Factors influencing decisions about neurogenic bladder and bowel surgeries among veterans and civilians with spinal cord injury.

OBJECTIVE: This study investigated factors influencing surgical decision-making (DM) to treat neurogenic bladder and bowel (NBB) dysfunction for veterans and civilians with spinal cord injury (SCI) in the United States (US). DESIGN: Semi-structured interviews complemented by survey measures. SETTING: Community-dwelling participants who received treatment at a major Midwestern US medical system, a nearby Veterans Affairs (VA) facility, and other VA sites around the US. PARTICIPANTS: Eighteen participants with SCI who underwent surgeries; completed semi-structured interviews and survey measures. INTERVENTIONS: Not applicable. OUTCOMES MEASURES: Semi-structured interviews were coded to reflect factors, DM enactment, and outcomes, including surgery satisfaction and quality of life (QOL). Quantitative measures included COMRADE, Ways of Coping Questionnaire, Bladder and Bowel Treatment Inventory, PROMIS Global Health and Cognitive Abilities scales, and SCI-QOL Bladder and Bowel short form. RESULTS: Themes identified about factors influencing DM included: recurrent symptoms and complications; balancing dissatisfaction with NBB management against surgery risks; achieving independence and life style adjustments; participant's driven solutions; support and guidance and trust in doctors; and access and barriers to DM. DM enactment varied across surgeries and individuals, revealing no clear patterns. Most participants were satisfied with the surgery outcomes. Some differences in demographics were observed between veterans and civilians. CONCLUSIONS: We have attempted to illustrate the process of NBB DM as individuals move from factors to enactment to outcomes. Attending to the complexity of the DM process through careful listening and clear communication will allow clinicians to better assist patients in making surgical decisions about NBB management.

Effects of highly selective sympathectomy on neurogenic bowel dysfunction in spinal cord injury rats.

Neurogenic bowel dysfunction, including hyperreflexic and areflexic bowel, is a common complication in patients with spinal cord injury (SCI). We hypothesized that removing part of the colonic sympathetic innervation can alleviate the hyperreflexic bowel, and investigated the effect of sympathectomy on the hyperreflexic bowel of SCI rats. The peri-arterial sympathectomy of the inferior mesenteric artery (PSIMA) was performed in T8 SCI rats. The defecation habits of rats, the water content of fresh faeces, the intestinal transmission function, the defecation pressure of the distal colon, and the down-regulation of Alpha-2 adrenergic receptors in colon secondary to PSIMA were evaluated. The incidence of typical hyperreflexic bowel was 95% in SCI rats. Compared to SCI control rats, PSIMA increased the faecal water content of SCI rats by 5-13% (P < 0.05), the emptying rate of the faeces in colon within 24 h by 14-40% (P < 0.05), and the defecation pressure of colon by 10-11 mmHg (P < 0.05). These effects lasted for at least 12 weeks after PSIMA. Immunofluorescence label showed the secondary down-regulation of Alpha-2 adrenergic receptors after PSIMA occurred mainly in rats' distal colon. PSIMA mainly removes the sympathetic innervation of the distal colon, and can relieve the hyperreflexic bowel in rats with SCI. The possible mechanism is to reduce the inhibitory effect of sympathetic activity, and enhance the regulatory effect of parasympathetic activity on the colon. This procedure could potentially be used for hyperreflexic bowel in patients with SCI.

"Imola-Montecatone" subtotal colectomy to improve bowel management in spinal cord injury patients. Retrospective analysis in 19 cases.

STUDY DESIGN: Retrospective single-center study. OBJECTIVES: Persons with spinal cord injury live with neurogenic bowel dysfunction. Difficulties with management of neurogenic bowel can increase over time with age and time post injury, with a negative impact on autonomy and quality of life. Many conservative treatments are available to improve bowel management; however, in case of failure, a colostomy may be considered. SETTING: Specialized Care Unit, Montecatone Rehabilitation Institute and General Surgery Division, Imola Hospital, Imola, Italy. METHODS: From 2016 to 2019, selected patients affected by SCI and bowel dysfunction failing conservative care were treated with subtotal colectomy associated with placement of a bioabsorbable prosthesis, to prevent parastomal hernia. The surgical procedure is presented along with results. RESULTS: Overall, 19 individuals underwent the described procedure; after 1 year of follow-up, we observed four minor complications: two cases of dehiscence of the abdominal incision, easily treated during hospital stay, and two cases of leakage of mucorrhoea. CONCLUSION: Our results demonstrate the efficacy of the procedure to improve bowel management in persons with spinal cord injury.

