Robotic conversion of cecostomy tube to catheterizable antegrade continence enema (ACE): Surgical technique.

ABSTRACT

INTRODUCTION: Antegrade continence enema (ACE) is a well described treatment for pediatric patients with neurogenic bowel refractory to medical and retrograde management. ACE can be carried out either by catheterizable channel with enteric conduit or a cecostomy tube appliance. For those patients who have issues with pain or leakage around the cecostomy appliance or wish to be appliance free, we present our initial results and description of a novel technique of laparoscopic conversion of cecostomy to catheterizable ACE which uses the existing tract and requires no enteric conduit. METHODS: A single institution, retrospective chart review was carried out for 2014-2017 to identify patients undergoing ACE conversion. Preoperative parameters included age, sex, weight, neurogenic bowel etiology and time from initial cecostomy. Perioperative data included length of surgery, length of hospitalization and postoperative complications (via Clavien-Dindo scale). Postoperative follow up, ancillary procedures pertinent to the ACE and status at time of submission are also presented. RESULTS: Six patients were identified (mean age 14.1 +/- 4.3 years) with median follow up of 36 months (range 18-65). Neurogenic bowel etiology was spina bifida in five and spinal cord injury in one; all patients had concurrent neurogenic bladder with preexisting appendicovesicostomy. Mean operative time was 168 +/- 37 min (range 122-228) and mean length of hospital stay was 2 days (range 1-4). Success rate is 83% (5/6 continue to catheterize ACE channel), with one patient opting back for appliance through same tract. One patient has required operative revision for stomal stenosis. CONCLUSION: To our knowledge, this is the first report describing robotic-assisted laparoscopic conversion of cecostomy tube to a catheterizable ACE. The surgical technique we describe is simple and safe with minimal morbidity to the patient. It does not require an enteral conduit, and may represent a valid treatment in patients without the option of using the appendix.