State of the Art Bowel Management for Pediatric Colorectal Problems: Anorectal Malformations.

Up to 79% of patients with anorectal malformations (ARMs) experience constipation and/or soiling after a primary posterior sagittal anoplasty (PSARP) and are referred to a bowel management program. We aim to report the recent updates in evaluating and managing these patients as part of the manuscript series on the current bowel management protocols for patients with colorectal diseases (ARMs, Hirschsprung disease, functional constipation, and spinal anomalies). The unique anatomic features of ARM patients, such as maldeveloped sphincter complex, impaired anal sensation, and associated spine and sacrum anomalies, indicate their bowel management plan. The evaluation includes an examination under anesthesia and a contrast study to exclude anatomic causes of poor bowel function. The potential for bowel control is discussed with the families based on the ARM index calculated from the quality of the spine and sacrum. The bowel management options include laxatives, rectal enemas, transanal irrigations, and antegrade continence enemas. In ARM patients, stool softeners should be avoided as they can worsen soiling.

Impact of antegrade enema initiation on healthcare utilization in pediatric patients: A population-based cohort study.

BACKGROUND: When constipation is refractory to first-line interventions, antegrade enema use may be considered. We aimed to assess the impact of this intervention on healthcare utilization. METHODS: We conducted a population-based, quasi-experimental study with pre-post comparison of the intervention group and a non-equivalent control group using linked clinical and health administrative data from Ontario, Canada. Subjects included children (0-18 years) who underwent antegrade enema initiation from 2007 to 2020 and matched controls (4:1) from the general population. To assess the change in healthcare utilization following antegrade enema initiation, we used negative binomial generalized estimating equations with covariates selected a priori. KEY RESULTS: One hundred thirty-eight subjects met eligibility criteria (appendicostomy = 55 (39.9%); cecostomy tube = 83 (60.1%)) and were matched to 550 controls. There was no significant difference in the change in the rate of hospitalizations (rate ratio (RR) 1.05, 95% confidence interval (CI) 0.35-1.75), outpatient visits (RR 1.05, 95% CI 0.91-1.18), or same-day surgical procedures (RR 1.51, 95% CI 0.60-2.43) across cases in 2 years following antegrade enema initiation compared with controls. Cases had an increased rate of emergency department (ED) visits, which was not observed in controls (RR 1.52, 95% CI 1.11-1.79), driven in part by device-related complications. CONCLUSIONS AND INFERENCES: Understanding healthcare utilization patterns following antegrade enema initiation allows for effective health system planning and aids medical decision-making. The observed increase in ED visits for device-related complications speaks to the need to improve preventive management to help mitigate emergency care after initiation of antegrade enemas.

Procedimiento de malone videoasistido en pediatria: primeros dos casos en Uruguay / Laparoscopic malone procedure in pediatrics: first cases in Uruguay / Procedimento de malone videoassistido em pediatria: dois primeiros casos no Uruguai

El procedimiento de apendicostomía continente para la realización de enemas anterógrados ha sido publicado ya hace varios años para el tratamiento de la incontinencia fecal y del estreñimiento de muy difícil manejo. Otra indicación del mismo incluye el estreñimiento severo, en el cual se agotaron las medidas farmacológicas y el único tratamiento efectivo es la realización de enemas. El objetivo principal del procedimiento es ofrecer a los niños y sus familias una alternativa a la hora de realizar los enemas, logrando una mayor adherencia al tratamiento y buscando alcanzar una mejor calidad de vida que permita adecuarse a las actividades con sus pares. Por otra parte permite al niño ir logrando cierta independencia gradual a medida que crezca, preparándolos para el futuro y haciéndolos participes activos de su cuidado. Se describen los primeros casos en donde utilizamos en nuestro medio el abordaje laparoscópico, sus indicaciones, la técnica quirúrgica y los resultados iniciales. Hemos constatado como ventaja principal los beneficios del abordaje mínimamente invasivo, como la exploración completa de la cavidad abdominal, el menor dolor postoperatorio, cicatrices más pequeñas, menor creación de adherencias.

The appendicostomy procedure for performing antegrade enemas has been published several years ago for the treatment of fecal incontinence and constipation that are very difficult to manage. The Malone procedure is performed in our setting, especially in patients with fecal incontinence secondary to neurological disorders such as myelomeningocele using a conventional approach. Other indications of it is severe constipation, in which pharmacological measures have been exhausted and the only effective treatment is enemas. The main objective of the procedure is to offer children and their families an alternative when performing enemas, achieving greater adherence to treatment and seeking to achieve a better quality of life that allows them to adapt to the activities of their peers. On the other hand, it allows the child to achieve a certain gradual independence as they grow, preparing them for the future and making them active participants in their care. The first cases in which we use the laparoscopic approach, its indications, the surgical technique and the initial results are described. We think that its main advantage is the benefits of the minimally invasive approach, such as complete exploration of the abdominal cavity, less postoperative pain, smaller scars, and less creation of adhesions.

O procedimento de apendicostomia continente para a realização de enemas anterógrados foi publicado há vários anos para o tratamento de incontinência fecal e constipação de difícil manejo. Outra indicação inclui constipação grave, na qual as medidas farmacológicas foram esgotadas e o único tratamento eficaz são os enemas. O principal objetivo do procedimento é oferecer às crianças e seus familiares uma alternativa na realização dos enemas, alcançando maior adesão ao tratamento e buscando alcançar uma melhor qualidade de vida que lhes permita adaptar-se às atividades com seus pares. Por outro lado, permite que a criança alcance uma certa independência gradual à medida que cresce, preparando-a para o futuro e tornando-a participante ativa em seus cuidados. São descritos os primeiros casos em que utilizamos a via laparoscópica, suas indicações, a técnica cirúrgica e os resultados iniciais. Confirmamos os benefícios da abordagem minimamente invasiva como principal vantagem, como exploração completa da cavidade abdominal, menos dor pós-operatória, cicatrizes menores e menor formação de aderências.

