British JoumalofSurgery 1994,81,1215

Short note

Caecal flap conduit for antegrade continence enemas E. M. KIELY, N . ADE-AJAYI and R . A . WHEELER Department of Surgery, The Hospitals for Sick Children, Great Onnond Street, London WCIN 3JH, UK Correspondence to: Mr E. M. Kiely Faecal incontinence may occur and persist despite surgical treatment of anorectal abnormalities, Hirschsprung’s disease and spina bifida The use of retrograde washouts to achieve cleanliness was reported by Shandling and Gilmour’. Malone et al.2 described the formation of a stoma with the appendix as conduit to enable antegrade colonic washouts to be performed using the principles of the Mitrofanoff channel3. This procedure frequently revolutionizes the lives of patients and their families4.

Some patients would benefit from antegrade washouts but have undergone appendicectomy. This paper describes the construction of a tubularized caecal flap as an alternative to the appendiceal stoma and reports on its use in six children.

Patients and methods The patients had intractable faecal incontinence and strong motivation, since the desire to be clean is critical to the success of the therapy.

One boy and four girls received the modified Malone procedure and one boy, who had. previously undergone right hemicolectomy, had a colonic flap fashioned distal to the ileocolic anastomosis. The mean age at the time of surgery was 7.6 years. Five patients had an anorectal abnormality and the sixth had sustained a perineal injury in a fall. The appendix had been removed previously in three children and in one patient had been used for a continent vesical (Mitrofanoff) conduit. The fifth child was awaiting this operation. One patient had undergone an unsatisfactory Malone procedure.

Paper accepted 14 December 1993

Tubularize

conduit

1 . .’

K - l Close caecal d e f k

Fig. 1 A laterally based caecal flap is raised, the resultant caecal defect closed and the flap tubularized

Preoperative preparation included purgation and prophylactic antibiotics. The caecum was mobilized and a laterally based 1 x 4 cm flap raised on a branch of the ileocolic artery. The caecal defect was closed with 5/0 polypropylene using interrupted extra- mucosal stitches (Fig. 1 ) and these were continued along the length of the flap to fashion a tube, which was brought out to the skin via a separate stab incision. Antegrade continence enemas were started with normal saline and phosphate about 10 days after operation. Individual regimens were developed with each child and parents for optimal results.

Results Follow-up ranged from 4 to 16 months. In four children there were no complications and the results of treatment were satisfactory with no soiling between washouts. One patient required stomal revision for stenosis; another was cleaner but stil l soiled occasionally and later developed stenosis requiring revision. Washouts were easier to give and soiling was no longer a problem.

Discussion Reflux through the stoma has not been a problem in patients who had a Malone procedure or in those with a caecal flap. Use of the appendix as a Malone stoma and in urinary reconstruction has led to calls for its preservation whenever possible5. Previous surgery and the relatively high incidence of malrotation in th is patient population make a preoperative contrast enema desirable. Urological experience suggests that there are several alternatives to the appendix as a conduif, including ileum, ureter, fallopian tube, skin tubes and the urethra. The caecal flap is a useful and safe option.

Acknowledgements The authors thank Rosa Phillips for the illustration.

References Shandling B, Gilmour RF. The enema continence catheter in spina bifida: successful bowel management. J Pediatr Surg 1987; 22: 271-3. Malone PS, Ransley FG, Kiely EM. Preliminary report: the antegrade continence enema. Lancet 1990; 3361217-18. Mitrofanoff P. Cystostomie continente trans-appendiculaire dam le traitement des vessies neurologiques. Chinugie Pediatrique

Squire R, Kiely EM, Carr B, Ransley PG, Duffy PG. The clinical application of the Malone antegrade colonic enema. J Pediatr

Wheeler R4, Malone PS. Use of the appendix in reconstructive surgery: a case against incidental appendicectomy. Br J Su*g

Woodhouse CR, Malone PR, Cumming J, Reilly TM. The Mitrofanoff principle for continent urinary diversion. Br J Urn/

1980; 21: 297-305.

Surg 1993;uI: 1012-15.

1991; 78 1283-5.

1989 63: 53-7.

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