Laparoscopic-Assisted Malone Appendicostomy in the Management of Fecal Incontinence in Children

Division of Pediatric Surgery, Department of Surgery, Colorectal Center for Children, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio 45229, USA.
Journal of Laparoendoscopic & Advanced Surgical Techniques (Impact Factor: 1.34). 03/2011; 21(5):455-9. DOI: 10.1089/lap.2010.0359
Source: PubMed


The antegrade continence enema procedure offers convenient enema administration for patients with fecal incontinence and can be performed by a minimally invasive approach that provides shorter hospital stay, less analgesia requirement, and better cosmesis. We present our experience using this approach for fecal incontinence patients and technical modifications to reduce complications.
Following successful management of fecal incontinence through bowel management using a daily rectal enema, 44 patients underwent a laparoscopic-assisted Malone appendicostomy procedure. We reviewed the diagnosis underlying the fecal incontinence, operative technique, duration of surgery, length of hospital stay, and postoperative complications.
The mean age at surgery was 8.6 ± 1.0 years. The diagnoses included anorectal malformations (31), idiopathic constipation (6), Hirschsprung disease (3), and others (4). All the patients underwent a V-V umbilico-appendicoplasty. The cecum was plicated around the base of the appendix in 34 patients (77%); this step was omitted in 10 (23%). The median follow-up was 21 months (range: 3-51 months). Twelve complications were recorded in 9 patients (20.5%)--leakage from the stoma in 1 (2.3%), stomal stenosis in 5 (11.4%), and a combination of both in 3 (6.8%)--with an overall stricture rate of 18.2% (8/44) and leakage rate of 9.1% (4/44). Strictures were managed with minor operative revision. Plicating the cecum was associated with a lower leakage rate compared with the nonplicated group (0/34, 0% versus 4/10, 40%; P = .002). All patients were consistently clean between enemas following their antegrade continence enema procedure.
The umbilical appendicostomy provides a convenient and cosmetic location for enema administration. Cecal plication, which is feasible using a laparoscopic-assisted approach, significantly reduces the leakage rate. Stomal stenoses remains a problem, may be lessened by a V-to-V umbilical to appendix anastomosis, and are easily fixed with a revision.

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    • "Antegrade enema through an appendicostomy was introduced in the early 1990s as an alternative to the rectal enema [8]. The main indication, besides fecal incontinence, has been to increase the child's autonomy in children who already have a good compliance to rectal enemas [9] [10]. Problems with compliance in young children with incontinence have never been described as an indication for operation. "
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    ABSTRACT: The Malone antegrade continence enema procedure improves quality of life for patients with bowel dysfunction. Stomal leakage has been reported, although no objective scale describes this type of incontinence. The value of cecal imbrication has not been fully elucidated on a large scale. We retrospectively reviewed pediatric patients who underwent Malone antegrade continence enema by a single surgeon between 2000 and 2010. Detailed information regarding degree and frequency of stomal incontinence was longitudinally recorded and analyzed. A classification system was developed, with grade 0 defined as no stomal incontinence, grade 1 a drop at the stoma or spotting on clothes 1 time or less per month, grade 2 spotting on clothing 2 to 4 times per month and grade 3 any leakage greater than 4 times per month. The Malone antegrade continence enema procedure was laparoscopic nonimbricated in 51 patients, open nonimbricated in 16 and open imbricated in 12. Mean followup was 3.5 years. Of cases where the appendix was not imbricated stomal incontinence was grade 0 in 69%, grade 1 in 19%, grade 2 in 7.5% and grade 3 in 4.5%. Two patients (3%) requested revision due to stomal incontinence. No patient who underwent Malone antegrade continence enema with imbrication had stomal leakage (p = 0.001). We reviewed the spectrum of stomal incontinence following Malone antegrade continence enema in 75 patients and developed a new grading scale to help standardize this complication. Imbrication provided stomal continence in all patients. Without imbrication almost 90% had no stomal incontinence or grade 1 leakage after long-term followup.
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