Outcomes of children with constipation and autism spectrum disorder treated with antegrade continence enemas.

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.

Percutaneous cecostomy: 25-year two institution experience.

BACKGROUND: Reports of technical success, adverse events, and long-term outcome of percutaneous cecostomy in children are limited. OBJECTIVE: To characterize technical success, 30-day severe adverse events, and long-term outcome of percutaneous cecostomy at two centers. MATERIALS AND METHODS: A retrospective review of hospital course and long-term follow-up (through May 2022) of percutaneous cecostomy tubes placed May 1997 to August 2011 at two children's hospitals was used. Outcomes assessed included technical success (defined as successful tube placement into the colon allowing antegrade colonic enemas), length of stay, 30-day severe adverse events, surgery consults, surgical repair, VP shunt infection, ongoing flushes, tube removal, duration between maintenance tube exchanges, and deaths. RESULTS: A total of 215 procedures were performed in 208 patients (90 institution A, 125 institution B). Tubes were placed for neurogenic bowel (72.1%, n = 155) and functional constipation (27.9%, n = 60). Technical success was 98.1% (211/215) and did not differ between centers (p = 0.74). Surgical repair was required for bowel leakage in 5.1% (11/215) and VP shunt infection was managed in 2.1% (2/95). Compared to functional constipation, patients with neurogenic bowel had higher % tube remaining (65.3% [96/147] versus 25.9% [15/58], p < 0.001) and higher ongoing flushes at follow-up (42.2% [62/147] versus 12.1% [7/58], p < 0.001). Tube removal for dissatisfaction occurred in 15.6% [32/205] and did not differ between groups (p = 0.98). Eight deaths due to co-morbidity occurred after a median of 7.4 years (IQR 9.3) of tube access. CONCLUSION: Percutaneous cecostomy is technically successful in the vast majority of patients and provided durable access in most. Bowel leakage and VP shunt infection are uncommon, severe adverse events.

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.

Acute Colonic Pseudo-Obstruction.

CASE SUMMARY: A 33-year-old man with a history of chronic alcohol use, generalized anxiety disorder, and hypertension presented to the emergency department after a syncopal event. He was admitted to the medical intensive care unit for alcohol withdrawal, requiring intubation and sedation. On hospital day 7, abdominal x-ray image demonstrated a dilated cecum to 12 cm, transverse colon dilation to 7 cm, and decompressed distal colon ( Fig. 1 ). CT scan of the abdomen and pelvis confirmed dilation of the cecum and ascending and transverse colons ( Fig. 2 ). Colonoscopy showed no evidence of distal obstruction, but colonic distension persisted, and he subsequently underwent cecal decompression with an open "blow-hole" cecostomy fully matured at skin level via a small right lower quadrant incision. The nasogastric tube was removed on postoperative day 2, and his diet was slowly advanced. Abdominal x-ray image on postoperative day 5 demonstrated no colonic dilation. He was discharged home on postoperative day 7. The patient re-presented to the hospital 3 months later with cecostomy prolapse. He underwent cecostomy takedown with ileocecectomy via circumstomal incision. He was discharged home on postoperative day 2.

Laparoscopic-asisted percutaneus endoscopic cecostomy (LAPEC) in the treatment of severe constipation of adults - single center study.

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.

Delivery routes for faecal microbiota transplants: Available, anticipated and aspired.

Fecal microbiota transplant (FMT) has seen a historic emergence in last decade with its sojourn recently entering into a chequered path, due to a few reports of infection and subsequent mortality. Though FMT has been extensively reported, there is no comprehensive report on the delivery routes available for this non-pharmacological treatment option. Safety, efficacy and cost of FMT not only depend on the quality of contents but also on the delivery route employed. A number of delivery routes are in use for conducting FMT, which include upper gastrointestinal routes (UGI) i.e. nasogastric/nasojejunal tube, endoscopy, oral capsules and lower gastrointestinal routes (LGI) like retention enema, sigmoidoscopy or colonoscopy. Capsules, both conventional as well as colon targeted have been the most commonly used formulations. Surprisingly, the success rates with conventional gastric delivery capsules and colon targeted capsules were found to be quite similar indicating the sufficiency of the inoculum size to withstand the microbial loss in the gastric milieu. Patient compliance, cost effectiveness, comfort of administration, level of invasiveness, patient's hospital admission, risk of aspiration and infections, multiplicity of administration required, recurrence rate are the main factors that seem to influence the choice for route of administration of physicians. The best route for FMT has not been established yet. Extensive studies are required to understand the interplay of route adopted, type of donor, physical nature of sample (fresh or frozen), patient compliance and cost effectiveness to design an approach for the risk free, convenient and cost-effective administration route for FMT.

