APPENDICEAL VERSUS ILEAL SEGMENT FOR ANTEGRADECONTINENCE ENEMA

LESLIE D. TACKETT, EUGENE MINEVICH, JOHN F. BENEDICT, JEFFREY WACKSMAN AND

CURTIS A. SHELDONFrom the Children’s Hospital Medical Center, Cincinnati, Ohio

ABSTRACT

Purpose: To assess outcomes after the antegrade continence enema procedure, we present ourresults with an ileal segment or the appendix in children with severe bowel dysfunction.

Materials and Methods: A retrospective review of 45 children who had undergone the creationof a continent cecostomy for severe chronic constipation and fecal incontinence was performed.

Results: The appendix was used to create the continent cecostomy in 28 patients (group 1) andileum 17 (group 2). Of 16 patients who underwent simultaneous construction of appendicealMitrofanoff neourethra, including continent catheterizable stoma, the appendix was split andused for the cecostomy and neourethra in 11. Overall, acceptable continence was achieved in 39(87%) patients and total continence 31 (69%). No significant difference was noted in the rate ofcontinence between groups 1 and 2. Nonstomal postoperative complications occurred in 5 pa-tients in group 1 and 3 group 2. Complications that required reoperation related to the continentcecostomy occurred in 10 patients, including stomal stenosis in 8, with 6 group 1 and 2 group 2(p �0.05), and stricture in 2, with 1 group 1 and 1 group 2. There were 2 patients who hadpreviously undergone colostomy for intractable constipation who were undiverted at the time ofthe creation of continent cecostomy. Both were continent postoperatively. There were 3 patients,including those 2 who presented with chronic severe constipation of unclear etiology, whounderwent colostomy for unrecoverable colonic dys-motility, of whom 1 subsequently requiredtotal colectomy.

Conclusions: The creation of a continent cecostomy for antegrade continence enema is asuccessful management option in children with debilitating fecal incontinence, and may enableundiversion of an existing colostomy. The appendix and ileal segment are viable options for theprocedure, with no significant difference noted in continence or complication rates.

KEY WORDS: enema, cecostomy, appendix, ileum

Severe bowel dysfunction often accompanies significanturological disease in the pediatric population. When refrac-tory fecal incontinence persists despite treatment with di-etary modification, timed toileting, cathartics, bulkingagents and enema programs, management with the ante-grade continence enema performed through a continent ce-costomy is a viable option. With this technique, several seriesshow continence rates from 60% to 94%, and excellent pa-tient and parental satisfaction.1–15 The appendix is mostcommonly used for creating the continent cecostomy. How-ever, when the appendix is absent or insufficient, severaloptions are available for the continent cecostomy, includingthe cecal flap, percutanous or open cecostomy tube place-ment, use of a cecostomy button, or segment of small bowelmay be tapered or reconfigured with the Monti procedure andimplanted into the cecum.16–24 In addition, when the appen-dix is required for another concomitant reconstructive en-deavor, such as the creation of a continent catheterizableurinary stoma, including the Mitrofanoff neourethra, a splitappendix technique may be used with cecal extension using astapling device, as we have reported previously.25 In thisstudy we present our continuing results, including long-termfollowup of our previous series, with an ileal segment or theappendix, including the technique of extension cecoplication,for the creation of an antegrade continence enema conduit inchildren with severe bowel dysfunction.

MATERIALS AND METHODS

From 1995 to 1999, 45 patients underwent the creation ofa continent cecostomy for management of refractory fecalincontinence after conventional therapy failed. Patient demo-graphics are shown in table 1. Hirschsprung’s disease wasexcluded with biopsy in the 2 children with severe constipa-tion of uncertain etiology. There are 2 children in our studywho have undergone renal transplantation for end stagerenal disease.

Continent cecostomy was performed as an isolated procedurein 10 patients. Of these patients 6 underwent preliminaryintraoperative diagnostic laparoscopy to localize the appen-dix. The remaining 35 patients underwent additional recon-structive procedures, including the creation of a Mitrofanoffneourethra in 25, augmentation cystoplasty 16, bladder neck

Accepted for publication August 31, 2001.

