). Behavioral issues only prevented 1 patient (3.0%) from proper ACE use. Eleven patients (36.6%) were able to transition to laxatives. There were significant improvements in patient-reported outcomes measures and quality of life. CONCLUSION Placement of an appendicostomy or cecostomy for management of FC in children with severe ASD was successful in treating constipation and improving quality of life.
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Affiliation(s)
- Shruthi Srinivas
- Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Ihab Halaweish
- Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Maria E Knaus
- Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Hira Ahmad
- Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Kristine L Griffin
- Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Kevin G Stephenson
- Department of Psychology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Lina Yossef
- Department of Pediatric Gastroenterology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Casey Trimble
- Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | | | - Anan Lu
- College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Alessandra Gasior
- Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Richard J Wood
- Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Kent C Williams
- Department of Pediatric Gastroenterology, Nationwide Children's Hospital, Columbus, Ohio, USA
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Baaleman DF, Vriesman MH, Lu PL, Benninga MA, Levitt MA, Wood RJ, Yacob D, Di Lorenzo C, Koppen IJ. Long-Term Outcomes of Antegrade Continence Enemas to Treat Constipation and Fecal Incontinence in Children. J Pediatr Gastroenterol Nutr 2023; 77:191-197. [PMID: 37195883 PMCID: PMC10348609 DOI: 10.1097/mpg.0000000000003833] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 03/17/2023] [Indexed: 05/19/2023]
Abstract
OBJECTIVES The objective of this study is to investigate long-term outcomes of antegrade continence enema (ACE) treatment in children with constipation or fecal incontinence. METHODS Prospective cohort study including pediatric patients with organic or functional defecation disorders who started ACE treatment. Data were collected at baseline and at follow-up (FU) from 6 weeks until 60 months. We assessed parent and patient-reported gastrointestinal health-related quality of life (HRQoL) using the Pediatric Quality of Life Inventory Gastrointestinal Symptoms Module (PedsQL-GI), gastrointestinal symptoms, adverse events, and patient satisfaction. RESULTS Thirty-eight children were included (61% male, median age 7.7 years, interquartile range 5.5-12.2). Twenty-two children (58%) were diagnosed with functional constipation (FC), 10 (26%) with an anorectal malformation, and 6 (16%) with Hirschsprung disease. FU questionnaires were completed by 22 children (58%) at 6 months, 16 children (42%) at 12 months, 20 children (53%) at 24 months, and 10 children (26%) at 36 months. PedsQL-GI scores improved overall with a significant increase at 12- and 24-month FU for children with FC and a significant increase in parent reported PedsQL-GI score at 36-month FU for children with organic causes. Minor adverse events, such as granulation tissue, were reported in one-third of children, and 10% of children needed a surgical revision of their ACE. The majority of all parents and children reported that they would "probably" or "definitely" choose ACE again. CONCLUSION ACE treatment is perceived positively by patients and parents and can lead to long-term improvement in gastrointestinal HRQoL in children with organic or functional defecation disorders.
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Affiliation(s)
- Desiree F. Baaleman
- From the Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children’s Hospital, Columbus, OH
- the Department of Pediatric Gastroenterology and Nutrition, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam & VU University, Amsterdam, The Netherlands
| | - Mana H. Vriesman
- From the Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children’s Hospital, Columbus, OH
- the Department of Pediatric Gastroenterology and Nutrition, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam & VU University, Amsterdam, The Netherlands
| | - Peter L. Lu
- From the Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children’s Hospital, Columbus, OH
- the Center for Colorectal and Pelvic Reconstruction, Nationwide Children’s Hospital, Columbus, OH
| | - Marc A. Benninga
- the Department of Pediatric Gastroenterology and Nutrition, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam & VU University, Amsterdam, The Netherlands
| | - Marc A. Levitt
- the Center for Colorectal and Pelvic Reconstruction, Nationwide Children’s Hospital, Columbus, OH
| | - Richard J. Wood
- the Center for Colorectal and Pelvic Reconstruction, Nationwide Children’s Hospital, Columbus, OH
| | - Desale Yacob
- From the Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children’s Hospital, Columbus, OH
- the Center for Colorectal and Pelvic Reconstruction, Nationwide Children’s Hospital, Columbus, OH
| | - Carlo Di Lorenzo
- From the Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children’s Hospital, Columbus, OH
- the Center for Colorectal and Pelvic Reconstruction, Nationwide Children’s Hospital, Columbus, OH
| | - Ilan J.N. Koppen
- From the Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children’s Hospital, Columbus, OH
- the Department of Pediatric Gastroenterology and Nutrition, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam & VU University, Amsterdam, The Netherlands