Use of Malone antegrade continence enemas in neurologic bowel dysfunction.

INTRODUCTION: Patients with neurogenic bowel dysfunction (NBD) suffer severe constipation and/or fecal incontinence that are very difficult to treat. Most medication-based and interventional treatments have been unsuccessful. The goal of this study was to assess the medium-term effectiveness of the Malone procedure in all patients with NBD, as an alternative to colostomy. PATIENTS AND METHODS: In this retrospective single-center study, 23 patients who underwent Malone's surgical treatment were analyzed. The main criteria were the usage of antegrade colonic enemas (ACE) after Malone's procedure at the most recent follow-up and comparison of quality of life scores before and after surgery. RESULTS: The post-procedure mortality was zero, but an overall morbidity of 60% was observed, including minor complications (Clavien 1, 2) in 56%. The median follow-up was 33 months. At the most recent follow-up, the utilization rate of the neo-appendicostomy for ACE was 69.6%; 76.9% of the patients using ACE reported improvement in quality of life scores. Secondary colostomy was performed in 21.7% for functional failure of the Malone procedure. CONCLUSION: The Malone procedure is a reliable technique that can be used in the therapeutic strategy for managing NBD patients with incontinence/constipation refractory to usual treatments. It should be considered as a therapeutic step to take before resorting to colostomy.

Malone Antegrade Continence Enemas vs. Cecostomy vs. Transanal Irrigation-What Is New and How Do We Counsel Our Patients?

PURPOSE OF REVIEW: No gold standard exists for managing neurogenic bowel dysfunction, specifically in individuals with spina bifida. Since the International Children's Continence Society published its consensus document on neurogenic bowel treatment in 2012, an increased focus on why we must manage bowels and how to improve our management has occurred. This review provides updated information for clinicians. RECENT FINDINGS: A surge in research, mostly retrospective, has been conducted on the success and satisfaction of three types of management for neurogenic bowel. All three management techniques have relatively high success rates for fecal continence and satisfaction rates. Selection of which treatment to carry out still is debated among clinicians. Transanal irrigation is a safe and effective management option for neurogenic bowel that does not require surgery. Antegrade enemas can be carried out via cecostomy tube or Malone antegrade continence enema with similar fecal continence outcomes.

Early Colostomy Formation Can Improve Independence Following Spinal Cord Injury and Increase Acceptability of Bowel Management.

Background: Colostomy formation can solve complications of bowel management following spinal cord injury (SCI). Newly injured patients at this spinal unit have chosen colostomy as a preferred option for bowel management. Objectives: To discover the reasons patients choose colostomy formation early following SCI and make comparison with those choosing it later, and to establish whether early colostomy is safe and advisable. Methods: Medical and nursing records of patients with SCI who chose to have a colostomy during the period 2005-2016 were examined retrospectively. Data were gathered concerning reasons for choosing a colostomy, early and later complications, the need for further surgery, and independence with bowel care before and after surgery. Patients were divided into two groups: those who chose a colostomy "early" during inpatient rehabilitation and those who chose it "later" as is traditional. Results: Reasons for choosing colostomy differed. Reducing reliance on caregiver and independence were of more importance to the early group; the later group chose colostomy to solve bowel care problems. Early complication rates in both groups were low. Longer term complications were higher in the early group, with the most common complication being rectal discharge. Parastomal hernia rates were low in both groups, as was the need for further surgery. Colostomy formation led to 20.8% of all patients gaining independence with bowel care. Conclusion: This study found colostomy to be a safe and effective option when performed early after SCI and demonstrates colostomy can be a means of gaining independence and making bowel care easier and more acceptable to the newly injured patient.

