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: 1.19). 03/2011; 21(5):455-9. DOI: 10.1089/lap.2010.0359
Source: PubMed

ABSTRACT 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.

  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Aim. The aim of this study is to evaluate postoperatively bowel symptoms of antegrade colon enema through appendicostomies in preschool children with anorectal malformation (ARM). Method. 164 children with ARM operated on with posterior sagittal anorectal plasty were included. The malformations were classified according to Krickenbeck classification. Seventeen children in preschool age had an appendicostomy. The bowel symptoms according to the Krickenbeck follow-up were analysed pre- and postoperatively. All complications were registered. A questionnaire on the use of the appendicostomy was answered. Results. The median age (range) at the time of the appendicostomy was 4 (1-6) years. The observation time was 5 (0.5-14) years. The main indications for appendicostomy were incontinence and noncompliance to rectal enemas. Postoperatively there was a significant decrease in soiling and constipation (P < 0.001). The total complication rate was 43% with infections (29%), stenosis (12%), and retrograde leakage (0). The median time required for giving enema in the appendicostomy was 45 minutes (range: 15-120) once a day varying from 2 times/week to 3 times/day. And: complications are less frequent than in older children. Conclusion. Appendicostomy in preschool children with ARM is a way to achieve fecal cleanness before school start. The infection rate was high, but other complications are less frequent than in older children.
    01/2013; 2013:297084. DOI:10.1155/2013/297084
  • [Show abstract] [Hide abstract]
    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.
    The Journal of urology 12/2011; 187(2):652-5. DOI:10.1016/j.juro.2011.10.017 · 3.75 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Abstract Purpose: The antegrade continence enema (ACE) is an option in the management of fecal incontinence and chronic constipation. We report our experience with a simple laparoscopic technique. Subjects and Methods: Data were collected on 16 children (8 boys) who underwent laparoscopic cecostomy for ACE. Success was defined as cessation of fecal soiling with no need for diapers. Results: Mean age at laparoscopic cecostomy was 11 years (range, 6-16 years). Mean follow-up after initial cecostomy was 22 months (range, 6-51 months). Diagnoses in 16 patients were functional constipation with soiling (n=14), incontinence after surgery for Hirschsprung's disease (n=1), and constipation secondary to mitochondrial disease (n=1). Seven had significant developmental or psychiatric problems. Three patients had primary placement of a trapdoor device (Chait); 13 had placement of a long tube, with later replacement by a skin-level device. We have evolved a laparoscopic-assisted percutaneous technique, using metallic anchor sutures on the cecum, and a dilator and peel-away sheath for introduction of the catheter. Complications occurred in 5 patients; 3 returned to the operating room: 1 for tube occlusion, 1 for suture granuloma, and 1 for a dislodged tube at 7 months postoperatively. One patient received intravenous antibiotics because of suspected peritonitis on the first postoperative day. One was re-admitted with abdominal pain. Five of 16 patients have failed therapy (four tubes removed and one tube in situ). Three have had only minor improvement. Eight have had successful ACE management, of whom 1 patient has had his tube removed after resolution of symptoms. Of 8 patients with no or minimal improvement with ACE, 5 have significant psychiatric problems. Conclusions: Laparoscopic-assisted percutaneous cecostomy has an excellent safety profile and patient comfort. The procedure is simple, secure, and reversible. Results were excellent in half of the patients. Associated psychiatric or behavioral problems may predict poor response to ACE.
    Journal of Laparoendoscopic & Advanced Surgical Techniques 01/2014; DOI:10.1089/lap.2013.0292 · 1.19 Impact Factor