Enema-Induced spastic left colon syndrome: An unintended consequence of chronic enema use.

BACKGROUND/PURPOSE: Enemas have become a common practice for treating fecal incontinence and severe constipation. Several patients receiving enemas complained of severe, colicky, abdominal pain during enema administration and complained that the duration for fluid to pass was progressively increasing. Contrast studies showed a startling picture of severe right colon dilatation and a spastic, narrow, left colon. An investigation was started to seek the origin and possible management of this condition. METHODS: Medical and radiologic records were reviewed retrospectively, with emphasis on the type and ingredients of enemas used, the duration the patients had been receiving enemas, and their original diagnosis. A literature review was done on previous reports of this condition and publications related to long-term use of enemas. RESULTS: This series included 22 patients (average age, 19.6 years; range, 8-54) with fecal incontinence due to anorectal malformations (10 cases), myelomeningocele (5), cloaca (2), severe colonic dysmotility (2), Hirschsprung's disease (2), and sacrococcygeal teratoma (1). The average duration of enema use was 13.7 years (range, 4-45). The composition of the enemas included saline/glycerin (six cases), only saline solution (five), saline/glycerin/soap (four), plain water (three), and one case each of molasses/milk, saline/glycerin/soap/phosphate, saline/phosphate, and only phosphate. The enemas were performed in an antegrade fashion in 21 cases and rectally in 1. All patients had a dilated right colon and a narrow, spastic, left, transverse, and descending colon. Four patients underwent colonoscopy, colonic manometry, and mucosal biopsies, which did not help in explaining the etiology of the problem. In the literature, 43 reports mentioned a "long-term follow-up" for the administration of enemas, but we could not find a description of symptoms, such as in our cases. CONCLUSIONS: An intriguing and, to our knowledge, previously unreported complication of chronic enema use is presented. We call attention to an overly concerning complication and report our findings in the hope that they will aid and stimulate more investigations into this condition. Several hypotheses to explain the cause are presented, as well as potential treatment options.

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.

Long-term outcomes of antegrade continence enema in children with chronic encopresis and incontinence: what is the optimal flush to use?

PURPOSE: Severe constipation and encopresis are significant problems in the pediatric population. Medical management succeeds in 50-70%; however, surgical considerations are necessary for the remainder such as the antegrade continence enema (ACE). The purpose of this study is to assess the long-term outcomes following the ACE procedure. METHODS: All patients undergoing an ACE over a 14-year period were included. Data on clinical conditions, treatments, and outcomes were collected. A successful outcome was defined as remaining clean with ≤ 1 accident per week. Comparative data were analyzed using the Fisher's exact test, Mann-Whitney U test, or Student's t test. RESULTS: There were 42 ACE patients, and overall, 79% had improvement in their bowel regimens. Encopresis rates decreased from 79 to 5% (P < 0.001). Admissions for cleanouts decreased from 52 to 19% (P = 0.003). All cases of Hirschsprung's, functional constipation and spina bifida were successful. Rates of success varied for other diseases such as slow-transit constipation (60%) and cerebral palsy (33%). A majority (85%) required a change in the enema composition for improvement. CONCLUSION: In our study, ACE reduced soiling, constipation, and need for fecal disimpaction. Higher volume saline flushes used once a day was the optimal solution and most preferred option. LEVEL OF EVIDENCE: Level 4 (retrospective case series or cohort).

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.

Outcomes and satisfaction in pediatric patients with Chait cecostomy tubes.

INTRODUCTION: Patients with spina bifida and other spinal dysraphisms commonly suffer from fecal incontinence and constipation, which can be treated with antegrade continence enemas. Currently, information regarding outcomes and satisfaction in children who have Chait cecostomy tubes is lacking. The aim of our study was to evaluate the effectiveness of Chait cecostomy tubes in management of constipation in children with spinal dysraphisms. MATERIALS AND METHODS: A questionnaire was completed by patients and/or their families during office visits at the University of Iowa or Nationwide Children's Hospital during follow-up pediatric urology office visits. Two study groups completed the questionnaires: 1) Patients with neurogenic bowels who had a cecostomy tube in place (CT) and 2) patients with neurogenic bowels with no cecostomy tube (NCT). The survey used Likert scaled and nonrated questions to assess demographics, bowel continence, and satisfaction. RESULTS: A total of 86 patients completed the questionnaire: 53 CT patients and 33 NCT patients. CT patients rated the effectiveness of their cecostomy tube in managing their constipation significantly higher than the NCT group rated the effectiveness of their conventional bowel management methods (p < 0.001). Within the CT group, 48% of patients had complete or near complete continence, 40% had partial fecal incontinence, while only 12% remained incontinent. Of the CT respondents, 88% were overall satisfied with the cecostomy tube (Figure) and 92% would have the cecostomy tube placed again. In addition, hygiene, independence, and social confidence were significantly improved compared with baseline. Complications associated with the Chait tube included granulation tissue that required treatment (60%) and pain with irrigation (24%). CONCLUSIONS: CT patients reported significantly improved constipation management, fecal continence, and improved quality of life compared with NCT patients. Our pilot study demonstrates that the Chait cecostomy tube is a well-tolerated, effective means for treating constipation and achieving fecal continence with minimal side effects in patients with neurogenic bowels.