Optimization of Pediatric Bowel Management Using an Antegrade Enema Troubleshooting Algorithm.

BACKGROUND: A successful flush is the ability to flush through the appendicostomy or cecostomy channel, empty the flush through the colon, and achieve fecal cleanliness. We evaluated our experience with patients who were having flush difficulties based on a designed algorithm. METHODS: Eight patients with flush difficulties were initially evaluated. Based on the need for additional surgery versus changes in bowel management therapy (BMT), we developed an algorithm to guide future management. The algorithm divided flush issues into before, during, and after flushing. Children aged <20 y who presented with flush issues from September 2018 to August 2019 were evaluated to determine our algorithm's efficacy. Specific outcomes analyzed included changes in BMT versus need for additional surgery. RESULTS: After algorithm creation, 29 patients were evaluated for flush issues. The median age was 8.4 y (interquartile range: 6, 14); 66% (n = 19) were men. Underlying diagnoses included anorectal malformations (n = 17), functional constipation (n = 7), Hirschsprung's disease (n = 2), spina bifida (n = 2), and prune belly (n = 1). A total of 35 flush issues/complaints were noted: 29% before the flush, 9% during the flush, and 63% after the flush. Eighty percent of issues before the flush required surgical intervention, wherease 92% of issues during or after the flush were managed with changes in BMT. CONCLUSIONS: Most flush issues respond to changes in BMT. This algorithm can help delineate which types of flush issues would benefit from surgical intervention and what problems might be present if patients are not responding to changes in their flush regimen.

Anterograde colonic irrigations by percutaneous endoscopic caecostomy in refractory colorectal functional disorders.

PURPOSE: In case reports or small studies, percutaneous endoscopic caecostomy (PEC) has been proposed as an alternative to the Malone intervention to perform antegrade colonic enemas. Our goal was to assess the feasibility, efficacy, and tolerance of PEC in a large group of patients with refractory colorectal functional disorders. METHODS: From September 2006 to April 2014, all patients undergoing PEC for constipation, fecal incontinence, and incontinence after rectal resection in two expert centers were studied. The PEC procedure consisted in anchoring the caecum to the abdominal wall (caecopexy) and placing a specifically designed tube in the colonic lumen to perform antegrade enemas. The quality of life (GIQLI), constipation (Kess), and incontinence (Cleveland) scores were assessed before PEC and at 3, 6, 12, and 24 months. RESULTS: A total of 69 patients were included. GIQLI scores were significantly improved in constipation group (n = 43), incontinence group (n = 19), and rectal resection group (n = 10). In the constipation group, Kess score decreased from 25.9 before PEC to 20.6 at 2 years (p = 0.01). In the incontinence and post-rectal resection groups, Cleveland scores decreased from 14.3 before PEC to 2.7 at 6 months (p = 0.01) and to 10.4 at 2 years (p = 0.04). Overall, PEC was considered successful by patients in 58%, 74%, and 90% of cases, in constipation, incontinence, and rectal resection groups, respectively. Chronic pain (52%) at the catheter site was the most frequent complication. CONCLUSIONS: Percutaneous endoscopic caecostomy for antegrade colonic enemas improves significantly the quality of life of patients with colorectal disorder refractory to medical treatment.

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

PURPOSE OF REVIEW: No gold standard exists for managing neurogenic bowel dysfunction, specifically in individuals with spina bifida. Since the International Children's Continence Society published its consensus document on neurogenic bowel treatment in 2012, an increased focus on why we must manage bowels and how to improve our management has occurred. This review provides updated information for clinicians. RECENT FINDINGS: A surge in research, mostly retrospective, has been conducted on the success and satisfaction of three types of management for neurogenic bowel. All three management techniques have relatively high success rates for fecal continence and satisfaction rates. Selection of which treatment to carry out still is debated among clinicians. Transanal irrigation is a safe and effective management option for neurogenic bowel that does not require surgery. Antegrade enemas can be carried out via cecostomy tube or Malone antegrade continence enema with similar fecal continence outcomes.

Percutaneous endoscopic cecostomy in the treatment of recurrent colonic pseudo-obstruction a case report of the first procedure in the Czech Republic.

