The Macedo-Malone antegrade colonic enema: A minimal invasive technique that precludes appendix use.

INTRODUCTION: Antegrade continence enema (ACE) is recommended for patients with fecal incontinence/constipation refractory to conservative management. The Malone ACE utilizes the appendix as a catheterizable channel whereas the Macedo-Malone (MM) precludes the use of the appendix. We aimed to illustrate the MM procedure. METHODS: The left colon is brought out through a small transverse incision on the upper left abdomen and a 3-cm transverse flap in a tenia is created. A 12-Fr silicone Foley catheter is placed on the mucosal surface of the flap to allow creating a tubular conduit. After closure of the anterior wall colonic, the continence valve mechanism is produced by embedding the tube over a serous lined tunnel created by interrupted sutures. The distal portion of the tube is anastomosed into a V shape to the skin flap to avoid stoma stenosis. DISCUSSION: The advantage of this technique is the all-the time availability for not requiring the appendix which some authors prefer to use for urinary reconstruction. In a previous study, we have shown that the MM produces a high rate (89%) of fecal continence (Mean follow-up: 75 months). CONCLUSION: We are convinced that this procedure can be incorporated into fecal incontinence/constipation armamentarium.

Antegrade Colonic Enema Channels in Pediatric Patients Using Appendix or Cecal Flap: A Comparative Robotic vs Open Series.

Introduction: We present perioperative outcomes of a single-center experience with robot-assisted antegrade colonic enema (ACE) channel creation for the treatment of chronic constipation refractory to medical therapy and compare it to the traditional open surgical approach. We also demonstrate a step-by-step video presentation of the robotic approach for cecal flap ACE performed as part of a dual continence procedure in patients with short length of appendix. Methods: A retrospective chart review of pediatric patients who underwent ACE channel creation between 2008 and 2020 was performed. We compared demographics and intraoperative and postoperative variables of the open vs robotic approach. Results: Among 28 patients, 15 were open and 13 robotic. To construct the ACE channel, a cecal flap was utilized in 36%, split appendix in 50%, full-length appendix in 11%, and sigmoid colon in 3% of patients. Both approaches showed equivalent estimated blood loss (50 mL [interquartile range; IQR = 20-100]), median length of hospital stay (7 days vs 8 days, p = 0.7), and median time to return to regular diet (4 days vs 5 days, p = 0.5) (Table 1). Patients in the open group were more likely to have a history of prior abdominal surgeries than those in the robotic group (80% vs 38.5%, p = 0.02). The risk of Clavien-Dindo grade 3 or more complications (40% vs 23.1%, p = 0.04) and the rate of ACE channel stenosis (46.7% vs 7.7%, p = 0.02) were significantly higher in the open approach. Channel stenosis was significantly higher in patients with an appendix ACE channel (87.5% vs 12.5%, p < 0.05) compared to those with cecal flap ACE. [Table: see text] Conclusion: Robot-assisted ACE channel creation is a safe and acceptable alternative with a significantly lower rate of channel stenosis and other clavien dindo grade 3 complications compared to the traditional open approach. Cecal flaps are also at a lower risk of stomal stenosis than appendix.

Double Appendix: Implications for the Emergency Department.

BACKGROUND: A double appendix, also known as vermiform appendix duplex, is a rare anomaly in humans, with a reported incidence of 1 in 25,000. The rarity of vermiform appendix duplication makes it a noteworthy medical occurrence. Approximately 100 reported cases have been documented since the first observed case in 1892. There are multiple types of appendiceal duplications, some of which include duplications of other organs. CASE REPORT: A 10-year-old boy was diagnosed with acute appendicitis by clinical examination and ultrasound. He underwent a laparoscopic appendectomy and had an unremarkable recovery. His pathology revealed acute suppurative appendicitis. Two months later, he presented to the emergency department due to bilateral lower abdominal pain with guarding and distension on examination. He underwent a computed tomography of the abdomen and pelvis secondary to concern for a postoperative abscess, which instead showed a normal-appearing retrocecal appendix containing oral contrast. The patient was diagnosed with constipation, and his symptoms resolved with an enema. Our patient had two completely separate appendices, one arising from the cecal tinea coli, and one retrocecal. Why Should an Emergency Physician Be Aware of This? Clinicians should be aware of this rare anomaly as a potential diagnosis in a patient with a history of prior appendectomy and clinical signs consistent with recurrent appendicitis. This also underscores the need for communication between doctors and patients, along with their families, to avoid delays in diagnosis in the future.

