www.elsevier.com/locate/jpedsurg

Journal of Pediatric Surgery (2008) 43, 1853–1857

Cecostomy button for antegrade enemas: survey of29 patientsFrançois Becmeura,⁎, Martine Demarcheb, Isabelle Lacreusea, Francesco Molinaroa,Isabelle Kauffmanna, Raphael Mooga, Florence Donnars a, Julie Rebeuha

aDepartment of Paediatric Surgery, Hautepierre Hospital, 67098 Strasbourg, FrancebDepartment of Paediatric Surgery, Citadelle Hospital, 4000 Liège, Belgium

Received 10 December 2007; revised 13 March 2008; accepted 13 March 2008

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Key words:Button cecostomy;Percutaneous cecostomy;Fecal incontinence;Constipation;Encopresis

Key words:Button cecostomy;Percutaneous cecostomy;Fecal incontinence;Constipation;Encopresis

AbstractObjective: This study evaluated the Trap-door button use (CookMedical, Bloomington, IL) for antegradeenemas in children.Methods: Since 2002, patients with fecal incontinence or encopresis and constipation underwentpercutaneous cecostomy under laparoscopy using a button.Technical details are described. Age at surgery,operative time, hospital stay, diagnosis, indications for cecostomy, and duration of follow-up wererecorded. A survey was proposed via a questionnaire that was sent to the patients. Patients wearing thebutton for less than 1 month were excluded from this evaluation.The survey concerned volume andfrequency of enemas, difficulties encountered, benefits and disadvantages of this method, and assessmentof the antegrade enemas in continence.Results: Twenty-nine patients, 18 males and 11 females, aged 3 to 21 years (mean, 8.5 years) underwentlaparoscopic Trap-door button placement. The indications for all the patients were intractable fecalincontinence in 24 cases and constipation with encopresis in 5 cases. Incontinence was because ofmyelomeningocele (n = 10), anorectal malformations (n = 11), caudal regression syndrome (n = 1), 22q11syndrome (n= 1), and Hirschsprung disease with encephalopathy with convulsions (n = 1). Constipationwith encopresis was because of sacrococcygeal teratoma (n = 1), cerebral palsy (n = 1), and acquiredmegarectum with psychiatric and social disorders (n = 3). A total of 26 cecostomy button placements and3 sigmoidostomy button placements were successful with no intraoperative complication. The meanoperative time was 25minutes (10-40 minutes), and the hospital stay was 2.5 days (1-4 days). Twenty-twoparents or patients answered the questionnaire. At the time of this survey, 2 patients had improved theirfecal continence and had had the button removed. A mean of 4 weekly enemas was enough to improvefecal continence troubles (range, 1 daily to 1 for 2 weeks). The volume for enemas was 250 to 1000 mL(mean, 700 mL). The time required for the irrigation of the bowel by gravity took from 5 to 60 minutes(mean, 25 minutes) for 20 patients. Before surgery, 14 patients needed a diaper, day and night, and 6needed sanitary protection. Soiling was a very significant inconvenience for all the patients. After surgery,only 5 patients needed a diaper (cerebral palsy, 22q11, cloacal malformation, myelomeningocele, bladderexstrophy) because of moderate results or urinary incontinence and continued soiling. Patients were askedto give an assessment (null = 0, bad = 1, fair = 2, good = 3, very good = 4). None of the patients felt therehad been no changes or a bad result. There were 5 patients who felt they had an average result, 5 a good

⁎ Corresponding author.E-mail address: francois.becmeur@chru-strasbourg.fr (F. Becmeur).

022-3468/$ – see front matter © 2008 Published by Elsevier Inc.oi:10.1016/j.jpedsurg.2008.03.043

1854 F. Becmeur et al.

result, and 12 a very good result. Themean gradewas 3.44 (17.2/20). A total of 3 patients had hypertrophicgranulation tissue formation around the cecostomy button, and 12 had tiny leakage.Conclusion: Percutaneous placement of a cecostomy button under laparoscopic control is an easy andmajor complication-free procedure. The use of the Trap-door device by the patients or with the help of theparents for antegrade enemas is effective and satisfactory. It improves the quality of life and is reversible.© 2008 Published by Elsevier Inc.

Antegrade enemas in patients with fecal incontinence orencopresis with constipation have proven successful andallow the patient to be independent [1].

We report our own series on laparoscopic cecostomy orsigmoidostomy for antegrade enemas and a survey concern-ing the use of the Trap-door button according to Chait et al[2] by questioning patients and their parents.

