Neoappendicostomy in the management of pediatric fecal incontinence
ABSTRACT The Malone appendicostomy, for antegrade enemas, has improved the quality of life for many children with fecal incontinence. In patients whose appendix has been removed, a neo-appendix can be created. We describe our approach and experience with this procedure as an option for surgeons managing children with fecal incontinence.
The procedure involves creating a transverse flap of cecum that receives its blood supply by a transverse mesenteric branch. This flap is then tubularized around a feeding tube. The surrounding colon is plicated around the neo-appendix to prevent leakage of stool. The tip of the flap is then anastomosed to the deepest portion of the umbilicus. We reviewed our experience with this procedure, including results and complications. IRB approval was obtained.
Eighty patients required a neo-appendicostomy. Sixty-six patients (82%) had an anorectal malformation, four had spina bifida, and ten had other diagnoses. The reasons for not having an appendix available included: "incidental" appendectomy (34, 42.5%), use of the appendix for a Mitrofanoff procedure (20, 25%), and Ladd's procedure (5, 6%). In fifteen patients (19%) we could find no appendix and assume that it was removed previously. Following neoappendicostomy, nine patients (11%) developed a stricture, and seven patients had leakage (9%). In 2004, we modified the appendiceal-umbilical anastomosis and among these patients, only one patient (3%) developed a stricture, compared with eight patients (18%) without the modification. All seven patients with leakage were within the first forty cases. No patient in the last forty cases had a leakage.
In patients with the potential for fecal incontinence, the appendix should be preserved. In patients without an appendix, the neo-appendicostomy is a valuable tool for fecally incontinent patients. We have found that the V-V anastomosis had a reduced rate of stricture, and the rate of leakage seems to be related to surgical experience.
SourceAvailable from: Giulia Brisighelli[Show abstract] [Hide abstract]
ABSTRACT: A common error in the initial operative management of patients with cloacal exstrophy is to create an ileostomy leaving the colon defunctionalized and connected to the urinary tract. These patients benefit from a "rescue operation" to give them the best opportunity to be future pull-through candidates. Nineteen patients were identified who underwent an inadequate diversion during the newborn period, leaving a distal defunctionalized colon, and required a "rescue operation". A retrospective review of the medical records of these patients was performed. A piece of colon was disconnected from the urinary tract, rescued from the pelvis, and incorporated into the fecal stream. The original stoma was closed, and an end colostomy was created. Fifteen patients were females and four were males. The length of rescued colon ranged from 5.5 to 20 cm. Symptoms present before the operation included: hyperchloremic acidosis (6), urinary tract infections (6), failure to thrive (5), sepsis (1), dehydration (1), and TPN dependent (1). There was resolution of these symptoms post-operatively. On follow up, 10 patients still have their colostomies as we are waiting for continued colonic growth, 6 patients had a pull-through after responding to our bowel management program through the stoma, 2 patients have a permanent stoma, and one patient expired. When patients with cloacal exstrophy, or its variants, receive an ileostomy or proximal colostomy at birth, a rescue operation should be attempted.Pediatric Surgery International 05/2014; 30(7). DOI:10.1007/s00383-014-3512-z · 1.06 Impact Factor
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ABSTRACT: Purpose A major research gap is determining the best age to perform an appendicostomy or cecostomy. This study hypothesizes that performance of appendicostomy/cecostomy prior to starting school (<6 years) would improve functional stooling and quality of life (QOL). Methods Patients who underwent appendicostomy/cecostomy for bowel management between 2003 and 2013 were retrospectively identified. Families were prospectively surveyed regarding current stooling habits (17 items) and a (7 item) pediatric QOL survey. Lower stooling survey scores represent better bowel control. Higher QOL scores indicated better quality. The primary outcome was to correlate age of appendicostomy/cecostomy to QOL score. Statistics were performed using paired, unpaired t tests, and Chi-square. p Values ≤0.05 were considered significant. Results 35 patients underwent placement of appendicostomy/cecostomy. Fourteen (40 %) patients/families were prospectively contacted (<6, n = 6; >6, n = 8). Stooling scores (15.17 ± 1.35 vs. 22.25 ± 1.70; for <6 vs. >6 years old, p = 0.009) and continence scores (6.33 ± 1.45 vs. 11.13 ± 1.64; p = 0.06), at time of contacting families, were significantly better in those undergoing appendicostomy/cecostomy in the <6 group. Pre-procedure QOL scores for the two groups were similar (p = 0.89). Post-procedure QOL significantly increased to the good subcategory for both age groups; however improvement was significantly better in the <6 age group vs. ≥6 group: 6.33 ± 0.92 vs. 3.13 ± 0.91 points (p = 0.03). A secondary parent survey showed significantly more families wished an appendicostomy/cecostomy were done earlier in the >6 vs. <6 group (87.5 vs. 33 %; p = 0.04). Conclusion Early placement of cecostomy or appendicostomy as part of a bowel management program may contribute to improved QOL and functional stooling.Pediatric Surgery International 07/2014; 30(7). DOI:10.1007/s00383-014-3520-z · 1.06 Impact Factor
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ABSTRACT: Continent catheterizable channels have revolutionized reconstructive surgery to achieve both urinary and fecal continence. The Mitrofanoff and Malone antegrade continent catheterizable channels offer improved quality of life relative to permanent incontinent stomas. A frequently employed surgical option for creating a Mitrofanoff when an existing appendicocecostomy exists involves harvesting a separate piece of intestine. If however the Malone has preceded the creation of a Mitrofanoff, we describe a surgical technique that may avoid the need for a bowel harvest and resultant anastomosis. We report our series of patients utilizing a novel alternative strategy in the select clinical circumstance of an existing appendicocecostomy to expand the armamentarium of the urologic reconstructive surgeon.Journal of Pediatric Surgery 04/2014; 49(4):656-9. DOI:10.1016/j.jpedsurg.2013.12.021 · 1.31 Impact Factor