Needlescopic Appendectomy in Children and Adolescents Using 14-Gauge Needles: A New Era.

Purpose: We are presenting a very minimally invasive technique for laparoscopic appendectomy (needlescopic appendectomy [NAP]) in children and adolescents using suture grasper device, epidural needle, and homemade isolated long diathermy probe without any conventional laparoscopic instruments. Patients and Methods: NAP was attempted in 48 patients with uncomplicated acute appendicitis at Al-Azhar, Tanta University Hospitals and other allied hospitals during the period from May 2017 to November 2018. The study included patients with acute appendicitis and patients scheduled for interval appendectomy. Exclusion criteria were patients with concealed appendix, patients with appendicular abscess or appendicular mass, patients with acute appendicitis complicated with generalized peritonitis, and patients unfit for laparoscopy. The appendix was brought outside through the umbilical port and the operation was completed extracorporeally. In cases of appendicitis with tethered cecum, the whole procedure was completed intracorporeally. Results: Forty-eight patients with acute uncomplicated appendicitis were treated by NAP. They were 36 males and 12 females with a mean age of 9 ± 3.7 years (range = 4-15 years). Two cases with concealed appendix and one case with appendicular mass were diagnosed during initial laparoscopy and excluded from the study. Thirty-two cases (71.11%) were completed intracorporeally and 13 cases (28.89%) were completed by extracorporeal NAP. The mean operative time was 33.29 ± 3.95 minutes (range = 27-40 minutes) for intracorporeal NAP and 20.9 ± 7.01 minutes (range = 14-40 minutes) for extracorporeal NAP. Degrees of cosmetic satisfaction of the patients and parents were excellent in 93.33% (N = 42/45 patients), and very good in 6.67% (N = 3/45 patients) of patients. Conclusion: NAP using needles only is a new technique that is very minimally invasive, very cheap, safe, reproducible, and easy to be done with outstanding cosmetic results.

A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis.

BACKGROUND: Antibiotic therapy has been proposed as an alternative to surgery for the treatment of appendicitis. METHODS: We conducted a pragmatic, nonblinded, noninferiority, randomized trial comparing antibiotic therapy (10-day course) with appendectomy in patients with appendicitis at 25 U.S. centers. The primary outcome was 30-day health status, as assessed with the European Quality of Life-5 Dimensions (EQ-5D) questionnaire (scores range from 0 to 1, with higher scores indicating better health status; noninferiority margin, 0.05 points). Secondary outcomes included appendectomy in the antibiotics group and complications through 90 days; analyses were prespecified in subgroups defined according to the presence or absence of an appendicolith. RESULTS: In total, 1552 adults (414 with an appendicolith) underwent randomization; 776 were assigned to receive antibiotics (47% of whom were not hospitalized for the index treatment) and 776 to undergo appendectomy (96% of whom underwent a laparoscopic procedure). Antibiotics were noninferior to appendectomy on the basis of 30-day EQ-5D scores (mean difference, 0.01 points; 95% confidence interval [CI], -0.001 to 0.03). In the antibiotics group, 29% had undergone appendectomy by 90 days, including 41% of those with an appendicolith and 25% of those without an appendicolith. Complications were more common in the antibiotics group than in the appendectomy group (8.1 vs. 3.5 per 100 participants; rate ratio, 2.28; 95% CI, 1.30 to 3.98); the higher rate in the antibiotics group could be attributed to those with an appendicolith (20.2 vs. 3.6 per 100 participants; rate ratio, 5.69; 95% CI, 2.11 to 15.38) and not to those without an appendicolith (3.7 vs. 3.5 per 100 participants; rate ratio, 1.05; 95% CI, 0.45 to 2.43). The rate of serious adverse events was 4.0 per 100 participants in the antibiotics group and 3.0 per 100 participants in the appendectomy group (rate ratio, 1.29; 95% CI, 0.67 to 2.50). CONCLUSIONS: For the treatment of appendicitis, antibiotics were noninferior to appendectomy on the basis of results of a standard health-status measure. In the antibiotics group, nearly 3 in 10 participants had undergone appendectomy by 90 days. Participants with an appendicolith were at a higher risk for appendectomy and for complications than those without an appendicolith. (Funded by the Patient-Centered Outcomes Research Institute; CODA ClinicalTrials.gov number, NCT02800785.).

In-hospital resource utilization, outcome analysis and radiation exposure in children undergoing appendicostomy vs cecostomy tube placement.