Epidural Analgesia Decreases Narcotic Requirements in Patients with Low Level Spina Bifida Undergoing Urological Laparotomy for Neurogenic Bladder and Bowel.

PURPOSE: Concerns regarding anatomical anomalies and worsening neurological symptoms have prevented widespread use of epidural catheters in patients with low level spina bifida. We hypothesize that thoracic epidural placement in the T9 to T10 interspace is safe and decreases narcotic requirements following major open lower urinary tract reconstruction in patients with low level spina bifida. MATERIALS AND METHODS: We reviewed consecutive patients with low level spina bifida who underwent lower urinary tract reconstruction and received epidurals for postoperative pain control. Controls were patients with low level spina bifida who received single injection transversus abdominis plane blocks and underwent similar procedures. Complications of epidural placement, including changes in motor and sensory status, were recorded. Opioid consumption was calculated using equivalent intravenous morphine doses. Mean and maximum pain scores on postoperative days 0 to 3 were calculated. RESULTS: Ten patients with low level spina bifida who underwent lower urinary tract reconstruction with epidural were matched to 10 controls with low level spina bifida who underwent lower urinary tract reconstruction with transverse abdominis plane block. Groups were demographically similar. All patients had full abdominal sensation and functional levels at or below L3. No epidural complications or changes in neurological status were noted. The epidural group had decreased opioid consumption on postoperative days 0 to 3 (0.75 mg/kg vs 1.29 mg/kg, p = 0.04). Pain scores were similar or improved in the epidural group. CONCLUSIONS: Thoracic epidural analgesia appears to be a safe and effective opioid sparing option to assist with postoperative pain management following lower urinary tract reconstruction in individuals with low level spina bifida.

Simultaneous Robotic-Assisted Laparoscopy for Bladder and Bowel Reconstruction.

INTRODUCTION: Patients with neurogenic bladder frequently also have bowel dysfunction and a simultaneous urologic and colorectal reconstruction is possible. We present our experience with combined reconstructive procedures using robot-assisted laparoscopy, and demonstrate the utility of a minimally invasive approach that considers both the bowel and bladder management of these patients. METHODS: We retrospectively reviewed all patients who underwent combined bowel and urologic reconstruction at our institution since the start of our multidisciplinary robotic program. RESULTS: Seven patients were identified in our cohort with a mean age of 6.4 years (3.8-10.1 years). Six patients had myelomeningocele and 1 had caudal regression. Malone appendicostomies were placed in all 7 patients. A split appendix technique was used as a conduit in 5 patients, in situ appendix in 1, and neoappendicostomy with cecal flap in 1. Six patients had a Mitrofanoff appendiceal conduit created, while 1 patient had a sigmoid colovesicostomy for urinary diversion. Five patients required bladder neck repair. One patient had stenosis of the Mitrofanoff and one patient had an anastomotic leak of the sigmoid anastomosis. The average operating time was 526 minutes (313-724 minutes). The median length of stay (LOS) was 5 days (4-7 days), excluding one outlier who suffered an anastomotic leak and had an extended LOS (50 days). All patients who underwent continent bladder reconstruction are dry on their current catheterizing regimen, 6/7 are clean with antegrade flushes. CONCLUSION: Patients with neurogenic bladder often have coexisting bowel dysfunction, which provides an opportunity to reconstruct both organ systems simultaneously and achieve social urinary and bowel continence. Before committing to any intervention, the surgeon should consider both the urologic and gastrointestinal needs of the patient, and perform the needed procedures simultaneously. We describe a number of combined operations aimed at bowel and bladder management that can be performed safely using robot-assisted laparoscopy.

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.

Variation in surgical management of neurogenic bowel among centers participating in National Spina Bifida Patient Registry.