1. Material and methods

1.1. Surgical technique

Two departments of pediatric surgery proposed the sametechnique for cecostomy button placement and use of thisdevice for management of fecal incontinence and encopresiswith constipation. Preparation of the patients was simple.The preparation included 1 or 2 enemas with serum saline(500 mL to 1 L) the day before surgery. A single-doseintravenous metronidazole was administered at the begin-ning of the procedure. Surgery was done under generalanesthesia. An open laparoscopy was performed with a5-mm 0° telescope through the umbilicus, and an additionaloperative trocar was placed in the left lower quadrant forcecostomy and in the right lower quadrant for sigmoidos-tomy. An 8–mmHg carbon dioxide pressure insufflation wasused. Laparoscopy allowed the selection of the site forcecostomy or sigmoidostomy by looking at the place wherethe cecum or the sigmoid colon could be hung: on to theanterior abdominal wall, thus avoiding placing it too close tothe iliac crest. Two U-stitches according to the Georgeson [3]procedure for gastrostomy were used to secure the bowel tothe abdominal wall. A long needle was inserted into the ChaitTrap-door button (Cook). A no. 11 blade was passed throughthe abdominal wall to prepare the entry of the button. Theneedle, covered by the button, was pushed through theparietal wall and straight into the bowel under laparoscopiccontrol (Figs. 1-5).

Fig. 1 The device and the needle.

1.2. Postoperative care

The U-stitches were removed 1 week after surgery, and thefirst enemas were done with a nurse in our institution so thattechnical details and different tricks about the care of thebutton and the skin around the cecostomy could be explained.

1.3. Evaluation

Age at surgery, operative time, hospital stay, diag-nosis, indications for cecostomy, and duration of follow-upwere recorded.

A survey was proposed via a questionnaire, which wassent to the patients. Patients wearing the button for less than1 month were excluded from this evaluation. The surveyconcerned volume and frequency of enemas, difficultiesencountered, benefits and disadvantages of this method, andassessment of the antegrade enemas in continence.

2. Results

Twenty-nine patients, 18 males and 11 females, aged 3 to21 years (mean, 8.5 years) underwent laparoscopic Trap-door button placement.

The indication for all the patients was intractable fecalincontinence in 24 cases and constipation with encopresis in5 cases (Table 1).

Fecal incontinence was due to myelomeningocele (n =10), anorectal malformations (n = 5), anorectal malforma-tions with a Currarino triad (n = 2), a cloacal malformation(n = 3), anorectal malformation with bladder exstrophy (n = 1),caudal regression syndrome (n = 1), 22q11 syndrome (n = 1),and Hirschsprung disease with encephalopathy with convul-sions (n = 1) (Table 2).

Fig. 2 Introducing the needle into the Trap-door button.

Fig. 5 Button in place, as it appears on the parietal wall.

Fig. 3 The needle, covered by the button, is pushed through theparietal wall and straight into the bowel under laparoscopic control.

1855Cecostomy button for antegrade enemas

Constipation with encopresis was responsible for thefoul smelling liquid stools in the children's underwearsecondary to fecal impaction owing to constipation. Con-stipation with encopresis was due to sacrococcygeal teratoma(SCT) (n = 1), cerebral palsy (n = 1), and acquiredmegarectum with psychiatric and social disorders (n = 3).Laxative medications, repeated and frequent enemas,biofeedback attempts after anorectal manometry, andpsychological support failed during periods longer than1 year (Table 3).

A total of 26 cecostomy button placements and 3sigmoidostomy button placements were successful with nointraoperative complication. The mean operative time was25 minutes (10-40 minutes), and the hospital stay was2.5 days (1-4 days). The patient with SCT had fecalimpaction in an acquired megarectum. The most importantpart of her problem was not incontinence but encopresis,which is why a sigmoidostomy was decided. The othersigmoidostomy was indicated in a boy who was operated

Fig. 4 Button in place.

previously for a high anorectal malformation. He developedan isolated megarectum.

Twenty-two parents or patients answered the question-naire. Two patients had had the button removed at the time ofthis survey. They kept the cecostomy device, respectively, for2.5 years and 11 months until they recovered goodcontinence because of an efficient physiotherapy withanorectal biofeedback.