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Gould MJ, Marcon MA, Nguyen GC, Benchimol EI, Moineddin R, Swayze S, Kopp A, Ratcliffe EM, Merritt N, Davidson J, Langer JC, Mistry N, Lorenzo AJ, Temple M, Walsh CM. Impact of antegrade enema initiation on healthcare utilization in pediatric patients: A population-based cohort study. Neurogastroenterol Motil 2023; 35:e14495. [PMID: 36377812 DOI: 10.1111/nmo.14495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 10/24/2022] [Accepted: 11/01/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND When constipation is refractory to first-line interventions, antegrade enema use may be considered. We aimed to assess the impact of this intervention on healthcare utilization. METHODS We conducted a population-based, quasi-experimental study with pre-post comparison of the intervention group and a non-equivalent control group using linked clinical and health administrative data from Ontario, Canada. Subjects included children (0-18 years) who underwent antegrade enema initiation from 2007 to 2020 and matched controls (4:1) from the general population. To assess the change in healthcare utilization following antegrade enema initiation, we used negative binomial generalized estimating equations with covariates selected a priori. KEY RESULTS One hundred thirty-eight subjects met eligibility criteria (appendicostomy = 55 (39.9%); cecostomy tube = 83 (60.1%)) and were matched to 550 controls. There was no significant difference in the change in the rate of hospitalizations (rate ratio (RR) 1.05, 95% confidence interval (CI) 0.35-1.75), outpatient visits (RR 1.05, 95% CI 0.91-1.18), or same-day surgical procedures (RR 1.51, 95% CI 0.60-2.43) across cases in 2 years following antegrade enema initiation compared with controls. Cases had an increased rate of emergency department (ED) visits, which was not observed in controls (RR 1.52, 95% CI 1.11-1.79), driven in part by device-related complications. CONCLUSIONS AND INFERENCES Understanding healthcare utilization patterns following antegrade enema initiation allows for effective health system planning and aids medical decision-making. The observed increase in ED visits for device-related complications speaks to the need to improve preventive management to help mitigate emergency care after initiation of antegrade enemas.
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Affiliation(s)
- Michelle J Gould
- Division of Gastroenterology, Hepatology, and Nutrition, Hospital for Sick Children, Toronto, Canada.,Department of Paediatrics, University of Toronto, Toronto, Canada
| | - Margaret A Marcon
- Division of Gastroenterology, Hepatology, and Nutrition, Hospital for Sick Children, Toronto, Canada.,Department of Paediatrics, University of Toronto, Toronto, Canada
| | - Geoffrey C Nguyen
- Division of Gastroenterology, Mount Sinai Hospital, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada.,ICES, Toronto, Canada
| | - Eric I Benchimol
- Division of Gastroenterology, Hepatology, and Nutrition, Hospital for Sick Children, Toronto, Canada.,Department of Paediatrics, University of Toronto, Toronto, Canada.,ICES, Toronto, Canada
| | - Rahim Moineddin
- Department of Family and Community Medicine, Division of Biostatistics, University of Toronto, Toronto, Canada
| | | | | | - Elyanne M Ratcliffe
- Division of Pediatric Gastroenterology and Nutrition, McMaster Children's Hospital, Hamilton, Canada.,Department of Pediatrics, McMaster University, Hamilton, Canada
| | - Neil Merritt
- Division of Pediatric Surgery, London Health Sciences Center, London, Canada
| | - Jacob Davidson
- Division of Pediatric Surgery, London Health Sciences Center, London, Canada
| | - Jacob C Langer
- Division of General and Thoracic Surgery, Hospital for Sick Children, Toronto, Canada.,Department of Surgery, University of Toronto, Toronto, Canada
| | - Niraj Mistry
- Department of Paediatrics, University of Toronto, Toronto, Canada.,Division of Paediatric Medicine, Hospital for Sick Children, Toronto, Canada
| | - Armando J Lorenzo
- Department of Surgery, University of Toronto, Toronto, Canada.,Division of Urology, Hospital for Sick Children, Toronto, Canada
| | - Michael Temple
- Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, Canada.,Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Catharine M Walsh
- Division of Gastroenterology, Hepatology, and Nutrition, Hospital for Sick Children, Toronto, Canada.,Department of Paediatrics, University of Toronto, Toronto, Canada.,SickKids Research and Learning Institutes, Toronto, Canada
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Taha AA, Eisen AM, Abdul Rahman HQ, Good KE, Freeman KA, Kotzin JD, Wolf MH, Azar NG, Davis KR, Austin JC. Cecostomy tubes improve bowel continence for pediatric patients with spina bifida: A retrospective analysis of outcomes from a single clinic. J Pediatr Rehabil Med 2023; 16:629-637. [PMID: 38073339 PMCID: PMC10789339 DOI: 10.3233/prm-220123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 09/18/2023] [Indexed: 01/01/2024] Open
Abstract
PURPOSE Pediatric patients with spina bifida often experience neurogenic bowel dysfunction. Although cecostomy tubes could improve bowel continence, their effectiveness is not well established in this population. The aims of this study were to better understand the effectiveness of cecostomy tubes relative to other management strategies (between-subject) and to explore their effectiveness among patients who received these placements (within-subject). METHODS Retrospective analysis of data from pediatric patients enrolled in a national spina bifida patient registry (n = 297) at a single multidisciplinary clinic was performed, covering visits between January 2014 -December 2021. Linear and ordinal mixed effect models (fixed and random effects) tested the influence of cecostomy status (no placement vs placement) and time (visits) on bowel continence while controlling for demographic and condition-specific covariates. RESULTS Patients with cecostomy tubes had higher bowel continence compared to patients without placements (B = 0.695, 95% CI [0.333, 1.050]; AOR = 2.043, p = .007). Patients with cecostomy tubes had higher bowel continence after their placements compared to before (B = 0.834, 95% CI [0.142, 1.540]; AOR = 3.259, p = 0.011). CONCLUSION Results indicate cecostomy tubes are effective for improving bowel continence in this pediatric population. Future research is needed to conduct risk analyses and determine the clinical significance of these effects.
