Cecostomy button for antegrade enemas: survey of
François Becmeura,⁎, Martine Demarcheb, Isabelle Lacreusea, Francesco Molinaroa,
Isabelle Kauffmanna, Raphael Mooga, Florence Donnarsa, Julie Rebeuha
aDepartment of Paediatric Surgery, Hautepierre Hospital, 67098 Strasbourg, France
bDepartment of Paediatric Surgery, Citadelle Hospital, 4000 Liège, Belgium
Received 10 December 2007; revised 13 March 2008; accepted 13 March 2008
Objective: ThisstudyevaluatedtheTrap-doorbuttonuse(CookMedical,Bloomington, IL)forantegrade
enemas in children.
Methods: Since 2002, patients with fecal incontinence or encopresis and constipation underwent
operative time, hospital stay, diagnosis, indications for cecostomy, and duration of follow-up were
recorded. A survey was proposed via a questionnaire that was sent to the patients. Patients wearing the
button for less than 1 month were excluded from this evaluation.The survey concerned volume and
frequency of enemas, difficulties encountered, benefits and disadvantages of this method, and assessment
of the antegrade enemas in continence.
Results: Twenty-nine patients, 18 males and 11 females, aged 3 to 21 years (mean, 8.5 years) underwent
laparoscopic Trap-door button placement. The indications for all the patients were intractable fecal
incontinence in 24 cases and constipation with encopresis in 5 cases. Incontinence was because of
myelomeningocele (n = 10), anorectal malformations (n = 11), caudal regression syndrome (n = 1),22q11
syndrome (n= 1), and Hirschsprung disease with encephalopathy with convulsions (n = 1). Constipation
with encopresis was because of sacrococcygeal teratoma (n = 1), cerebral palsy (n = 1), and acquired
megarectum with psychiatric and social disorders (n = 3). A total of 26 cecostomy button placements and
3 sigmoidostomy button placements were successful with no intraoperative complication. The mean
parents or patients answered the questionnaire. At the time of this survey, 2 patients had improved their
fecal continence and had had the button removed. A mean of 4 weekly enemas was enough to improve
fecal continence troubles (range, 1 daily to 1 for 2 weeks). The volume for enemas was 250 to 1000 mL
(mean, 700 mL). The time required for the irrigation of the bowel by gravity took from 5 to 60 minutes
(mean, 25 minutes) for 20 patients. Before surgery, 14 patients needed a diaper, day and night, and 6
neededsanitary protection. Soilingwasavery significant inconvenienceforallthe patients.After surgery,
only 5 patients needed a diaper (cerebral palsy, 22q11, cloacal malformation, myelomeningocele, bladder
exstrophy) becauseofmoderate results orurinaryincontinence andcontinuedsoiling.Patientswereasked
to give an assessment (null = 0, bad = 1, fair = 2, good = 3, very good = 4). None of the patients felt there
had been no changes or a bad result. There were 5 patients who felt they had an average result, 5 a good
E-mail address: firstname.lastname@example.org (F. Becmeur).
0022-3468/$ – see front matter © 2008 Published by Elsevier Inc.
Journal of Pediatric Surgery (2008) 43, 1853–1857
granulation tissue formation around the cecostomy button, and 12 had tiny leakage.
Conclusion: Percutaneous placement of a cecostomy button under laparoscopic control is an easy and
major complication-free procedure. The use of the Trap-door device by the patients or with the help of the
parents for antegrade enemas is effective and satisfactory. It improves the quality of life and is reversible.
© 2008 Published by Elsevier Inc.
Antegrade enemas in patients with fecal incontinence or
encopresis with constipation have proven successful and
allow the patient to be independent .
We report our own series on laparoscopic cecostomy or
sigmoidostomy for antegrade enemas and a survey concern-
ing the use of the Trap-door button according to Chait et al
 by questioning patients and their parents.
1. Material and methods
1.1. Surgical technique
Two departments of pediatric surgery proposed the same
technique for cecostomy button placement and use of this
device for management of fecal incontinence and encopresis
with constipation. Preparation of the patients was simple.