TABLE 1. Patient demographics

No. males 23No. females 22Mean pt. age at surgery (range yrs.) 10.5 (3.8–25.8)Mean followup (range mos.) 26.3 (4–65)No. diagnosis:

Myelomeningocele 29Imperforate anus 7VATER (vertebral defect, imperforateanus, tracheoesophageal fistula, radial,renal dysplasia) Association

3

Cloacal anomaly 3Spinal cord injury 1Severe constipation of uncertain etiology 2

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reconstruction 21, ureteral reimplantation 16, orchiopexy 1,colostomy takedown 2, transureteral ureterostomy 1, vaginalpull-through 1, excision of prolapsed rectal mucosa 1, analdilatation 1 and endoscopy 3.

The appendix was used to create the continent cecostomyin 28 patients (group 1), and ileum 17 (group 2), includingtapered ileum 16, and the Monti procedure 1. The creation ofthe continent cecostomy with the appendix was performed asdescribed previously.23, 25 Of 16 patients who underwent con-struction of appendiceal Mitrofanoff neourethra the appendixwas split, and the split appendix technique25 was used tocreate the cecostomy and neourethra in 11, in whom 8 weremade possible by extension cecoplication. Extension cecopli-cation also allowed the use of an appendix with otherwiseinsufficient luminal length for continent cecostomy in 3 pa-tients.

When the use of a nonappendiceal conduit was required, asegment of ileum was isolated and reconfigured by taperingover a 12Fr catheter or with the Monti procedure as de-scribed previously,24 and then implanted into an anteriortaenia in the cecum. The stoma was placed in the right lowerquadrant in all patients except 1 with intestinal malrotation,in whom the stoma was placed in the left lower quadrant and1 at the umbilicus. In all patients a U-flap technique wasused to create the skin stoma. Postoperatively the cecostomywas left intubated with a 10 or 12Fr silicone Foley catheterfor 3 to 6 weeks. Irrigation via the cecostomy was startedafter ileus resolved, and the irrigation program was adjustedin regard to volume and frequency according to clinical re-sponse. Statistical analysis was performed with Fisher’s ex-act test.

RESULTS

Early postoperative complications unrelated to the stomaoccurred in only 2 patients in group 2, including woundinfection 1 and small bowel obstruction 1, and 5 in group 1 (p�0.05), including pseudomembranous colitis 2, wound infec-tion 2 and small bowel obstruction due to an internal hernia1. Late nonconduit complications occurred in 2 patients. Onepatient underwent an emergent total colectomy due to co-lonic vascular congestion. This patient had a history of cloa-cal anomaly, and imperforate anus with persisting anal ste-nosis and presented with severe constipation causing lowerextremity vascular compromise. In 36 hours of admission tothe hospital peritoneal signs developed in the patient whothen underwent exploratory laparotomy, which revealed co-lonic ischemia and necrosis. The other patient had fixedbowel loops on serial abdominal radiographs for evaluation ofileus. She was taken to the operating room for explorationand underwent a diverting ileostomy due to bowel perfora-tion.

Followup ranged from 3 to 55 months (mean 24.3). Overall,acceptable continence, including occasional mild soiling, wasachieved in 39 (87%) patients, with total continence in 31(69%). Excluding the children from study who underwentcolostomy or ileostomy and were therefore, not using thececostomy for continence, the functional continence rate in-creased to 97% acceptable and 77% total. No significant dif-

ference was noted in the rate of continence between groups 1(68% total, 86% acceptable) and 2 (71% total, 88% acceptable,table 2). There were 2 patients who had previously under-gone colostomy for intractable constipation who were undi-verted at the time of the creation of continent cecostomy, andboth were continent postoperatively.