INTRODUCTION AND OBJECTIVES: Continence enemas for the purpose of bowel management may be delivered via trans-anal retrograde irrigations, and via antegrade conduits including surgical appendicostomy or placement of cecostomy tube (CT). An appreciation of the relative advantages and disadvantages of each antegrade continence enema (ACE) procedure allows clinicians, parents and children to make an informed decision regarding which procedure is most appropriate in individual cases. The objective of this study was to evaluate the differences in in-hospital resource utilization, surgical outcomes and radiation exposure between children undergoing appendicostomy creation and CT placement at our institution. METHODS: We conducted a retrospective chart review of children undergoing these procedures at our institution over a 10-year period. All patients 0-18 years of age undergoing either procedure for any indication were included. Data on demographics, length of stay (LOS), radiation exposure events (REE), and surgical outcomes were collected. RESULTS: One hundred fifteen (63 appendicostomy/52 CT) patients were included. Those undergoing CT placement had significantly increased post-procedural LOS, catheter exchanges and REE compared to those undergoing appendicostomy (see Table). Reported rates of bowel control were similar between the two groups, and there was no significant difference in rates of surgical complications, although each group had unique, procedure-specific complications. DISCUSSION AND CONCLUSION: In our study, appendicostomy holds a clear advantage over CT in terms of post-procedural LOS, as well as REE. In general, children with CTs require more planned and unplanned device maintenance procedures than those with appendicostomy. These findings aside, the rates of success for bowel control between the two groups are similar, and the incidence of complications does not differ significantly between the two groups. CT remains a safe and effective conduit for delivery of ACEs, and is a particularly good option in patients whose appendix has been lost or used for another conduit. However, patients wishing to avoid repeated procedures and radiation exposure may find the option of appendicostomy more attractive.

A case report of appendix mucinous adenocarcinoma that recurred after additional surgery and a brief literature review.

BACKGROUND: The clinical incidence of appendiceal mucinous adenocarcinoma is low. Moreover, the case reports of postoperative relapse after surgery are rarely based on literature search results. Here, we report such a case spanning nearly 7 years and and review the relevant literature. CASE PRESENTATION: A 50-year-old female underwent additional surgery after appendectomy, and pathological examination confirmed mucinous adenocarcinoma. The patients underwent HIPEC (hyperthermic intraoperative chemotherapy) and adjuvant chemotherapy. Twenty-six months after the previous surgeries, another surgery, HIPEC, and adjuvant chemotherapy were performed again due to tumour recurrence. To date, the follow-up time is 43 months, and no recurrence or metastasis has been found. CONCLUSIONS: Appendix mucinous adenocarcinoma has a poor prognosis and the diagnosis depends on pathological and immunohistochemical examinations. Its clinical manifestations are non-specific, and CRS + HIPEC should be used for treatment, which is safe and effective.

Tube cecostomy versus appendicostomy for antegrade enemas in the management of fecal incontinence in children: A systematic review.

BACKGROUND: Few studies have directly compared between cecostomy and appendicostomy for the management of fecal incontinence in pediatric population. This systematic review of the literature describes outcomes and complications following both procedures. We also reviewed studies reporting impact on quality of life and patient satisfaction. METHODS: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), and Google Scholar were searched for chronic constipation pediatric patients who underwent cecostomy or appendicostomy. Two reviewers independently screened studies, extracted data, and assessed quality. RESULTS: An initial literature search retrieved 633 citations. After review of all abstracts, 40 studies were included in the final analysis, assessing a total of 2086 patients. The overall rate of complications was lower in the cecostomy group compared to the appendicostomy group (16.6% and 42.3%, respectively). Achievement of fecal continence and improvement in patient quality of life were found to be similar in both groups, however the need for revision of surgery was approximately 15% higher in the appendicostomy group. CONCLUSION: Cecostomy has less post procedural complications, however rates of patient satisfaction and impact on quality of life were similar following both procedures. LEVEL OF EVIDENCE: III.

A New Appendicostomy Technique to Prevent Stomal Stenosis.

