Short-term outcomes of Chait Trapdoor for antegrade continence enema in adults.

OBJECTIVE: To examine our short-term experience of antegrade continence enema (ACE) delivered via a Chait Trapdoor (Cook Medical, Bloomington, IN) in adults with intractable neurogenic bowel. METHODS: We performed a retrospective review at the Universities of Utah and Minnesota of 15 patients with Chait Trapdoor placed for the purpose of ACE from 2011 to 2013. Our primary outcome was continued utilization of the Chait Trapdoor. Secondary outcomes included volume of ACE used and time to produce a bowel movement. RESULTS: All patients had neurogenic bowel refractory to conventional bowel regimen. Mean follow-up was 6 months (range, 1-17 months). Thirteen patients had the Chait Trapdoor placed in the splenic flexure and 2 had it placed in the cecum. Of the 15 patients, 12 (80%) were still using the Chait Trapdoor at last follow-up. A median of 425 mL (range, 120-1000 mL) of fluid was used to produce a bowel movement in 5-120 minutes. Two patients developed postoperative wound infections, requiring return to the operating room (Clavien IIIb). Long-term complications included 5 patients with a dislodged tube requiring replacement by interventional radiology and 2 patients with local cellulitis. Two patients had the Chait Trapdoor moved to a new location to improve efficacy. CONCLUSION: Although the revision, removal, and complication rates were high, 80% of the patients were satisfied with the function and continued to use the Chait Trapdoor. The volume of irrigation required for ACE and the time it takes to produce a bowel movement vary significantly between patients.

Minimally invasive approach for treatment of urinary and fecal incontinence in selected patients with spina bifida.

OBJECTIVES: At our institution, the use of cecostomy tubes has provided a successful method for managing severe constipation in patients with spina bifida, with good patient and caretaker satisfaction and minimal morbidity. We have developed a modified technique to allow placement of the cecostomy tube under direct vision during laparoscopic appendicovesicostomy. We present our initial experience and technique. METHODS: Patients with a normal bladder capacity and compliance who were scheduled for creation of an appendicovesicostomy and who also had refractory constipation were offered concurrent cecostomy tube placement. At the laparoscopic procedure, we performed percutaneous placement of the cecostomy tube through the abdominal wall under direct visualization. Subsequently, dissection of the appendix with its mesentery was performed. The detrusor muscle was dissected and a trough for the appendix created. Laparoscopic anastomosis of the appendix to the bladder mucosa and approximation of the detrusor over the appendix created a nonrefluxing channel. RESULTS: Three patients have undergone concurrent cecostomy tube placement at appendicovesicostomy. No complications have been encountered thus far. On follow-up, the cecostomy tube scar has been well concealed and appears no different from the ones placed under radiologic guidance. The patients have been using the catheterizable channel to access the bladder and dry performing intermittent catheterization without difficulties. CONCLUSIONS: In patients with a neurogenic bladder who do not qualify for major bladder reconstructive procedures, such as augmentation cystoplasty or bladder neck repair, social continence and independence can be achieved with minimally invasive surgery. Concomitant laparoscopic appendicovesicostomy and cecostomy tube placement may be a suitable surgical option.