PURPOSE: Optimal management of neurogenic bowel in patients with spina bifida (SB) remains controversial. Surgical interventions may be utilized to treat constipation and provide fecal continence, but their use may vary among SB treatment centers. METHODS: We queried the National Spina Bifida Patient Registry (NSBPR) to identify patients who underwent surgical interventions for neurogenic bowel. We abstracted demographic characteristics, SB type, functional level, concurrent bladder surgery, mobility, and NSBPR clinics to determine whether any of these factors were associated with interventions for management of neurogenic bowel. Multivariable logistic regression with adjustment for selection bias was performed. RESULTS: We identified 5,528 patients with SB enrolled in the 2009-14 NSBPR. Of these, 1,088 (19.7%) underwent procedures for neurogenic bowel, including 957 (17.3%) ACE/cecostomy tube and 155 (2.8%) ileostomy/colostomy patients. Procedures were more likely in patients who were older, white, non-ambulatory, with higher-level lesion, with myelomeningocele lesion, with private health insurance (all p< 0.001), and female (p= 0.006). On multivariable analysis, NSBPR clinic, older age (both p< 0.001), race (p= 0.002), mobility status (p= 0.011), higher lesion level (p< 0.001), private insurance (p= 0.002) and female sex (p= 0.015) were associated with increased odds of surgery. CONCLUSIONS: There is significant variation in rates of procedures to manage neurogenic bowel among NSBPR clinics. In addition to SB-related factors such as mobility status and lesion type/level, non-SB-related factors such as patient age, sex, race and treating center are also associated with the likelihood of undergoing neurogenic bowel intervention.

Neurogenic ppendicopathy. A report of 8 cases.

INTRODUCTION: Neurogenic appendicopathy is not a very well-known disease. OBJECTIVE: To analyze the experience in the management of neurogenic appendicopathy in a tertiary hospital, assessing its clinical presentation, histological staging, the treatment carried out and its clinical evolution. METHOD: The study population included patients with histopathological criteria for neurogenic appendicopathy who did not present with MEN 2B syndrome, neurofibromatosis type I or Cowden syndrome. An analysis was carried out of tissue samples taken from a simple appendectomy after a diagnosis of neurogenic appendicopathy between 2000 and 2013, inclusive. The histopathological criteria were neurogenic hyperplasia with S-100 protein positivity and neuron-specific enolase in the immunohistochemical analysis. RESULTS: Of the 4,969 samples from the appendectomies analyzed, 0.16% (n = 8) met histopathological criteria of neurogenic appendicopathy. The age at presentation was 27.8 ± 12 years. Four patients were male and four were female. All patients started with abdominal pain in the right iliac fossa (RIF), and were operated on due to a diagnosis of acute appendix, with a simple appendectomy being performed. In four cases, another associated disease accounted for the pain in the RIF. With regard to histopathological type, submucosal neurogenic hyperplasia was present in five patients and fibrous obliteration in three patients. No statistically significant differences were found between the histological types. After surgery, during a mean follow up of 73.2 ± 28 months (15-105), all the patients remained asymptomatic. CONCLUSION: Neurogenic appendicopathy is an uncommon entity that can evolve as abdominal pain which is similar to acute appendix. Simple appendectomy is curative.

Ambulatory patients with spina bifida are 50% more likely to be fecally continent than non-ambulatory patients, particularly after a MACE procedure.