PURPOSE: Stomal stenosis has been reported to occur in 12% to 45% of patients following Malone antegrade continence enema and Mitrofanoff appendicostomy. The standard stoma technique entails excision of the distal appendix. We evaluated a novel technique with preservation of the appendiceal tip and vessels, and opening the lumen in a more proximal and vascular area to determine whether the incidence of stenosis would be decreased. MATERIALS AND METHODS: Medical records of patients who underwent appendicostomy for Malone antegrade continence enema or urinary diversion were retrospectively evaluated. We included cases with a minimum of 1 year of followup and those in which the distal portion of a complete appendix was oriented for use as the stomal end in the umbilicus. Variables such as age, gender, body mass index, antegrade continence enema or urinary diversion, open or laparoscopic approach, cecal and appendiceal adhesions, retrocecal position, cecal imbrication, technique and stenosis were recorded. Cox proportional hazards analyses were performed to determine association of covariates. RESULTS: A total of 123 patients met inclusion criteria. The incidence of stenosis following standard stoma technique was 13% (12 of 93 patients) with a median followup of 9.4 years. Of these cases 75% occurred within 1 year of surgery. Stomal stenosis did not occur after the new stoma technique in 30 patients with a median followup of 3.3 years. Only technique cohort (standard vs new) was associated with stenosis (p=0.04). CONCLUSIONS: Stomal stenosis of appendicostomy may be lessened by preservation of the distal appendiceal vasculature and tip, and opening the lumen in a more proximal location.

A comparison of surgical complications after appendicostomy and neoappendicostomy in pediatric patients.

PURPOSE: There are limited data on neoappendicostomy complications owing to small patient populations. This study compares appendicostomy and neoappendicostomy procedures with an emphasis on major postoperative complications requiring either a surgical or interventional radiology procedure. METHOD: A single-institution retrospective review included all patients with complete medical charts in the Cincinnati Children's Colorectal Database who underwent either an appendicostomy or neoappendicostomy from August 2005 through December 2016. Demographics, details of the procedure, and major postoperative complications were evaluated. RESULTS: 261 patients (appendicostomy n = 208, neoappendicostomy n = 53) with a median follow up time of 2.5 years resulted in 84 patients (appendicostomy n = 60, neoappendicostomy n = 24) experiencing a total of 118 complications requiring surgical or radiologic intervention with a significant difference between the groups (29% vs 45%, RR = 1.79 (95% CI: 1.24-2.60), p < 0.01). Skin level stricture was the most common complication (20% appendicostomies vs 30% neoappendicostomies, p = 0.13). CONCLUSIONS: Appendicostomies and neoappendicostomies can be an effective way to manage fecal incontinence; however, 32% of our patients experienced a complication that required either a surgical or interventional radiology procedure. Patients need to be informed of the possible complications that are associated with appendicostomy and neoappendicostomy construction. TYPE OF STUDY: Single institution retrospective review. LEVEL OF EVIDENCE: IV.

Operative treatment for intussusception: Should an incidental appendectomy be performed?

BACKGROUND/OBJECTIVES: An incidental appendectomy is performed by some surgeons during operative treatment for intussusception to eliminate future appendicitis as a diagnostic consideration. However, an appendectomy can increase the risk of infection and other noninfectious complications making an incidental appendectomy controversial. We examined outcomes for surgical intervention for intussusception with appendectomy (SWA) compared to surgical reduction alone (SRA). METHODS: The Pediatric Health Information System database, 8/2008-9/2015, was retrospectively analyzed for patients under the age of five who required an operative intervention for intussusception without bowel resection. Demographic data and postoperative outcomes were analyzed. Available data included need for postoperative enema, subsequent small bowel obstruction, recurrent intussusception, length of stay (LOS), and adjusted total cost (ATC). RESULTS: Fifty-seven percent (748/1312) of patients had appendectomy performed during surgical reduction, 564 (43%) did not. ATC ($10,594 vs. $8939, p < 0.001) and LOS (3.0 vs. 2.48, p < 0.001) are higher in the SWA group. Rates of readmission are similar, but post-operative small bowel obstruction may be higher in the SWA group (1.3% vs. 0.35%, p = 0.06). CONCLUSION: There is a higher mean LOS and ATC in the SWA group. This study suggests that appendectomy during surgery for uncomplicated intussusception should be reconsidered and requires further investigation. TYPE OF STUDY: retrospective comparative study. LEVEL OF EVIDENCE: III.

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.

No Appendix is Too Short-Simultaneous Mitrofanoff Catheterizable Vesicostomy and Malone Antegrade Continence Enema (MACE) for Children with Spina Bifida.