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Affiliation(s)
- Asma A. Taha
- School of Nursing, Oregon Health & Science University, Portland, OR, USA
| | - Aaron M. Eisen
- School of Nursing, Oregon Health & Science University, Portland, OR, USA
| | | | - Kelsey E. Good
- School of Nursing, Oregon Health & Science University, Portland, OR, USA
| | - Kurt A. Freeman
- Institute on Development and Disability, Department of Pediatrics, School of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Jennifer D. Kotzin
- Institute on Development and Disability, Department of Pediatrics, School of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Margaret H. Wolf
- Institute on Development and Disability, Department of Pediatrics, School of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Najood G. Azar
- School of Nursing, California State University, Fullerton, Fullerton, CA, USA
| | - Kelley R. Davis
- Institute on Development and Disability, Department of Pediatrics, School of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - J. Christopher Austin
- Department of Urology, Division of Pediatric Urology, School of Medicine, Oregon Health and Sciences University, Portland, OR, USA
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Husťak R, Škuta R, Dobrovodský A, Habiňák M, Kudlová D, Janegová A, Plavčanová E, Rajec J, Martínek J. Laparoscopic-asisted percutaneus endoscopic cecostomy (LAPEC) in the treatment of severe constipation of adults - single center study. Rozhl Chir 2022; 101:22-27. [PMID: 35148613 DOI: 10.33699/pis.2022.101.1.22-27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
INTRODUCTION Effective treatment for chronic constipation is a real clinical challenge, especially in patients with severe symptoms. If conservative measures do not help, usually subtotal colectomy with ileorectal anastomosis has been used as the treatment of choice for refractory slow-transit constipation, but consequences may unfavorably affect quality of life. Percutaneous endoscopic caecostomy (PEC) with antegrade colonic enema (ACE) is a minimally invasive alternative to avoid radical surgery in order to improve bowel movement. Recently, of various catheter placement techniques, a laparoscopic-assisted percutaneous endoscopic cecostomy has been applied in clinical praxis. METHODS We performed retrospective analysis of 5 patients with Chait Trapdoor catheter placed for purpose of ACE by LAPEC. Main outcome was to assess clinical success of PEC defined by an improvement of at least 50% of baseline KESS at 6M. Secondary outcomes were: procedural parameters and safety of procedure. RESULTS Since may 2019 to march 2021, LAPEC was performed in 5 patients. Median follow-up was 14 months (7V12). All PECs were placed successfully in cecum. Treatment success reached 60% (3/5) of patients. Postoperative complication occurred in three patients. CONCLUSION LAPEC provides both endoscopic and laparoscopic visualization, thereby, significantly decreasing potential risks by ensuring precise and safe access to the cecum. Antegrade colonic enema through PEC provides improvement of bowel movement in highly selected patient with severe symptoms.