Stomal complication rates are shown in table 2. Complica-tions that required reoperation related to the continent ce-costomy occurred in 10 patients, including stomal stenosis in8, with 6 group 1 and 2 group 2, (p �0.05), and stricture in 2,with 1 group 1 and 1 group 2 (p �0.05). Stomal stenosisoccurred from 1 month to 3 years after the initial procedure(mean 1 year, median 5 months). There were 2 patients whorequired repeat revision due to recurrent stenosis. One pa-tient in group 2 presented with a stricture that was dilated,and an indwelling catheter was left in the cecostomy. Thepatient subsequently presented after the Foley catheter hadbeen traumatically removed, with balloon intact and leakagefrom the cecostomy. Attempts to control the leakage with abutton appliance failed, and the patient required completetakedown and recreation of the continent cecostomy. Thispatient was totally continent.

Difficulty with catheterization occurred in 7 patients, ofwhom 3 in group 1 and 1 group 2 were treated with anindwelling Foley catheter for a traumatic false passage andhad no further problems. The other 2 patients with ilealconduits and 1 appendiceal conduit were treated by changingto a catheter coude tip with good results.

There were 5 patients who required fecal diversion afterthe creation of continent cecostomy (see Appendix). Of thesediversions 2 were temporary. Then 3 (7%) patients, includingthose 2 with severe constipation of uncertain etiology, under-went colostomy for unrecoverable colonic dys-motility, ofwhom 1 subsequently required total colectomy.

DISCUSSION

The role of antegrade continence enema for management ofrefractory fecal incontinence has been demonstrated in sev-eral series. Our overall success rate for total (69%) and ac-ceptable (87%) continence after the procedure is consistentwith the literature, and we have demonstrated the potentialof this procedure to allow undiversion in children with severerecto-genitourinary anomaly. We found no difference be-tween the 2 groups in regard to the success of the antegradecontinence enema procedure. Of the 3 patients who under-went colostomy due to unrecoverable colonic dys-motility 2had presented with severe constipation of uncertain etiology.Although this subgroup of patients is small in our series,others have suggested limited success in this population.When the 5 children who have undergone ileostomy or colos-tomy are excluded from our study the success rate increasesto 97% acceptable and 77% total continence.

From a technical standpoint, if the appendix is availableand sufficient the antegrade continence enema procedure ispreferred, as it does not require the added morbidity or timerequired for bowel anastomosis. In our study postoperativesmall bowel obstruction occurred in 1 patient in each group.Although the patient in group 2 underwent only a creation of

TABLE 2. Success rates and stomal complications

Group 1 Group 2 Overall Functional*

No. 28 17 45 40No. continence (%):

Acceptable 24 (86) 15 (88) 39 (87) 39 (97)Total 19 (68) 12 (71) 31 (69) 31 (77)

No. stomal complications (%):Stenosis 6 (21) 2 (12) 8 (18)Difficult catheterization 4 (14) 3 (18) 7 (15)Stricture 1 (2) 1 (2) 2 (4)

* Excludes patients who underwent fecal diversion after the creation of a continent cecostomy.

APPENDICEAL VERSUS ILEAL SEGMENT FOR ANTEGRADE CONTINENCE ENEMA684

the continent cecostomy without continent urinary recon-struction, he had undergone multiple prior intra-abdominalsurgeries. The patient in group 1 underwent a concomitantcreation of an appendiceal Mitrofanoff, and the small bowelobstruction was due to an internal hernia.

In many patients the creation of the continent cecostomywas performed in conjunction with other reconstructive pro-cedures, including augmentation cystoplasty. In several ofthese patients the ileum was used for bladder augmentationand continent cecostomy, and only a single bowel anastomo-sis was required. Although 1 advantage of the Monti tech-nique for the creation of the conduit is the short segment ofileum required (approximately 2.5 cm.) in comparison to thetapering procedure, we have not encountered the short bowelsyndrome in any patients. Overall, the most common compli-cation reported is stomal stenosis, occurring in up to 30% ofpatients in some series, and thought to occur more frequentlywith the appendix due to the frail blood supply.

