The success rate of antegrade enemas for the management of idiopathic constipation.

PURPOSE: Most patients with idiopathic constipation achieve daily voluntary bowel movements with stimulant laxatives after a "Structured Bowel Management Program" (BMP). A small percentage require rectal enemas. One week in a BMP to find the right enema recipe results in a success rate great than 95%. Once the enema is radiologically and clinically effective, antegrade continent enema procedures (ACE) can afford patients an alternative route of enema administration. This study summarized the outcomes of children with idiopathic constipation who receive antegrade enemas (AE) with or without a prior BMP. METHODS: This was a single institution, retrospective cohort study of children with idiopathic constipation who underwent ACE procedures indicated by different providers from 2015-2020. We categorized the outcomes with AE after the ACE procedure as: "successful outcome" when the AE produced a daily bowel movement, no involuntary bowel movements, and no more fecal impactions, "unsuccessful outcome" was defined when the patient continued having involuntary bowel movements or fecal impaction requiring cleanouts despite a daily AE, and "unnecessary outcome" was defined when the patient was no longer doing AE, but had daily bowel movements, and no involuntary bowel movements or fecal impactions. RESULTS: Thirty-eight children with idiopathic constipation had an ACE. The most frequent indication for ACE was a failure of medical treatment. The most common medical treatment was polyethylene glycol. Before ACE, 34 (89%) patients did not have a BMP; 18 patients were on rectal enemas and 16 on laxatives. All four with BMP (100%) had a successful rectal enema. After ACE, 12 (31%) patients had successful antegrade enemas, including the four with previous successful BMP with rectal enemas. Twenty patients (52%) had unsuccessful antegrade enemas, and in 6 (15%), the ACE was unnecessary (Fig. 1). CONCLUSION: Using antegrade enemas without a previously successful formula for rectal enemas has resulted in a high rate of unsuccessful and unnecessary procedures. BMP for children with idiopathic constipation who needs rectal enemas offers a high possibility to find the proper rectal enema recipe and ensures higher rates of successful AE.

More Synchronous Peritoneal Disease but Longer Survival in Younger Patients with Carcinomatosis from Colorectal Cancer Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy.

BACKGROUND: Colonoscopy to detect colorectal cancer (CRC) is recommended starting at age 50 years; however, CRC rates are increasing in the prescreening population. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) has been proven effective in select patients with peritoneal carcinomatosis (PC) from CRC, although it has not been evaluated specifically in patients < 50 years. METHODS: CRC patients aged < 50 years at diagnosis undergoing CRS/HIPEC 2007-2017 were compared with those aged ≥ 50 years. Age distribution was analyzed in patients undergoing colectomy alone versus CRS/HIPEC for CRC 1993-2013. RESULTS: A total of 98 patients underwent CRS/HIPEC, of which 44% were < 50 years. Younger patients were more likely to present with synchronous peritoneal metastases (p = 0.050). Receipt of perioperative chemotherapy was comparable (p = not significant [NS]). Charlson Comorbidity Index and ECOG score were similar (p = NS). Tumor grade was similar (p = NS). Peritoneal Carcinomatosis Index, total organs resected, and anastomoses created were comparable (p = NS). Major Clavien-Dindo morbidity and LOS were similar (p = NS). Younger patients survived longer after CRS/HIPEC (p = 0.011). Demographic data from patients undergoing colectomy (n = 225) and CRS/HIPEC (n = 98) showed that age < 50 years was increasingly common with the more aggressive procedure (9% and 44% respectively, p < 0.001). CONCLUSIONS: Younger patients with PC from CRC presented more often with peritoneal metastases at the time of diagnosis. Yet despite similar perioperative features at CRS/HIPEC, they survived longer than older patients. Patients undergoing CRS/HIPEC are overall younger than those undergoing index colectomy.