OBJECTIVE: To present the results of simultaneous creation of both Mitrofanoff stoma and Malone antegrade continence stoma (MACE) using simple division of the appendix and a cecal extension method. MATERIALS AND METHODS: Between June 2011 and November 2016, simultaneous Mitrofanoff and MACE was performed in 16 children (12 children-simple division of the appendix, 4 children-appendicovesicostomy and cecal extension of the appendix). Extension of the appendix was achieved by tubularization of the excised cecal flap next to the short appendicular stump. The new extended channel was then wrapped by cecal wall. RESULTS: Follow-up was 40 months (10-74 months). Currently, in all children, both stomas are easily catheterizable. Obstruction of MACE occurred in 5 children (4 with split appendix, 1 with extended appendix); Mitrofanoff stomal stenosis occurred in 1 child. Endoscopic revision and prolonged catheterization of stenotic stomas were effective in all cases. Wound infection and dehiscence was noted in 2 children (both with split appendix). Drainage and intravenous antibiotics were effective. All Mitrofanoffs are continent. In 4 children there is incident minor leakage of the MACE (3 with split appendix and in 1 with extended appendix). CONCLUSION: The split appendix procedure is feasible. Cecal extension of the appendix seems to be a good option when the appendix is too short for a simple split procedure.

Surgical management of functional constipation: An intermediate report of a new approach using a laparoscopic sigmoid resection combined with malone appendicostomy.

INTRODUCTION: We previously reported our surgical technique for functional constipation for patients who have failed medical management using a novel collaborative approach with gastroenterology input, pre-operative contrast enema, colonic manometry, and laxative protocol combined with a laparoscopic colonic resection with Malone appendicostomy. Now we report our intermediate outcomes. METHODS: Patients who failed bowel management program for functional constipation were reviewed from 3/2014-2/2017. Patients with Hirschsprung disease, anorectal malformation, tethered cord, spina bifida, Trisomy 21, cerebral palsy, mitochondrial disease, or prior colon resection were excluded. RESULTS: Of 31 patients (14 females; median age 12years, follow-up 10.3months) with functional constipation and failed medical management, 26 (84%) had preoperative colonic manometry which, in addition to the contrast enema, guided laparoscopic colon resection. Ten patients (32.3%) are clean with no flushes (1 takes no laxatives, 8 are on low dose laxatives only, and 1 patient was clean on laxatives but chose to switch back to flushes). Of the 21 patients that remain on antegrade flushes, 20 (95.2%) are clean, and one patient (4.8%) continues to soil. We define clean as no soiling and no abnormal stool burden on x-ray. Laxative trials are planned for all patients on an antegrade flush regimen. CONCLUSION: Our intermediate results show that laparoscopic colon resection with Malone appendicostomy allows the majority of patients to be clean on antegrade flushes, and some to be on no or minimal laxatives. TYPE OF STUDY: Retrospective review. LEVEL OF EVIDENCE: 3.

Laparoscopic Appendicostomy Low-Profile Balloon Button for Antegrade Enemas in Children.

INTRODUCTION: The Malone appendicostomy is a continent channel used for antegrade enemas. It requires daily cannulation and is susceptible to stenosis. We use an indwelling low-profile balloon button tube inserted through the appendix into the cecum for antegrade enemas. We hypothesized that this method is effective at managing constipation or fecal incontinence and is associated with a low rate of stenosis. METHODS: Children who underwent laparoscopic appendicostomy balloon button placement at our institution from January 2011 to April 2017 were identified. The primary outcome was success in managing constipation or fecal continence as measured by the Malone continence scale. Postoperative complications were analyzed. RESULTS: Thirty-six children underwent the procedure, 35 of which met the inclusion criteria. Thirty-one patients (88.5%) underwent the operation for idiopathic constipation, 3 patients (8.6%) for anorectal malformation, and 1 patient (2.9%) for hypermobility. Rate of open conversion was 3%. A full response was obtained in 24 patients (68.6%), partial response in 9 patients (25.7%), and 2 patients failed (5.7%). One patient developed an internal hernia requiring laparotomy and later developed mucosal prolapse. One patient developed a stricture noted at button change. Seven patients (20%) underwent reversal of their appendicostomy tube: 5 due to return of normal bowel function and 2 due to discomfort with flushes. CONCLUSION: A laparoscopic appendicostomy with a balloon button tube is an effective means of addressing chronic constipation or fecal incontinence. The stenosis rate associated with tube appendicostomy may be lower than those reported for Malone antegrade continence enema procedures.

Appendiceal Intussusception: A Diagnostic Challenge.