Despite treatment with conservative measures, includingdilatation followed by the use of an indwelling catheter for 2to 4 weeks and/or increasing the frequency of catheterizationup to 3 times daily without increasing the frequency of irri-gation, we noted stomal stenosis requiring surgical revisionin 18% of our patients overall. The majority of patients hadappendiceal cecostomy. However, because of the small num-ber of patients, this result did not represent a statisticallysignificant difference between the 2 groups (21% versus12%). The use of ileum for the creation of the cecostomy,especially with the tapering technique, has been associatedwith increased difficulty in catheterization.2 This effect hasnot been our experience. Of our 7 patients in whom catheter-ization was difficult 4 (14%) were from group 1 and 3 (18%)group 2. These patients were easily treated by changing to acoude tip and temporary indwelling Foley catheter for 2 to 3weeks for a traumatic false passage.

CONCLUSIONS

The creation of a continent cecostomy for antegrade conti-nence enema is a successful management option in childrenwith debilitating fecal incontinence and may enable undiver-sion of an existing colostomy. The appendix and ileal segmentare viable options for the creation of the continent cecostomy,with no significant difference noted in continence or compli-cation rates. Extension cecoplication facilitates the use of asplit appendix technique when a neourethra and continencececostomy are created.

APPENDIX: PATIENTS REQUIRING FECAL DIVERSION AFTERCONTINENT CECOSTOMY

PatientNo. Diagnosis Clinical History

1 Severe constipation 6-Year-old female. History ofdysfunctional voiding andchronic severe constipation.Botulinum toxin type A injec-tion failed with the creation ofcontinent cecostomy. Under-went diverting colostomy fol-lowed by total abdominal colec-tomy with an ileoanal pouchprocedure.

2 Severe constipation 8-Year-old female. History ofdysfunctional voiding and re-current obstipation. Botulinumtoxin type A injection failedwith creation of continent cecos-tomy. Three months later un-derwent diverting colostomydue to persistent fecal impac-tion.

3 Myelomeningocele 5-Year-old male. History ofchronic fecal impaction requir-ing hospitalization. Recurrentchronic impaction developedand the patient underwent anend-sigmoid colostomy 10months after continent cecos-tomy procedure.

4 Myelomeningocele 13-Year-old female. Failure tothrive after continent recon-struction. Had a fixed loop ofdilated small bowel on serialradiographs that indicated asmall bowel perforation with aloculated intra-abdominal ab-scess. Underwent temporarydiverting ileostomy 3 monthsafter initial procedure.

5 Cloacal anomaly 9-Year-old female. History ofpersistent anal stenosis andchronic constipation after pull-through procedure. Underwentcontinent cecostomy with ac-ceptable continence and occa-sional constipation. Six yearsafter initial procedure, admittedto hospital for treatment of se-vere constipation and signs ofan acute abdomen developed.At surgery the entire colon wasischemic with areas of necrosis,and subsequent pathologicalexamination showed only signsof venous congestion. Under-went total colectomy and ileos-tomy.

REFERENCES

1. Malone, P. S., Ransley, P. G. and Kiely, E. M.: Preliminary report:the antegrade continence enema. Lancet, 336: 1217, 1990

2. Squire, R., Kiely, E. M., Carr, B. et al: The clinical application ofthe Malone antegrade continence enema. J Pediatr Surg, 28:1012, 1993

3. Koyle, M. A., Kaji, D. M., Duque, M. et al: The Malone antegradecontinence enema for neurogenic and structural fecal inconti-nence and constipation. J Urol, 154: 759, 1995

4. Griffiths, D. M. and Malone, P. S.: The Malone antegrade conti-nence enema procedure. J Pediatr Surg, 30: 68, 1995

5. Ellsworth, P. I., Webb, H. W., Crump, J. M. et al: The Maloneantegrade colonic enema enhances the quality of life in chil-dren undergoing urological incontinence procedures. J Urol,155: 1416, 1996

6. Dick, A. C., McCallion, W. A., Brown, S. et al: Antegrade colonicenemas. Br J Surg, 83: 642, 1996

7. Levitt, M. A., Soffer, S. Z. and Pena, A.: Continent appendicos-tomy in the bowel management of fecally incontinent children.J Pediatr Surg, 32: 1630, 1997

8. Schell, S. R., Giles, J., Toogood, D. M. et al: Control of fecalincontinence: continued success with the Malone procedure.Surgery, 122: 626, 1997