The preparation included 1 or 2 enemas with serum saline
(500 mL to 1 L) the day before surgery. A single-dose
intravenous metronidazole was administered at the begin-
ning of the procedure. Surgery was done under general
anesthesia. An open laparoscopy was performed with a
5-mm 0° telescope through the umbilicus, and an additional
operative trocar was placed in the left lower quadrant for
cecostomy and in the right lower quadrant for sigmoidos-
tomy. An 8–mm Hg carbon dioxide pressure insufflation was
used. Laparoscopy allowed the selection of the site for
cecostomy or sigmoidostomy by looking at the place where
the cecum or the sigmoid colon could be hung: on to the
anterior abdominal wall, thus avoiding placing it too close to
the iliac crest. Two U-stitches according to the Georgeson 
procedure for gastrostomy were used to secure the bowel to
theabdominal wall. Along needle was inserted into the Chait
Trap-door button (Cook). A no. 11 blade was passed through
the abdominal wall to prepare the entry of the button. The
needle, covered by the button, was pushed through the
parietal wall and straight into the bowel under laparoscopic
control (Figs. 1-5).
1.2. Postoperative care
first enemas were done with a nurse in our institution so that
technical details and different tricks about the care of the
Age at surgery, operative time, hospital stay, diag-
nosis, indications for cecostomy, and duration of follow-up
A survey was proposed via a questionnaire, which was
sent to the patients. Patients wearing the button for less than
1 month were excluded from this evaluation. The survey
concerned volume and frequency of enemas, difficulties
encountered, benefits and disadvantages of this method, and
assessment of the antegrade enemas in continence.
Twenty-nine patients, 18 males and 11 females, aged 3 to
21 years (mean, 8.5 years) underwent laparoscopic Trap-
door button placement.
The indication for all the patients was intractable fecal
incontinence in 24 cases and constipation with encopresis in
5 cases (Table 1).
Fecal incontinence was due to myelomeningocele (n =
10), anorectal malformations (n = 5), anorectal malforma-
tions with a Currarino triad (n = 2), a cloacal malformation
caudal regression syndrome (n = 1), 22q11 syndrome (n = 1),
and Hirschsprung disease with encephalopathy with convul-
sions (n = 1) (Table 2).
The device and the needle.
Introducing the needle into the Trap-door button.
1854F. Becmeur et al.
Constipation with encopresis was responsible for the
foul smelling liquid stools in the children's underwear
secondary to fecal impaction owing to constipation. Con-
stipation with encopresis was due to sacrococcygeal teratoma
(SCT) (n = 1), cerebral palsy (n = 1), and acquired
megarectum with psychiatric and social disorders (n = 3).
Laxative medications, repeated and frequent enemas,
biofeedback attempts after anorectal manometry, and
psychological support failed during periods longer than
1 year (Table 3).
A total of 26 cecostomy button placements and 3
sigmoidostomy button placements were successful with no
intraoperative complication. The mean operative time was
25 minutes (10-40 minutes), and the hospital stay was
2.5 days (1-4 days). The patient with SCT had fecal
impaction in an acquired megarectum. The most important
part of her problem was not incontinence but encopresis,
which is why a sigmoidostomy was decided. The other
sigmoidostomy was indicated in a boy who was operated
previously for a high anorectal malformation. He developed
an isolated megarectum.
Twenty-two parents or patients answered the question-
naire. Two patients had had the button removed at the time of
this survey.They keptthe cecostomy device, respectively, for
2.5 years and 11 months until they recovered good
continence because of an efficient physiotherapy with
A mean of 4 weekly enemas was enough to improve fecal
continence troubles (range, 1 daily to 1 for 2 weeks). The
time required for the irrigation of the bowel by gravity was
bottle was hung 1.2 m above the toilet seat (range, 50-
enemas. Time spent in the toilets was 50 minutes (range, 10-
90 minutes). A total of 19 patients preferred to do the enema
in the evening, whereas 3 preferred to do it in the morning. A
diaper was required for the first hours after the enema in
12 patients. Most patients preferred wearing diapers during
the first night after the enema, fearing any leakage.
Before surgery, 13 patients needed rectal enemas, 9 used
special medications to help the bowel movement; fourteen
patients needed a diaper, day and night, and 6 needed a
sanitary protection. Soiling was a significant inconvenience
for 19 patients.