We present the case of an 89-year-old polymorbid female patient with recurrent acute colonic pseudo-obstruction who was treated by performing percutaneous endoscopic cecostomy as the first procedure of its kind in the Czech Republic. The patient presented repeatedly with ileous conditions without evidence of an organic cause. Surgical colostomy was proposed with a possibility of subtotal colectomy as an ultimum refugium due to an insufficient effect of maximum conservative management and a need for repeated endoscopic decompression. In this particular patient, however, any kind of surgical intervention posed a major risk and was eventually abandoned. Finally, percutaneous endoscopic cecostomy was proposed as an alternative to resolve the situation. The procedure was carried out without complications and with an immediate effect. The patient has been free of the symptomatology of intestinal obstruction in the long term having the option of intermittent intestinal decompression as needed.

Analysis of Factors Associated with Patient or Caregiver Regret following Surgery for Fecal Incontinence.

PURPOSE: Malone antegrade continence enema has been a successful and widely used procedure for achieving fecal continence in children. We present data on the previously uninvestigated issue of patient and caregiver regret following surgery for intractable constipation and fecal incontinence. MATERIALS AND METHODS: We reviewed all patients undergoing antegrade continence enema or cecostomy creation at a single institution between 2006 and 2016. Patients and caregivers were assessed for decisional regret using the Decisional Regret Scale. Results were correlated with demographics, surgical outcomes and complications. RESULTS: A total of 81 responses (49 caregivers and 32 patients) were obtained. Mean followup was 49 months. Decisional regret was noted in 43 subjects (53%), including mild regret in 38 (47%) and moderate to severe regret in 5 (6%). No statistical difference in regret was noted based on gender, complications or performance of concomitant procedures. On regression analysis incontinence was strongly associated with decisional regret (OR 4.4, 95% CI 1.1-18.1, p <0.001) and regret increased as age at surgery increased, particularly when patients were operated on at age 13 to 15 years (OR 2.6, 95% CI 1.0-6.4 for age 13 years; OR 2.9, 95% CI 1.1-7.8 for age 14 years; OR 3.1, 95% CI 1.1-8.8 for age 15 years). CONCLUSIONS: This is the first known study describing decisional regret following surgery for fecal incontinence. Surgical factors aimed at achieving continence may be effective in decreasing postoperative regret. The finding of increased regret in teenage patients compared to younger children should be shared with families since it may impact the age at which surgery is pursued.

Slowed relaxation of diaphragm in septic rats is associated with reduced expression of sarco-endoplasmic reticulum CA2+ -ATPase genes SERCA1 and SERCA2.

INTRODUCTION: The aim of this study was to study the effects of sepsis on diaphragm relaxation properties and the associated expression of sarco-endoplasmic reticulum Ca2+ -ATPase genes SERCA1 and SERCA2. METHODS: Rats were randomized to undergo either sham surgery or cecal ligation and puncture (CLP). Diaphragm isometric relaxation parameters were measured after 24 h. The mRNA expression and protein content of SERCA1 and SERCA2 in diaphragm muscles were determined. RESULTS: Both diaphragm maximal twitch and tetanus relaxation rates were reduced. Twitch half-relaxation time was prolonged after normalization to half of peak twitch tension. The mRNA expression and protein content of SERCA1 and SERCA2 were decreased. CONCLUSIONS: Slowed relaxation of the diaphragm in septic rats was associated with reduced expression of SERCA1 and SERCA2. Muscle Nerve 54: 1108-1113, 2016.

Medical and surgical management of neurogenic bowel.

PURPOSE OF REVIEW: Neurogenic bowel dysfunction (NBoD) commonly affects patients with spina bifida, cerebral palsy, and spinal cord injury among other neurologic insults. NBoD is a significant source of physical and psychosocial morbidity. Treating NBoD requires a diligent relationship between patient, caretaker, and provider in establishing and maintaining a successful bowel program. A well designed bowel program allows for regular, predictable bowel movements and prevents episodes of fecal incontinence. RECENT FINDINGS: Treatment options for NBoD span conservative lifestyle changes to fecal diversion depending on the nature of the dysfunction. Lifestyle changes and oral laxatives are effective for many patients. Patients requiring more advanced therapy progress to transanal irrigation devices and retrograde enemas. Those receiving enemas may opt for antegrade enema administration via a Malone antegrade continence enema or Chait cecostomy button, which are increasingly performed in a minimally invasive fashion. Select patients benefit from fecal diversion, which simplifies care in more severe cases. SUMMARY: Many medical and surgical options are available for patients with NBoD. Selecting the appropriate medical or surgical treatment involves a careful evaluation of each patient's physical, psychosocial, financial, and geographic variables in an effort to optimize bowel function.

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.