9. Graf, J. L., Strear, C., Bratton, B. et al: The antegrade conti-nence enema procedure: a review of the literature. J PediatrSurg, 33: 1294, 1998

10. Driver, C. P., Barrow, C., Fishwick, J. et al: The Malone ante-grade continence enema procedure: outcome and lessons of 6years’ experience. Pediatr Surg Int, 13: 370, 1998

11. Hensle, T. W., Reiley, E. A. and Chang, D. T.: The Maloneantegrade continence enema procedure in the management ofpatients with spina bifida. J Am Coll Surg, 186: 669, 1998

12. Wilcox, D. T. and Kiely, E. M.: The Malone (antegrade conti-nence enema) procedure: early experience. J Pediatr Surg, 33:204, 1998

13. Curry, J. I., Osborne, A. and Malone, P. S.: How to achieve asuccessful Malone antegrade continence enema. J PediatrSurg, 33: 138, 1998

14. Curry, J. I., Osborne, A. and Malone, P. S.: The MACE procedure:experience in the United Kingdom. J Pediatr Surg, 34: 338, 1999

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15. Lynch, A. C., Beasley, S. W., Robertson, R. W. et al: Comparisonof results of laparoscopic and open antegrade continence en-ema procedures. Pediatr Surg Int, 15: 343, 1999

16. Kiely, E. M., Ade-Ajayi, N. and Wheeler, R. A.: Caecal flapconduit for antegrade continence enemas. Br J Surg, 81: 1215,1994

17. Chait, P. G., Shandling, B., Richards, H. M. et al: Fecal inconti-nence in children: treatment with percutaneous cecostomytube placement—a prospective study. Radiology, 203: 621,1997

18. Shandling, B., Chait, P. G. and Richards, H. F.: Percutaneouscecostomy: a new technique in the management of fecal incon-tinence. J Pediatr Surg, 31: 534, 1996

19. DePeppo, F., Iacobelli, B. D., De Gennaro, M. et al: Percutaneousendoscopic cecostomy for antegrade colonic irrigation in fecallyincontinent children. Endoscopy, 31: 501, 1999

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EDITORIAL COMMENT

The authors have not only compared different bowel segments forMACE construction, but also demonstrated 2 important issues re-lated to patient selection. Although the timeframe of analysis is

relatively short (4 years), these surgeons have reported equal suc-cess/complication rates regardless of whether the appendix or ta-pered ileum was used for the catheterizable stoma. The Monti-Yanghas been our preferred neo-appendix when the real one cannot beused. The simplicity and reliability of the Monti-Yang techniquehave been well demonstrated. However, as with any technique, it iswhichever one works best in one’s hands that should be used, givenno increase in morbidity.

The issues of patient selection are paramount if optimal results areto be achieved. Despite reporting on only 2 patients, the authors areto be commended for performing undiversion in both who initiallypresented with permanent colostomies. We agree that considerationshould be given to undiversion when the rationale for the colostomyis questionable and the family/patient understand the potentialrisks/benefits of reinstituting continuity of the gastrointestinal tract.Lastly, the authors show that we cannot reliably predict in whichpatients continent cecostomy will fail. All 5 patients who requiredsecondary fecal diversion suffered from severe constipation/impac-tion regardless of the primary diagnosis (dysfunctional elimination,spina bifida, cloacal anomaly).

In an effort to identify the potential success of a permanent Maloneantegrade continence enema, we have recently had our radiologistsor gastroenterologists percutaneously place a temporary cecostomycatheter in patients with a history of severe constipation and/or areactive external sphincter. This technique, in essence, is like usingtraining wheels on a bicycle. If the results using the catheter areacceptable, the patient is offered the opportunity to remain as isversus undergo conversion to a permanent stoma.

Martin A. KoyleDepartment of Pediatric UrologyThe Children’s Hospital and University of

Colorado School of MedicineDenver, Colorado

andPadraig S. J. MaloneWessex Centre for Paediatric SurgerySouthampton, United Kingdom

APPENDICEAL VERSUS ILEAL SEGMENT FOR ANTEGRADE CONTINENCE ENEMA686