INTRODUCTION: While fecal incontinence (FI) affects many patients with spina bifida (SB), it is unclear if it is associated with ambulatory status. OBJECTIVE: To determine if ambulatory status is associated with FI, and a potential confounding variable, in patients with and without a Malone antegrade continence enema (MACE). STUDY DESIGN: This study retrospectively reviewed of patients aged ≥8 years with SB who were enrolled in an international quality of life study at outpatient visits (January 2013 to September 2015). Patients reported FI over the last 4 weeks (strict criteria: any FI/accidents vs no FI). Patients unable to self-report FI due to developmental delay were excluded. Those who were ambulating outdoors with/without braces/crutches were considered community ambulators. Non-parametric tests and logistic regression were used for analysis. RESULTS: A total of 115 patients with a MACE and 57 without a MACE were similar in gender (P = 0.99), ventriculoperitoneal status (P = 0.15) and age (16.0 vs 15.4 years, P = 0.11). Median ages at MACE procedure and follow-up were 7.0 and 8.2 years, respectively, and all used the MACE ≥3x/week. They were less likely to be ambulators (54.8 vs 71.9%, P = 0.03). In patients with a MACE, 64 (55.7%) had total fecal continence, compared with 29 (50.9%) without a MACE (P = 0.62). In the MACE group, ambulators were more likely to be continent compared with non-ambulatory patients (65.1 vs 44.2%, P = 0.04) (Table). Although not statistically significant, a similar difference was observed in the non-MACE group (56.1 vs 37.5%, P = 0.25). In the MACE group, continent and incontinent patients, regardless of ambulatory status, had similar rates of MACE use, additive use and time for MACE completion (P ≥ 0.43). MACE ambulators were more likely to be continent than MACE non-ambulators on multivariate analysis (OR 3.26, P = 0.01). DISCUSSION: This study reported higher than typical FI rates since: (1) it used a stringent definition of total fecal continence; (2) patients without FI were perhaps less likely to participate; and (3) it relied on patient-reported rather than clinician-reported outcomes. This cross-sectional study should not be interpreted as "MACE procedure is ineffective;" this would require a longitudinal study. The present findings may not apply to young children or those with significant developmental delay (patients excluded from the study). CONCLUSIONS: Ambulatory patients with SB are 50% more likely to have total fecal continence on long-term follow-up, particularly after a MACE procedure. Ambulatory status is a significant confounder of FI and should be considered in future analyses.

Medical and surgical management of neurogenic bowel.

PURPOSE OF REVIEW: Neurogenic bowel dysfunction (NBoD) commonly affects patients with spina bifida, cerebral palsy, and spinal cord injury among other neurologic insults. NBoD is a significant source of physical and psychosocial morbidity. Treating NBoD requires a diligent relationship between patient, caretaker, and provider in establishing and maintaining a successful bowel program. A well designed bowel program allows for regular, predictable bowel movements and prevents episodes of fecal incontinence. RECENT FINDINGS: Treatment options for NBoD span conservative lifestyle changes to fecal diversion depending on the nature of the dysfunction. Lifestyle changes and oral laxatives are effective for many patients. Patients requiring more advanced therapy progress to transanal irrigation devices and retrograde enemas. Those receiving enemas may opt for antegrade enema administration via a Malone antegrade continence enema or Chait cecostomy button, which are increasingly performed in a minimally invasive fashion. Select patients benefit from fecal diversion, which simplifies care in more severe cases. SUMMARY: Many medical and surgical options are available for patients with NBoD. Selecting the appropriate medical or surgical treatment involves a careful evaluation of each patient's physical, psychosocial, financial, and geographic variables in an effort to optimize bowel function.

Percutaneous Cecostomy in Adult Patients: Safety and Quality-of-Life Results.

PURPOSE: To assess the safety and quality of life in adult patients undergoing cecostomy tube placement. MATERIALS AND METHODS: Percutaneous cecostomy was performed in 23 adults (10 men and 13 women) with neurogenic bowel for whom noninvasive therapeutic approaches for chronic refractory constipation or fecal incontinence had failed. Mean patient age was 41 years (range, 19-74 y). A retrospective, standardized questionnaire evaluated satisfaction and quality of life before and after cecostomy. RESULTS: All 23 cecostomy procedures were technically successful with no intraprocedural complications. At a mean follow-up of 42 months (range, 1-160 mo), there was one (5%) major complication, a pericecal abscess. One or more minor complications in 11 of 23 (48%) patients included leaking around the tube (5 of 23; 22%) and partial or complete dislodgment of the tube (3 of 23; 13%). In all cases, the cecostomy tube was exchanged successfully. Satisfaction scores improved from a mean of 2.2 points (range, 0-6 points; median, 1.5) to 7.6 points (range, 4-10 points; median, 8). The percentage of patients using laxative softeners decreased from 74% to 40%, and patients requiring assistance decreased from 52% to 35% after cecostomy placement. CONCLUSIONS: Percutaneous cecostomy is a safe procedure for the management of adult patients. Patients are able to achieve greater independence in their activities of daily living and are highly satisfied with the outcomes.

