APPENDICEAL VERSUS ILEAL SEGMENT FOR ANTEGRADECONTINENCE ENEMA
LESLIE D. TACKETT, EUGENE MINEVICH, JOHN F. BENEDICT, JEFFREY WACKSMAN ANDCURTIS A. SHELDON
From the Childrens Hospital Medical Center, Cincinnati, Ohio
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.115 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.1624 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. Hirschsprungs 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 (3.825.8)Mean followup (range mos.) 26.3 (465)No. diagnosis:
Myelomeningocele 29Imperforate anus 7VATER (vertebral defect, imperforateanus, tracheoesophageal fistula, radial,renal dysplasia) Association
Cloacal anomaly 3Spinal cord injury 1Severe constipation of uncertain etiology 2
0022-5347/02/1672-0683/0THE JOURNAL OF UROLOGY Vol. 167, 683686, February 2002Copyright 2002 by AMERICAN UROLOGICAL ASSOCIATION, INC. Printed in U.S.A.
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 Fishers ex-act test.
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 (p0.05), 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 feca