Outcomes after enterostomies in children with and without motility disorders: A description and comparison of postoperative complications.

PURPOSE: To provide an overview of complications after ileostomy or colostomy procedures in children, and to compare outcomes between patients with gastrointestinal motility disorders (i.e. functional constipation, Hirschsprung's disease, pediatric intestinal pseudo-obstruction (PIPO)) and children without motility disorders (including necrotizing enterocolitis, anorectal malformation and inflammatory bowel disease). METHODS: We performed a retrospective study of children who underwent an enterostomy procedure at our institution. The number and type of complications and subsequent reoperations after ostomy formation were determined. Complications were scored using the Clavien-Dindo classification. A complication of ≥ grade III-b was considered a high-grade complication. RESULTS: 129 children with an ileostomy and 61 children with a colostomy were included. Of these, 62 children (32.6%) had motility disorders; functional constipation (n=40), Hirschsprung's disease (n=18) and PIPO (n=4). The total prevalence of complications was 73.2%. Comparing the perioperative data, children with motility disorders significantly more often underwent a laparoscopic procedure (59.7% vs. 10.9%, p=0.000) and had an end stoma-configuration (37.1% vs. 14.1%, p=0.000) as compared to children without motility disorders. Children with motility problems had a higher complication rate (88.7% vs. 65.5%, OR 4.1, 95% CI 1.7-9.8, p=0.001) compared to children without motility problems, and a larger proportion of complications was classified as high-grade complications (61.8% vs. 31.0% p =0.002). CONCLUSION: A high complication rate after enterostomy formation was detected. Children with gastrointestinal motility disorders had more and more severe complications as compared to children without motility disorders. LEVEL OF EVIDENCE: Level III TYPE OF STUDY: Retrospective comparative study.

Comparison of antegrade continence enema treatment and sacral nerve stimulation for children with severe functional constipation and fecal incontinence.

BACKGROUND: To compare antegrade continence enema (ACE) treatment and sacral nerve stimulation (SNS) in children with intractable functional constipation (FC) and fecal incontinence (FI). METHODS: We performed a retrospective review of children 6-18 years old with FC and FI treated with either ACE or SNS at our institution. We recorded symptoms at baseline, 6 months, 12 months, 24 months, and their most recent visit after starting treatment. We compared improvement in FI, bowel movement (BM) frequency, abdominal pain, laxative use, and complications. Patients were contacted to evaluate perceived benefit using the Glasgow Children's Benefit Inventory. KEY RESULTS: We included 23 patients treated with ACE (52% female, median age 10 years) and 19 patients treated with SNS (74% female, median age 10 years). Improvement in FI was greater with SNS than ACE at 12 months (92.9% vs 57.1%, P = .03) and 24 months (100% vs 57.1%, P = .02). Improvement in BM frequency was greater with ACE, and children were more likely to discontinue laxatives at all follow-up time points (all P < .05). Improvement in abdominal pain was greater with ACE at the most recent visit (P < .05). Rate of complications requiring surgery was similar between groups (26.3% vs 21.7%). Benefit was reported in 83.3% and 100% of ACE and SNS groups, respectively (NS). CONCLUSIONS AND INFERENCES: Although both ACE and SNS can lead to durable improvement in children with FC and FI, SNS appears more effective for FI and ACE more effective in improving BM frequency and abdominal pain and in discontinuation of laxatives.

A comparison of Malone appendicostomy and cecostomy for antegrade access as adjuncts to a bowel management program for patients with functional constipation or fecal incontinence.

BACKGROUND: Appendicostomy and cecostomy are two approaches for antegrade enema access for children with severe constipation or fecal incontinence as adjuncts to a mechanical bowel management program. Each technique is associated with a unique set of complications. The purpose of our study was to report the rates of various complications associated with antegrade enema access techniques to help guide which option a clinician offers to their patients. METHODS: We reviewed all patients in our Center who received an appendicostomy or cecostomy from 2014 to 2017 who were participants in our bowel management program. RESULTS: 204 patients underwent an antegrade access procedure (150 appendicostomies and 54 cecostomies). Skin-level leakage (3% vs. 22%) and wound infections (7% vs. 28%) occurred less frequently in patients with appendicostomy compared to cecostomy. Nineteen (13%) appendicostomies required revision for stenosis, 4 (3%) for mucosal prolapse, and 1 (1%) for leakage. The rates of stenosis (33 vs. 12%) and wound infection (13 vs. 6%) were higher in patients who received a neoappendicostomy compared to an in situ appendicostomy. Intervention was needed in 19 (35%) cecostomy patients, 15 (28%) for an inability to flush or a dislodged tube, and 5 for major complications including intraperitoneal spillage in 4 (7%) and 1 (2%) for a tube misplaced in the ileum, all occurring in patients with a percutaneously placed cecostomy. One appendicostomy (1%) patient required laparoscopic revision after the appendicostomy detached from the skin. CONCLUSION: Patients had a lower rate of minor and major complications after appendicostomy compared to cecostomy. The unique complication profile of each technique should be considered for patients needing these procedures as an adjunct to their care for constipation or fecal incontinence. TYPE OF STUDY: Retrospective comparative study. LEVEL OF EVIDENCE: Level III.