The artificial somato-autonomic reflex arch does not improve bowel function in subjects with spinal cord injury.

STUDY DESIGN: Prospective cohort study. OBJECTIVE: Although introduced for neurogenic bladder dysfunction, it has been suggested that the artificial somato-autonomic reflex arch alleviates neurogenic bowel dysfunction (NBD). We aimed at evaluating the effects of the reflex arch on NBD. SETTING: Denmark. METHODS: Ten subjects with supraconal spinal cord injury (SCI) (nine males, median age 46 years) had an anastomosis created between the ventral part of the fifth lumbar or first sacral nerve root and the ventral part of the second sacral nerve root. Standardized assessment of segmental colorectal transit times with radiopaque markers, evaluation of scintigraphic assessed colorectal emptying upon defecation, scintigraphic assessment of colorectal transport during stimulation of the reflex arch, standard anorectal physiology tests and colorectal symptoms were performed at baseline and 18 months after surgery. RESULTS: No significant change was observed in colorectal emptying upon defecation (median 31% of the rectosigmoid at baseline vs 75% at follow-up, P=0.50), no movement of colorectal contents was observed during stimulation of the reflex arch. Segmental colorectal transit times, anal sphincter pressures and rectal capacity did not change, and no change was seen in NBD score (median 13.5 (baseline) vs 12.5 (follow-up), P=0.51), St Marks fecal incontinence score (4.5 vs 5.0, P=0.36) and Cleveland constipation score (6.0 vs 8.0, P=0.75). CONCLUSIONS: The artificial somato-autonomic reflex arch has no effect on bowel function in subjects with supraconal SCI.

Development of hydronephrosis secondary to poorly managed neurogenic bowel requiring surgical disimpaction in a patient with spinal cord injury: a case report.

CONTEXT: Case of an adult patient with paraplegia managing neurogenic bladder with intermittent catheterization who was not performing a standard bowel program for management of neurogenic bowel. FINDINGS: Patient presented with increasing spasticity, fecal incontinence, and abdominal pain and ultimately was hospitalized for management. Imaging revealed massive fecal impaction, resulting in ureteral obstruction and hydronephrosis. Despite repeated aggressive bowel regimens, serial abdominal X-rays showed continued large stool burden. Ultimately surgical intervention was required to evacuate the colon and subsequently the hydronephrosis resolved. CONCLUSION/CLINICAL RELEVANCE: This case illustrates the importance of proper management of neurogenic bowel, as significant medical complications, such as hydronephrosis can occur with poorly managed neurogenic bowel.

Surgery for constipation in patients with prior spinal cord injury: the Department of Veterans Affairs experience.

OBJECTIVE: Patients with spinal cord injury (SCI) typically have difficulty with constipation. Some undergo surgery for bowel management. We predicted that SCI patients would have higher mortality and/or morbidity rates following such surgery than neurally intact patients receiving the same procedures. We sought to evaluate this using a large population-based data set. METHODS: Patients receiving care at Department of Veterans Affairs Medical Centers (DVAMCs) with computer codes for SCI and constipation who later underwent colectomy, colostomy, or ileostomy during fiscal years 1993-2002 were identified. Charts were requested from the VAMCs where the surgery had been performed and a retrospective chart review of these charts was done. We collected data on patient demographics, six specific pre-operative co-morbidities, surgical complications, and post-operative mortality. Comparisons were made to current literature evaluating a population receiving total abdominal colectomy and ileorectal anastomosis for constipation but not selected for SCI. RESULTS: Of 299 patients identified by computer search, 43 (14%) had codes for SCI and 10 of 43 (24%) met our inclusion criteria. All were symptomatic and had received appropriate medical management. Co-morbid conditions were present in 9 of 10 patients (90%). There were no deaths within 30 days. The complication rate was zero. The mean post-operative length of stay was 17 days. CONCLUSIONS: Patients with SCI comprise about 14% of the population who receive surgery for severe constipation in the Department of Veterans Affairs system. The mortality and morbidity rates in these patients are similar to those reported in other constipated patients who have surgery for intractable constipation. Our data suggest that stoma formation ± bowel resection in patients with SCI is a safe and effective treatment for chronic constipation.