A mean of 4 weekly enemas was enough to improve fecalcontinence troubles (range, 1 daily to 1 for 2 weeks). Thevolume for enemas was 250 to 1000mL (mean, 700mL). Thetime required for the irrigation of the bowel by gravity was5 to 60minutes (mean, 25minutes) for 20 patients. The serumbottle was hung 1.2 m above the toilet seat (range, 50-180 cm). However, 2 patients used a syringe for the antegradeenemas. Time spent in the toilets was 50 minutes (range, 10-90 minutes). A total of 19 patients preferred to do the enemain the evening, whereas 3 preferred to do it in the morning. Adiaper was required for the first hours after the enema in12 patients. Most patients preferred wearing diapers duringthe first night after the enema, fearing any leakage.

Before surgery, 13 patients needed rectal enemas, 9 usedspecial medications to help the bowel movement; fourteenpatients needed a diaper, day and night, and 6 needed asanitary protection. Soiling was a significant inconveniencefor 19 patients.

After surgery, only 5 patients needed a diaper because ofaverage results or urinary incontinence and persistent soiling.For these patients, the reason was urinary incontinence(cloacal malformation, myelomeningocele, bladder exstro-phy) or remaining stool leakage (cerebral palsy, 22q11).

Patients were asked to give an assessment (null = 0, bad =1, fair = 2, good = 3, very good = 4). None of the patients feltthere had been no changes or a bad result; 5 felt they had afair result, 5 a good one, and 12 very good. The mean gradewas 3.44 (17.2/20).

Five patients thought the surgical procedure was painful.Six patients needed to change the button for various reasons

Table 1 Indications for antegrade enema

Indication n

Intractable fecal incontinence 24Constipation with encopresis 5

Table 3 Constipation and encopresis

Indication n

SCT 1Cerebral palsy 1Acquired megarectum + psychocial disorders 3

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(the button was dislodged in 3 cases, broken in 1 case, dirtyin 2 cases), although it was easy to change. The patients thatunderwent enema through the button were satisfied. Thetechnique is straightforward and can be done by the patientsthemselves. Three patients had hypertrophic granulationtissue formation around the cecostomy button. Topicalsilver nitrate therapy provided good results. A total of10 patients had no leakage at all around the button, 12 hadminor tiny leakage.

There were 7 patients who felt that the button was not veryesthetic, and 3 especially so in the swimming pool. However,12 patients considered this button completely satisfying. Itallowed them to wash themselves easily (22 cases), go to theswimming pool (19 cases), and practice any sport (18 cases).

3. Discussion

3.1. Surgical technique

In 1990, Malone et al [4] reported their first ingeniousexperience on antegrade continence enema through appen-dicostomy. Many complications were described. Most ofthem were stroma troubles requiring a new surgery. Someappendicostomies were difficult to catheterize.

That is why Shandling and Chait [5] proposed a newmethod of performing cecostomy for antegrade enema in1996. They performed a percutaneous cecostomy underfluoroscopy with local anesthesia. They offered [2] a newdevice (the Trap-door button according to Chait, manufac-tured by Cook Medical) that avoided catheterization of anychannel and offered the advantages of a continent stomy.

Rivera et al [6] reported a new approach in 2001 withpercutaneous colonoscopic cecostomy. Yagmurlu et al [1]reported the first series of laparoscopic cecostomy buttonplacement in the pediatric age group in 2006.

Table 2 Intractable fecal incontinence (details)

Indication n

Myelomeningocele 10Caudal regression syndrome 1Anorectal malformation 5Currarino triad 2Cloacal malformation 1Anorectal malformation + bladder exstrophy 1Hirschsprung disease + encephalopathy 122q11 syndrome 1

Our first experience began in same way as Georgeson, bya laparoscopic approach [1]. We added in our first 3 cases acolonoscopy to have good control of the button placement inthe bowel. However, we felt that it was not essential andlengthened the procedure. That is why we no longer usedcolonoscopy during this surgery. We simplified the originaltechnique proposed by the Cook set, hence avoiding theinsertion of a needle, a guide wire, and dilators. We simplyuse the button, which can be rigidified by a long needleavailable in the Cook set.

3.2. Comments

Incontinence and encopresis are not socially acceptable.Most of our patients with main fecal continence disorders donot want to be treated with diets and rectal enemas any more.Although they try hard to live with their disability and avoidbeing mocked at school and told off by their parents, they cannever be clean and often depress without trying somethingefficient. Some of the patients with anorectal malformationshave moderate bad results in terms of fecal continence, butbecause it is unpleasant, they refuse to have an intensivephysiotherapy of the anal sphincter. Rectal enemas aredegrading when the patient is older. That is why the buttonaccording to Chait is a very good alternative. It avoids amajor surgery with risks of redo.