After surgery, only 5 patients needed a diaper because of
average results or urinary incontinence and persistent soiling.
For these patients, the reason was urinary incontinence
(cloacal malformation, myelomeningocele, bladder exstro-
phy) or remaining stool leakage (cerebral palsy, 22q11).
Patients were asked to give an assessment (null = 0, bad =
1, fair = 2, good = 3, very good = 4). None of the patients felt
there had been no changes or a bad result; 5 felt they had a
fair result, 5 a good one, and 12 very good. The mean grade
was 3.44 (17.2/20).
Five patients thought the surgical procedure was painful.
Six patients needed to change the button for various reasons
Button in place.
Button in place, as it appears on the parietal wall.
parietal wall and straight into the bowel under laparoscopic control.
The needle, covered by the button, is pushed through the
1855Cecostomy button for antegrade enemas
(the button was dislodged in 3 cases, broken in 1 case, dirty
in 2 cases), although it was easy to change. The patients that
underwent enema through the button were satisfied. The
technique is straightforward and can be done by the patients
themselves. Three patients had hypertrophic granulation
tissue formation around the cecostomy button. Topical
silver nitrate therapy provided good results. A total of
10 patients had no leakage at all around the button, 12 had
minor tiny leakage.
There were 7patients whofelt that thebutton wasnot very
esthetic, and 3 especially so in the swimming pool. However,
12 patients considered this button completely satisfying. It
allowed them to wash themselves easily (22 cases), go to the
swimming pool (19 cases), and practice any sport (18 cases).
3.1. Surgical technique
In 1990, Malone et al  reported their first ingenious
experience on antegrade continence enema through appen-
dicostomy. Many complications were described. Most of
them were stroma troubles requiring a new surgery. Some
appendicostomies were difficult to catheterize.
That is why Shandling and Chait  proposed a new
method of performing cecostomy for antegrade enema in
1996. They performed a percutaneous cecostomy under
fluoroscopy with local anesthesia. They offered  a new
device (the Trap-door button according to Chait, manufac-
tured by Cook Medical) that avoided catheterization of any
channel and offered the advantages of a continent stomy.
Rivera et al  reported a new approach in 2001 with
percutaneous colonoscopic cecostomy. Yagmurlu et al 
reported the first series of laparoscopic cecostomy button
placement in the pediatric age group in 2006.
Our first experience began in same way as Georgeson, by
a laparoscopic approach . We added in our first 3 cases a
colonoscopy to have good control of the button placement in
the bowel. However, we felt that it was not essential and
lengthened the procedure. That is why we no longer used
colonoscopy during this surgery. We simplified the original
technique proposed by the Cook set, hence avoiding the
insertion of a needle, a guide wire, and dilators. We simply
use the button, which can be rigidified by a long needle
available in the Cook set.
Incontinence and encopresis are not socially acceptable.
Most of our patients with main fecal continence disorders do
not want to be treated with diets and rectal enemas any more.
Although they try hard to live with their disability and avoid
being mocked at school and told offby their parents, they can
never be clean and often depress without trying something
efficient. Some of the patients with anorectal malformations
have moderate bad results in terms of fecal continence, but
because it is unpleasant, they refuse to have an intensive
physiotherapy of the anal sphincter. Rectal enemas are
degrading when the patient is older. That is why the button
according to Chait is a very good alternative. It avoids a
major surgery with risks of redo.
Granulation tissue and minor or tiny leakage along the
button are considered as minor and acceptable complications
by the patients and their parents. To improve these issues, the
enema must be done slowly to avoid leakage and to regularly
avoid new fecal impactions; by doing this, there is no
complication. Furthermore, these transitory complications
never require a new surgery.
Two patients had had the button removed at the time of
this survey. The buttons were removed in the clinic without
any pain. There is no fistula. The stomy closed sponta-
neously in less than 48 hours under a dry dressing. These
2 patients kept the cecostomy device, respectively, for
2.5 years and 11 months until they recovered good conti-
nence. With the cecostomy button, they felt secure and did
not soil; they could compare this method with their
previous rectal enemas, which were tedious and depriving.