Associated Factors for Antegrade Continence Enemas for Refractory Constipation and Fecal Incontinence.

OBJECTIVE: Determine clinical and manometric parameters associated with success of antegrade continence enemas (ACEs) administered via cecostomy in the treatment of constipation and fecal overflow incontinence. METHODS: We performed a retrospective review of clinical symptoms and manometry (colonic and anorectal) before cecostomy in 40 pediatric patients (20 males, 20 females). The mean age at time of follow-up was 9.5 ±â€Š4.4 years with a mean follow-up time of 12.2 ±â€Š10.9 months. Clinical outcomes were defined as good, if subjects had >3 bowel movements per week, <2 episodes of soiling per week, and absence of pain at the time of follow-up after cecostomy. RESULTS: Before cecostomy, the mean duration of constipation and/or fecal incontinence was 7.7 ±â€Š4.4 years, mean number of BMs was 1.5 ±â€Š0.9 per week, and soiling episodes 4.12 ±â€Š3.5 per week; 24 (60%) patients had abdominal pain. At follow-up 30 out of 40 patients had a good outcome, and 10 had a poor outcome; with a difference in the number of weekly BM of 5.7 ±â€Š2.2 versus 1.5 ±â€Š0.9, P < 0.001, and soiling episodes (0.4 ±â€Š1.5 vs 4 ±â€Š3.1, P < 0.001). There was no difference in the duration of symptoms between groups. Obesity was more common in the poor-outcome group, 60% versus 21% (P = 0.01). Abdominal pain was more common in the poor-outcome group, 100% versus 47% (P = 0.003). Normal colonic manometry was associated with good outcome, whereas absence of high-amplitude propagating contraction (HAPC) in any part of the colon was associated with poor outcome. No other differences in colonic manometry were observed between the good- and poor-outcome groups with the exception of a trend toward decreased number of sigmoid HAPCs in the poor-outcome group (P = 0.07). No differences were observed in anorectal manometry measurements between good- and poor-outcome groups with the exception of an observable increased baseline resting pressure in the poor outcome (P = 0.05). CONCLUSIONS: Obesity and abdominal pain tend to be associated with poor outcomes after cecostomy for refractory constipation. Normal colonic and anorectal manometry were associated with good outcome. Absence of HAPC in any part of the colon, and increased baseline resting pressure of the anal canal were more associated with poor outcome. No other specific differences in either colonic or anorectal manometric parameters were observed in patients with good versus poor outcomes with cecostomy. Large prospective studies potentially combining other diagnostic modalities such as colonic transit studies are needed to determine the optimal tests to predict successful outcomes from cecostomy.

Percutaneous endoscopic cecostomy (introducer method) in chronic intestinal pseudo-obstruction: Report of two cases and literature review.

We report on two patients with recurrent episodes of chronic intestinal pseudo-obstruction (CIPO). A 50-year-old woman with severe multiple sclerosis and an 84-year-old man with Parkinson's disease and dementia had multiple hospital admissions because of pain and distended abdomen. Radiographic and endoscopic findings showed massive dilation of the colon without any evidence of obstruction. Conservative management resolved symptoms only for a short period of time. As these patients were poor candidates for any surgical treatment we carried out percutaneous endoscopic colostomy by placing a 20-Fr tube in the cecum with the introducer method. The procedure led to durable symptom relief without complications. We present these two cases and give a review through the existing literature of the procedure in CIPO.

Current Surgical Management of Pediatric Idiopathic Constipation: A Systematic Review of Published Studies.

OBJECTIVE: Surgery for pediatric idiopathic constipation (IC) is undertaken after failure of bowel management programs. Decisions are influenced by rectal biopsy, transit studies, megacolon/megarectum, degree of soiling/incontinence, and anorectal manometry profile(s). A systematic review of ALL published studies critically evaluates outcomes of surgery for IC. METHODS: MEDLINE (PubMed), Google Scholar, and EMBase were searched for English-language articles only. Studies included (1) peer-review publications with 3 or more patients, and (2) clinical outcomes defined by authors. RESULTS: Forty-five reports (1157 patients) met full inclusion criteria. Only 2 papers were randomized controlled trials. Many had small patient numbers (median n = 16; range: 3-114). Twenty-three described heterogenous populations with variant pathology. Follow-up was short (median = 1.5 years: range: 3 months-14 years). The antegrade continence enema operation (ACE)-[open/laparoscopic assisted, cecostomy, or "left sided" ACE]-was judged as successful in 82% of cases, although high morbidity and reoperations were reported. Colon resection and pull through operations had "good" outcome(s) in 79% of children with 17% reporting significant morbidity and a 10% incidence of revisional surgery. Anal dilatation did not improve outcome(s). Botulinum toxin injection scored equally effective compared to internal sphincter myectomy in short-term follow-up. Permanent colostomy was considered successful in 86% of refractory IC cases. CONCLUSIONS: Surgical management and outcome(s) for pediatric IC are based on low-quality evidence. No single operation was considered "best practice." This study crucially highlights that surgeons must develop better care strategies.

