Long-Term outcomes of cecostomy tube insertion for patients with bowel dysfunction: A retrospective review.

BACKGROUND: Constipation is common in the pediatric population and in severe forms it can lead to debilitating fecal incontinence which has a significant impact on quality of life. Cecostomy tube insertion is a procedural option for cases refractory to medical management, however there is limited data investigating the long-term success and complication rate. METHODS: A retrospective review was performed evaluating patients at our centre undergoing cecostomy tube (CT) insertion between 2002 and 2018. The primary outcomes of the study were the rate of fecal continence at 1-year, and the incidence of unplanned exchanges prior to annual scheduled exchange. Secondary outcomes include the frequency of anaesthetic requirements and length of hospital stay. Descriptive statistics, t-test, and chi-square analysis was performed where appropriate using SPSS v25. RESULTS: Of 41 patients, the average age at the time of initial insertion was 9.9 years with the average length of stay in hospital being 3.47 days. The most common etiology of bowel dysfunction was spina bifida, which was present in 48.8% (n = 20) of patients. Fecal continence was achieved in 90% (n = 37) of patients at 1 year and the average rate of cecostomy tube exchange was 1.3/year with an average of 3.6 general anaesthetics being required by patients and the average age of no longer requiring one being 14.9 years. DISCUSSION: Analysis of patients undergoing cecostomy tube insertion at our centre has further supported the use of cecostomy tubes as a safe and effective option for management of fecal incontinence refractory to medical management. However, a number of limitations exist in this study including its retrospective design and failure to investigate changes in quality of life using validated questionnaires. Additionally, while our research provides greater insight to practitioners and patients what degree of care and types of complications or issues they may encounter with an indwelling tube over the long-term, our single-cohort design limits any conclusions that could be made regarding optimal management strategies for overflow fecal incontinence through direct comparison with other management strategies. CONCLUSIONS: CT insertion is a safe and effective method for managing fecal incontinence due to constipation in the pediatric population, however, unplanned exchange of tube due to malfunction, mechanical breakage, or dislodgment occurs frequently and may impact quality of life and independence. LEVEL OF EVIDENCE: IV.

The impact of antegrade continence enemas on bladder function in patients with neurogenic bladder and bowel.

INTRODUCTION: In neurologically intact children with constipation and lower urinary tract symptoms, treatment of constipation frequently results in improved or resolved lower urinary tract symptoms. The impact of treatment of constipation on bladder function in children with a neurogenic bowel and bladder is not well studied. The objective of this study was to evaluate the impact of antegrade continence enemas (ACE) via Chait tube on urodynamic study (UDS) parameters and urinary continence in patients with neurogenic bowel and bladder (NGB). We hypothesized that following ACE some patients would demonstrate improved UDS parameters and improved urinary continence. MATERIALS AND METHODS: A review of patients with NGB who underwent a cecostomy was performed. Inclusion criteria required UDS within 12 months before and after Chait tube placement and no change in clean intermittent catheterization or anticholinergic medications. UDS parameters assessed included bladder capacity, bladder compliance, and bladder stability. In addition, the frequency of antegrade continence enemas and encopresis were reviewed as was the frequency of UTIs before and after the surgery. RESULTS: 8 children met inclusion criteria, including 5 girls and 3 boys, with a mean (range) age of 8.5 years (5-13). All children were on clean intermittent catheterization and 7 were on anticholinergic medications. The patients demonstrated a significant improvement in constipation and encopresis (p < 0.05). All but 1 patient had resolution of encopresis, and 6 of 7 patients who had constipation before ACE management had a resolution of constipation. 2 patients (25%) developed urinary continence (i.e., dry between CIC), and 2 others had improvement in continence. 3, 2, and 2 patients had urodynamic improvement in bladder capacity, compliance, or stability, respectively. However, no significant improvement in urinary incontinence or UDS parameters was demonstrated for the group overall. DISCUSSION: Our data demonstrate that some children with neurogenic bowel and bladder will have improvement in continence and UDS parameters following the initiation of ACE. Despite significant improvement in constipation and encopresis, the frequency of bladder improvement in this population appears less than that reported in neurologically intact children following treatment of constipation. Confirmatory studies with a larger number of children are needed. However, since constipation appears to negatively impact bladder function in some children with neurogenic bowel and bladder, it is reasonable to try to eliminate significant constipation in these patients before increasing pharmaceutical management of their neurogenic bladder.

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.