Outcomes following fecal continence procedures in patients with neurogenic bowel dysfunction.

PURPOSE: Malone antegrade continence enema and cecostomy button improve quality of life in patients with neurogenic bowel. However, they have not been compared regarding fecal continence outcomes. We compared these 2 procedures with respect to continence, complications and conversions. MATERIALS AND METHODS: We retrospectively reviewed the charts of patients who underwent Malone antegrade continence enema or cecostomy at the University of Alberta between January 2006 and January 2011. A total of 26 patients underwent Malone antegrade continence enema, of whom 20 underwent concomitant Monti procedure and bladder augmentation, 5 a laparoscopically assisted procedure and 1 concomitant ileovesicostomy. A total of 23 patients underwent cecostomy, of whom 1 underwent ileovesicostomy, 1 bladder augmentation, 1 a Monti procedure with bladder augmentation and 1 laparoscopic cecostomy. Continence was defined as ability to wear underwear with no accidents at most recent annual followup, which was a minimum of 1 year postoperatively. RESULTS: Fecal continence rates were 84.6% for Malone antegrade continence enema and 91.3% for cecostomy. There were no statistically significant differences in continence based on procedure (p = 0.48), age (p = 0.97) or gender (p = 0.54). Of patients who underwent cecostomy 8.7% switched to the Malone antegrade continence enema, while 11.5% with Malone antegrade continence enema switched to cecostomy. Mean length of hospital stay for patients undergoing cecostomy vs laparoscopically assisted Malone antegrade continence enema was 4.0 vs 5.2 days (p = 0.15). Complications included stomal pain (23.1% of patients) and difficulty with catheterizing (19.2%) following Malone antegrade continence enema, and difficulty flushing (26.1%) following cecostomy. CONCLUSIONS: There were no significant differences between Malone antegrade continence enema and cecostomy button with respect to fecal continence or complication rates. Each approach poses unique challenges, suggesting that patients and families need to understand the differences to make an individualized choice.

Total continence reconstruction using the artificial urinary sphincter and the Malone antegrade continence enema.

PURPOSE: Surgical management of children with myelomeningocele addresses 2 aspects of the disease, neurogenic bladder and neurogenic bowel. Results of total continence reconstruction using an artificial urinary sphincter and Malone antegrade continence enema are presented. MATERIALS AND METHODS: We performed a retrospective chart review of patients who underwent simultaneous artificial urinary sphincter placement and a Malone antegrade continence enema procedure. From 1997 to 2007 a total of 21 patients with myelomeningocele underwent total continence reconstruction using the artificial urinary sphincter. Mean patient age was 10.4 years (range 6 to 22) and mean followup was 4.7 years (range 0.66 to 11.7). Artificial urinary sphincter cuff was placed around the bladder neck. A Malone antegrade continence enema was performed using appendix in 19 patients and cecal based flaps in 2. Two patients underwent concomitant augmentation cystoplasty. Six patients had concomitant Mitrofanoff vesicostomy using split appendix in 4 and Monti tube in 2. RESULTS: Immediate postoperative complications were observed in 5 patients, including prolonged ileus (2), urinary tract infection (2) and superficial wound dehiscence (1). Seventeen patients (81%) achieved complete urinary continence and 5 were voiding with sphincter cycling. Improvement in urinary continence with dry intervals greater than 3 hours was reported in 2 patients. There were 19 patients (90%) who reported fecal continence, with 2 reporting soiling 1 to 2 times a week. Malone antegrade continence enema stoma stenosis occurred in 3 patients and 2 required revisions. Sixteen patients (76%) achieved complete continence of stool and urine. During followup 2 artificial urinary sphincters were explanted and 8 patients (38%) underwent bladder augmentation. CONCLUSIONS: Urinary and fecal continence in patients with myelomeningocele is achievable with a single total continence reconstruction procedure using the artificial urinary sphincter and the Malone antegrade continence enema with durable results.