Clinical outcome and efficacy of antegrade colonic enemas administered via an indwelling cecostomy catheter in adults with defecatory disorders.

BACKGROUND: Antegrade colonic enemas are used in selected adult patients with defecatory disorders. Conduit stenosis requiring revisional surgery is common. OBJECTIVE: The aim of the study was to determine whether stenosis could be avoided by using an indwelling antegrade continence enema catheter in an appendiceal or cecal conduit, and to describe medium-term clinical outcomes. DESIGN: This study was a retrospective case series. SETTING: The study was conducted at a tertiary referral hospital in Sydney, Australia. PATIENTS: Adults administering antegrade colonic enemas to manage defecatory disorders were selected for the study. METHODS: Patients with an indwelling antegrade continence enema catheter completed a face-to-face survey when they attended the clinic for catheter change. A postal survey was sent to nonattenders, and, if it was not returned, the patient was contacted, and the survey was completed by telephone. The survey asked about irrigation techniques, satisfaction, confidence to manage, and continence, using quantitative scores. RESULTS: Fifty-four patients (45 female; mean age, 49 years) had constipation (n = 31), incontinence (n = 6), both incontinence and constipation (n = 2) or obstructed defecation due to gracilis neosphincter (n = 5), congenital anomalies (n = 8), or spinal injuries (n = 2). Thirty-five patients (65%) continued to irrigate for a mean follow-up of 5.5 years (range, 4 months to 13.7 years). Mean enema volume was 1178 mL (95% CI, 998-1357; range, 350-2000 mL), and half the patients added a stimulant to the irrigation. Mean total toileting time was 59 minutes (95% CI, 48-66; range, 15-120 minutes). Twenty-one patients had incontinence between irrigations, and in 17% incontinence was severe (St. Mark score >12). Satisfaction (visual analogue scale = 8.1) and confidence to partake in social activities (visual analogue scale = 8.2) and all-day activities (visual analogue scale = 7.1) were high. Complications included superficial wound infection (n = 15), wound infection requiring surgery (n = 6), paraconduit hernia (n = 2), and indwelling antegrade continence enema catheter dislodgement (n = 33). There was no conduit track stenosis. LIMITATIONS: The study is a medium-term retrospective case series using patient-reported outcomes and clinical records without a control group. CONCLUSIONS: With the use of the indwelling antegrade continence enema catheter, appendicostomy and cecostomy stenosis requiring revisional surgery was avoided. Antegrade colonic irrigation failed in about one-third of cases; in the 65% who continued to irrigate, satisfactory functional outcome was achieved.

Percutaneous Cecostomy in Adult Patients: Safety and Quality-of-Life Results.

PURPOSE: To assess the safety and quality of life in adult patients undergoing cecostomy tube placement. MATERIALS AND METHODS: Percutaneous cecostomy was performed in 23 adults (10 men and 13 women) with neurogenic bowel for whom noninvasive therapeutic approaches for chronic refractory constipation or fecal incontinence had failed. Mean patient age was 41 years (range, 19-74 y). A retrospective, standardized questionnaire evaluated satisfaction and quality of life before and after cecostomy. RESULTS: All 23 cecostomy procedures were technically successful with no intraprocedural complications. At a mean follow-up of 42 months (range, 1-160 mo), there was one (5%) major complication, a pericecal abscess. One or more minor complications in 11 of 23 (48%) patients included leaking around the tube (5 of 23; 22%) and partial or complete dislodgment of the tube (3 of 23; 13%). In all cases, the cecostomy tube was exchanged successfully. Satisfaction scores improved from a mean of 2.2 points (range, 0-6 points; median, 1.5) to 7.6 points (range, 4-10 points; median, 8). The percentage of patients using laxative softeners decreased from 74% to 40%, and patients requiring assistance decreased from 52% to 35% after cecostomy placement. CONCLUSIONS: Percutaneous cecostomy is a safe procedure for the management of adult patients. Patients are able to achieve greater independence in their activities of daily living and are highly satisfied with the outcomes.