INTRODUCTION: Appendiceal intussusception is a rare condition in children characterized by an invagination of the appendix into the cecum to various degrees. The treatment is appendectomy; however since symptoms are not specific, clinical diagnosis is challenging and frequently only intraoperative. We present a series of five patients with appendiceal intussusception and discuss features that may direct the pediatric surgeon to achieve early recognition and provide optimal treatment. MATERIALS AND METHODS: The database of a tertiary medical center was retrospectively reviewed for all patients treated for appendiceal intussusception during the period from January 1995 to January 2016. Data collected by chart review included demographics, clinical characteristics, imaging studies, surgical technique, and outcome. The findings were analyzed by descriptive statistics. RESULTS: This series included five patients (two females and three males) with ages ranging between 27 and 42 months (mean: 35.2). Patients presented with intermittent abdominal pain (IAP, all five patients), alternate vomiting (three of five patients), alternate diarrhea (two of five patients), fever (two of five patients), and rectal bleeding (one of five patients). The average length of symptoms was 22.6 days. Eighteen diagnostic studies were performed, including abdominal ultrasound for all patients, barium enema for three patients with secondary ileocolic intussusception, and abdominal computed tomography (CT) for one patient. The average number of studies per patient was 3.6. In surgery, the appendiceal intussusception was found to be complete in four patients, whereas it was partial in the remaining patient. In all patients, appendectomy was performed with resection of a small rim of cecal wall due to marked congestion and edema in an attempt to decrease recurrence. CONCLUSION: The mainstay of clinical presentation is intermittent abdominal pain while patients may be completely asymptomatic between attacks. Appendiceal intussusception may act as a leading point to ileocolic intussusception and is frequently concealed by it. The treatment is appendectomy. Both pediatric surgeons and radiologists should be aware of this occurrence to provide adequate management and avoid complications.

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.

Comparing inpatient versus outpatient bowel preparation in children and adolescents undergoing appendicovesicostomy.

PURPOSE: The need for mechanical inpatient bowel preparation (IBP) in reconstructive pediatric urology has come under scrutiny, secondary to literature demonstrating little benefit regarding outcomes. Starting in 2013, a majority of patients undergoing reconstructive procedures at our institution no longer underwent IBP. We hypothesized that outpatient bowel preparation (OBP) would reduce length of stay (LOS) without increasing postoperative complications after appendicovesicostomy surgery. MATERIALS AND METHODS: An institutional database of patients undergoing lower urinary tract reconstruction between May 2010 and December 2014 was reviewed. Starting in 2013, a departmental decision was made to replace IBP with OBP. Patients undergoing an augmentation cystoplasty or continent ileovesicostomy were excluded because of insufficient numbers undergoing OBP. Patients undergoing IBP were admitted 1 day prior to surgery and received polyethylene glycol/electrolyte solution. A personalized preoperative OBP was introduced in 2013. Cost data were obtained from the Pediatric Health Information System. RESULTS: Sixty-seven patients met the inclusion criteria, with 30 (44.8%) undergoing IBP. There were no differences with respect to gender, age, presence of ventriculoperitoneal shunt, body mass index, glomerular filtration rate, preoperative diagnosis, operative time, and prior or simultaneous associated surgeries (p ≥ 0.07). Patients undergoing an IBP had a longer median LOS (7 vs. 5 days, p = 0.0002) and a higher median cost (US$4,288, p = 0.01). Postoperative complications in both groups were uncommon and were classified as Clavien-Dindo grade 1-2, with no statistical difference (IBP 20.0% vs. OBP 5.4%, p = 0.13). No serious postoperative complication occurred, such as a dehiscence, bowel obstruction, or shunt infection. DISCUSSION: This is the first analysis of hospitalization costs and IBP, showing a higher median cost of US$4288 compared with OBP. The LOS was shorter with an OBP (figure), similar to a previous report. Similar complication rates between the groups add to the growing body of literature that avoidance of IBP is safe in pediatric lower urinary tract reconstruction. Being a retrospective review of a practice change, differences in care that influenced cost and LOS may be missing. Also, as the surgeons do not know if a usable appendix is initially present, our data may not extrapolate to all patients. Despite these potential limitations, our data support the safety of utilizing OBP in patients with a high likelihood of a usable appendix, including those undergoing a synchronous Malone antegrade continence enema via a split-appendix technique. CONCLUSION: In patients undergoing an appendicovesicostomy, preoperative IBP led to longer LOS and higher costs of hospitalization. OBP was not associated with increased risks of postoperative complications.