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Esparaz JR, Waters AM, Mathis MS, Mortellaro VE. Reducing Constipation-Related Admissions: The Effectiveness of Antegrade Continence Enema Procedures in Children. Am Surg 2021; 88:2327-2330. [PMID: 34060378 DOI: 10.1177/00031348211023429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Constipation in pediatrics remains a common problem. Antegrade continence enema (ACE) procedures have been shown to decrease the distress of daily therapy. Patients are able to administer more aggressive washouts in the outpatient setting. Therefore, we hypothesize that patients following an ACE procedure would have reduced admissions for constipation. METHODS Patients who underwent an ACE procedure at a large children's hospital from 2015 to 2018 were included. Demographics, diagnosis, procedure, and preoperative/postoperative hospital admissions were analyzed. RESULTS Forty-eight patients were included in the study. Over half were diagnosed with idiopathic constipation. Majority of patients underwent an appendicostomy (88%, n = 42). Preoperatively, 26 patients were admitted for a combined total of 63 times for constipation. Postoperatively, 4 patients were admitted for a total of 5 visits (P = .021). Twenty-eight patients required a nonscheduled appendicostomy tube replacement. CONCLUSION This study demonstrates ACE procedures can improve constipation-related symptoms in children and are associated with decrease hospital admissions.
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Affiliation(s)
- Joseph R Esparaz
- Division of Pediatric Surgery, 22078Children's of Alabama, Birmingham, AL, USA
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Alicia M Waters
- Division of Pediatric Surgery, 22078Children's of Alabama, Birmingham, AL, USA
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Michelle S Mathis
- Division of Pediatric Surgery, 22078Children's of Alabama, Birmingham, AL, USA
| | - Vincent E Mortellaro
- Division of Pediatric Surgery, 22078Children's of Alabama, Birmingham, AL, USA
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
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Stoica RT, Cordoş I, Macri A. Post-Pneumonectomy ARDS and Ogilvie Syndrome - A Case Report. J Crit Care Med (Targu Mures) 2018; 4:34-37. [PMID: 29967899 DOI: 10.1515/jccm-2018-0007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Accepted: 01/30/2018] [Indexed: 11/15/2022]
Abstract
Introduction The Acute Respiratory Distress Syndrome (ARDS) is a severe hypoxemic acute lung injury that may complicate lung resections. Reported mortality is very high, up to 50%. This report covers an ARDS case occurring post left pneumonectomy, with a favorable outcome, despite association with an acute colonic pseudo-obstruction syndrome (Ogilvie syndrome) that required abdominal surgery for decompression. Case Report A 60-year old Caucasian male, diagnosed with a stage IIIA left lung tumor underwent a left pneumonectomy. On the second postoperative day, the patient developed ARDS, requiring ventilatory support. Two days later, as the multiple organ dysfunction worsened, a bowel obstruction occurred. With an acute colonic pseudo-obstruction diagnosis, the decision was to perform laparotomy and a temporary cecostomy. A subsequent improvement in the respiratory parameters and vital functions resulted in weaning from ventilator 8 days after the onset of the ARDS and transfer to the surgery ward 14 days after pneumonectomy.
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Affiliation(s)
- Radu T Stoica
- "Marius Nasta" Pneumophtisiology Institute, Bucharest, Romania.,Faculty of Medicine, "Titu Maiorescu" University, Bucharest, Romania
| | - Ioan Cordoş
- "Marius Nasta" Pneumophtisiology Institute, Bucharest, Romania.,"Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Anca Macri
- "Marius Nasta" Pneumophtisiology Institute, Bucharest, Romania
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Miller ZA, Mohan P, Tartaglione R, Narayanan G. Bowel Obstruction: Decompressive Gastrostomies and Cecostomies. Semin Intervent Radiol 2017; 34:349-360. [PMID: 29249859 DOI: 10.1055/s-0037-1608706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Over the past 30 years, image-guided placement of gastrostomies and cecostomies for gastrointestinal decompression has developed into a safe and effective treatment for symptomatic bowel obstruction. Gastrostomies and cecostomies relieve patient symptoms, can prevent serious complications such as colonic perforation, and may bridge patients to more definitive treatment for the underlying cause of obstruction. This article will review the history of decompressive gastrostomies and cecostomies as well as the indications, contraindications, technique, complications, and outcomes of these procedures.
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Affiliation(s)
- Zoe A Miller
- Department of Interventional Radiology, University of Miami-Miller School of Medicine, Miami, Florida
| | - Prasoon Mohan
- Department of Interventional Radiology, University of Miami-Miller School of Medicine, Miami, Florida
| | - Robert Tartaglione
- Department of Interventional Radiology, University of Miami-Miller School of Medicine, Miami, Florida
| | - Govindarajan Narayanan
- Department of Interventional Radiology, University of Miami-Miller School of Medicine, Miami, Florida
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Abstract
Stomas provide fecal diversion in emergent and elective settings. Preoperative planning and counseling are extremely important to the creation of an acceptable and functional ostomy for the surgeon and patient. Proper site selection will help decrease the incidence of postoperative complications. Ileostomy, colostomy, and cecostomy indications and techniques are discussed.
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Affiliation(s)
- Marc I Brand
- Rush Medical College, Department of General Surgery, Rush-Presbyterian-St. Luke's Medical Center, Chicago, IL 60612, USA.
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