Granulation tissue and minor or tiny leakage along thebutton are considered as minor and acceptable complicationsby the patients and their parents. To improve these issues, theenema must be done slowly to avoid leakage and to regularlyavoid new fecal impactions; by doing this, there is nocomplication. Furthermore, these transitory complicationsnever require a new surgery.

Two patients had had the button removed at the time ofthis survey. The buttons were removed in the clinic withoutany pain. There is no fistula. The stomy closed sponta-neously in less than 48 hours under a dry dressing. These2 patients kept the cecostomy device, respectively, for2.5 years and 11 months until they recovered good conti-nence. With the cecostomy button, they felt secure and didnot soil; they could compare this method with theirprevious rectal enemas, which were tedious and depriving.They could also achieve a good result with sphincterphysiotherapy and become confident of their own abilitiesto be continent, thus avoiding discourteous remarks fromtheir family and schoolmates.

The principle of the button cecostomy seems excellent, butit needs to be evaluated among the patients and their parents.

1857Cecostomy button for antegrade enemas

Taking care of disabled children often leads to repeatedsurgical attempts to improve comfort and lifestyle. Develop-ing minimally invasive procedures [7] and using new devicescan allow us to help in a much better way than was previouslypossible. Appendix can be kept aside to ensure, if required, acontinent vesicostomy according to Mitrofanoff. In agree-ment with the minimally invasive technique and if there is noavailable appendix, cecostomy button could be usedassociated with a vesicostomy button to provide a continenturinary stoma [8].

This series about 29 patients with a Trap-door cecostomy istoo short to be compared with Malone antegrade continenceenema (MACE) results. Nevertheless, complications thatoccurred with cecostomy button placement and use areconsidered as minor complications because their managementdid not require surgery and were easy to treat. The MACEissues and complications are well known: traumatic catheter-ization and false passage, rare extravasation with peritonitisrequiring immediate laparotomy [9], stoma stenosis requiringoperative revision, and fecal leakage [10,11].

The aim of this study was to present technical details forcecostomy button placement and primary results of thisprocedure for antegrade enema. This procedure could be analternative for surgeons not confident with continentcatheterizable stomas surgery. Next studies with longersurvey and more patients will answer the question: Whichtechnique is better for handicapped patients, minimalinvasive procedure such as Trap-door button placement asdescribed in this study or MACE procedure? We can alreadystate that indications will be complementary with advantagesof this new technique for patients who do not want any moresurgery, for those who had had previous appendectomy, forthose with associated vesicostomy, or in case of temporaryindications for antegrade enemas.

Patients in this series are satisfied; it is essential that theseresults should be compared with those of other treatments inorder for the patient to have the best treatment option. Newstudies must be done comparing the quality of life with acecostomy button vs a stomy according to Malone.

References

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[2] Chait PG, Shandling B, Richards HF. The cecostomy button. J PediatrSurg 1997;32:849-51.

[3] Georgeson KE. Laparoscopic fundoplication and gastrostomy. SeminLap Surg 1998;5:25-30.

[4] Malone PS, Ransley PG, Kiely EM. Preliminary report: the antegradecontinent enema. Lancet 1990;336:1217-8.

[5] Shandling B, Chait PG, Richards HF. Percutaneous cecostomy: a newtechnique in the management of fecal incontinence. J Pediatr Surg1996;31:534-7.

[6] Rivera MT, Kugathasan S, Berger W, et al. Percutaneous colonoscopiccecostomy for management of chronic constipation in children.Gastrointest Endosc 2001;53:1-5.

[7] Lorenzo AJ, Chait PG, Wallis MC, et al. Minimally invasive approachfor treatment of urinary and fecal incontinence in selected patients withspina bifida. Urol 2007;70:568-71.

[8] Hitchcock RJ, Sadiq MJ. Button vesicostomy: a continent urinarystoma. J Pediatr Urol 2007;3:104-8.

[9] Defoor W, Minevich E, Reddy P, et al. Perforation of Maloneantegrade continence enema: diagnosis and management. J Urol 2005;174(4 Pt 2):1644-6.

[10] Mattix KD, Novotny NM, Shelley AA, et al. Malone antegradecontinence enema (MACE) for fecal incontinence in imperforate anusimproves quality of life. Pediatr Surg Int 2007;23:1175-7.

[11] Castellan MA, Gosalbez R, Labbie A, et al. Outcomes of continentcatheterizable stomas for urinary and fecal incontinence: comparisonamong different tissue options. BJU Int 2005;95:1053-7.