They could also achieve a good result with sphincter
physiotherapy and become confident of their own abilities
to be continent, thus avoiding discourteous remarks from
their family and schoolmates.
it needs to be evaluated among the patients and their parents.
Indications for antegrade enema
Intractable fecal incontinence
Constipation with encopresis
Intractable fecal incontinence (details)
Caudal regression syndrome
Anorectal malformation + bladder exstrophy
Hirschsprung disease + encephalopathy
Constipation and encopresis
Acquired megarectum + psychocial disorders
1856F. Becmeur et al.
Taking care of disabled children often leads to repeated
surgical attempts to improve comfort and lifestyle. Develop-
ing minimally invasive procedures  and using new devices
possible. Appendix can be kept aside to ensure, if required, a
continent vesicostomy according to Mitrofanoff. In agree-
ment with the minimally invasive technique and if there is no
available appendix, cecostomy button could be used
associated with a vesicostomy button to provide a continent
urinary stoma .
Thisseriesabout 29patients witha Trap-doorcecostomy is
too short to be compared with Malone antegrade continence
enema (MACE) results. Nevertheless, complications that
occurred with cecostomy button placement and use are
considered as minor complications because their management
did not require surgery and were easy to treat. The MACE
issues and complications are well known: traumatic catheter-
ization and false passage, rare extravasation with peritonitis
requiring immediate laparotomy , stoma stenosis requiring
operative revision, and fecal leakage [10,11].
The aim of this study was to present technical details for
cecostomy button placement and primary results of this
procedure for antegrade enema. This procedure could be an
alternative for surgeons not confident with continent
catheterizable stomas surgery. Next studies with longer
survey and more patients will answer the question: Which
technique is better for handicapped patients, minimal
invasive procedure such as Trap-door button placement as
described in this study or MACE procedure? We can already
state that indications will be complementary with advantages
of this new technique for patients who do not want any more
surgery, for those who had had previous appendectomy, for
those with associated vesicostomy, or in case of temporary
indications for antegrade enemas.
Patients in this series are satisfied; it is essential that these
results should be compared with those of other treatments in
order for the patient to have the best treatment option. New
studies must be done comparing the quality of life with a
cecostomy button vs a stomy according to Malone.
 Yagmurlu A, Harmon CM, Georgeson KE. Laparoscopic cecostomy
button placement for the management of fecal incontinence in children
with Hirschsprung's disease and anorectal anomalies. Surg Endosc
 Chait PG, Shandling B, Richards HF. The cecostomy button. J Pediatr
 Georgeson KE. Laparoscopic fundoplication and gastrostomy. Semin
Lap Surg 1998;5:25-30.
 Malone PS, Ransley PG, Kiely EM. Preliminary report: the antegrade
continent enema. Lancet 1990;336:1217-8.
 Shandling B, Chait PG, Richards HF. Percutaneous cecostomy: a new
technique in the management of fecal incontinence. J Pediatr Surg
 Rivera MT, Kugathasan S, Berger W, et al. Percutaneous colonoscopic
cecostomy for management of chronic constipation in children.
Gastrointest Endosc 2001;53:1-5.
 Lorenzo AJ, Chait PG, Wallis MC, et al. Minimally invasive approach
for treatment of urinary and fecal incontinence in selected patients with
spina bifida. Urol 2007;70:568-71.
 Hitchcock RJ, Sadiq MJ. Button vesicostomy: a continent urinary
stoma. J Pediatr Urol 2007;3:104-8.
 Defoor W, Minevich E, Reddy P, et al. Perforation of Malone
antegrade continence enema: diagnosis and management. J Urol 2005;
174(4 Pt 2):1644-6.
 Mattix KD, Novotny NM, Shelley AA, et al. Malone antegrade
continence enema (MACE) for fecal incontinence in imperforate anus
improves quality of life. Pediatr Surg Int 2007;23:1175-7.
 Castellan MA, Gosalbez R, Labbie A, et al. Outcomes of continent
catheterizable stomas for urinary and fecal incontinence: comparison
among different tissue options. BJU Int 2005;95:1053-7.
1857Cecostomy button for antegrade enemas