Left colonic antegrade continence enema: experience gained from 19 cases

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<ul><li><p>neas</p><p>aDivision of Pediatric Surgery, DbDepartment of Urology, Yonsei</p><p>dure is an effective treatment modality in patients with</p><p>biofeedbacks. Until 1990, when Malone et al devised the</p><p>continence enema [MACE]), the progression of such con-</p><p>off procedure. Moreover, the failure rate of MACE increases</p><p>if the blood supply to the appendix is inadequate. Monti et al</p><p>modified the MACE procedure by using a retubularized ileal</p><p>segment, instead of the appendix, for the continence stoma</p><p>Index words:Left antegrade</p><p>continence enema;</p><p>Fecal incontinence;</p><p>Constipation;</p><p>Retubularized ileum;</p><p>Retubularized</p><p>sigmoid colon</p><p>Journal of Pediatric Surgery (2006) 41, 17501754* Corresponding author. Tel.: +82 2228 2116; fax: +82 313 8289.intractable constipation and fecal incontinence, including</p><p>meningomyelocele, high anorectal malformation, cloacal</p><p>anomaly, or traumatic spinal neuropathy [1-3]. These patients</p><p>generally have a history of failed medical management by</p><p>way of anorectal suppositories, conventional enemas, and</p><p>ditions was to persistent defecation problems or permanent</p><p>colostomy [2-4]. Yet MACE was not problem-free. The</p><p>MACE procedure is impossible in patients lacking an</p><p>appendix because of previous appendectomy or whose</p><p>appendix has been used for urinary conduit during Mitrofan-The colonic antegrade continence enema (ACE) proce- antegrade continence enema procedure (Malones antegrademalformations or any other condition predisposing to fecal incontinence or constipation intractable to</p><p>conventional treatment.</p><p>D 2006 Elsevier Inc. All rights reserved.0022-3468/$ see front matter D 2006</p><p>doi:10.1016/j.jpedsurg.2006.05.048</p><p>E-mail address: shchoi@yumc.yonseWon Han , Seung Hoon Choi</p><p>epartment of Surgery, Yonsei University College of Medicine, Seoul 120-752, South Korea</p><p>University College of Medicine, Seodaemun-gu, Seoul 120-752, South Korea</p><p>AbstractPurpose: As problems have developed with the right colonic antegrade continence enema procedure(Malones procedure/Montis retubularized ileocolostomy), left colonic antegrade continence enema</p><p>(LACE) procedure, in which retubularized ileum or sigmoid colon is anastomosed into the sigmoid colon,</p><p>has gained popularity. The aim of the study was to describe our experience with the LACE procedure.</p><p>Methods: We retrospectively reviewed 19 LACE procedures that were performed at the YonseiUniversity College of Medicine Hospital (Seoul, Korea) from March 2001 to March 2005.</p><p>Results: Male-to-female ratio was 11:8, with median age of 10 years (range, 3-34 years). Most commondiagnosis was meningomyelocele (78.9%, 15/19). The median total follow-up period was 23 months</p><p>(range, 3-37 months); median antegrade continence enema volume used was 600 mL (range, 250-</p><p>1500 mL); and median transit time was 30 minutes (range, 15-60 minutes). Patients performed antegrade</p><p>continence enema with an average of once every 2 days (range, 0.3-3 days). Social continence was</p><p>achieved in 14 patients (73.7%). Regurgitation of fecal material through stoma was not reported at all in</p><p>17 patients (89.5%).</p><p>Conclusions: We recommend LACE as the procedure of choice for children with congenitalLeft colonic antegrade contiexperience gained from 19 c</p><p>Seong Min Kima, Sang bElsevier Inc. All rights reserved.</p><p>i.ac.kr (S.H. Choi).nce enema:es</p><p>a,*</p><p>www.elsevier.com/locate/jpedsurg[5,6]. Still, however, there were complications. The right side</p></li><li><p>of the colon or cecum is inherently dilated in neuropathic</p><p>bowel disorders and so required larger ACE volumes or</p><p>longer ACE transit times. Patients or their caregivers</p><p>frequently complained of moderate to severe abdominal</p><p>pain or nausea during the ACE procedure [7].</p><p>Liloku et al [8] reported a left Monti-Malone procedure</p><p>to overcome the problems associated with MACE. Since</p><p>that report, other authors have reported good results [9,10].</p><p>In this article, we present the clinical consequences in 19</p><p>patients who underwent left colonic antegrade continence</p><p>enema (LACE) and an analysis of the treatment outcomes</p><p>and complications.</p><p>1. Materials and methods</p><p>Between March 1999 and March 2005, antegrade</p><p>continence enema (ACE) procedure was performed on</p><p>23 patients. Of these, Malones procedure was performed</p><p>on 4 patients, with their own appendices for cutaneous</p><p>stoma (appendicocutaneostomy), and the LACE procedure</p><p>was performed on 19 patients with retubularized segments</p><p>of ileum (ileal Montis tube) or sigmoid colon (left Monti-</p><p>Malone procedure) (Table 1). Our analysis here is of the</p><p>19 patients who received LACE procedure. All LACE</p><p>procedures were performed by the same pediatric surgeon</p><p>(SH Choi). Segments of ileum or sigmoid colon with a</p><p>length 2.5 to 3.0 cm were made with care to preserve their</p><p>vascular arcades, and the remaining bowel was anasto-</p><p>mosed in an end-to-end fashion (hand-sewn). A previously</p><p>made ring of bowel segments was opened along the</p><p>antimesenteric border using a Bovie coagulator (detubula-</p><p>rization) with the rectangular bowel flap plate wrapped</p><p>lengthwise around a 16F Foley catheter. The detubularized</p><p>bowel was retubularized with multiple interrupted absorb-</p><p>able sutures under the guidance of a 16F Foley catheter.</p><p>One end of the retubularized bowel was anastomosed to</p><p>the sigmoid colon and the other was exteriorized as a</p><p>cutaneous stoma into the umbilicus and anastomosed to an</p><p>umbilical stab incision. Witzel-type anti-refluxing sero-</p><p>muscular reinforcement was performed with several</p><p>sutures in the sigmoid colon. Antimesenteric border of a</p><p>20- to 30-cm segment of the ileum (for ileocystoplasty) or</p><p>sigmoid colon (sigmoidocystoplasty) was detubularized</p><p>with electrical cutting after meticulous povidone-iodine</p><p>irrigation. By sweeping with dry gauze, the mucosal layer</p><p>of the bowel segment was removed. This bowel segment</p><p>was taken down onto the bladder mucosa, then anasto-</p><p>mosed with bladder muscle from posterior to anterior using</p><p>absorbable interrupted sutures (Fig. 1) An ACE test via</p><p>Foley catheter was performed 10 to 12 days after the</p><p>operation with 50 to 100 mL of normal saline. The ACE</p><p>volume and interval were adjusted until proper bowel</p><p>movement was observed.</p><p>The treatment outcomes of colonic ACE procedures were</p><p>evaluated in terms of ACE volume, interval, and transit time</p><p>roced</p><p>lume</p><p>L)</p><p>00</p><p>00</p><p>00</p><p>50</p><p>00</p><p>00</p><p>00</p><p>00</p><p>00</p><p>00</p><p>11 F 5 MMC IC RI 3 500</p><p>00</p><p>00</p><p>00</p><p>50</p><p>00</p><p>00</p><p>00</p><p>00</p><p>toplas</p><p>alform</p><p>last</p><p>id co</p><p>Left colonic antegrade continence enema 175112 F 4 MMC SC RS 35 6</p><p>13 F 8 MMC IC RI 16 10</p><p>14 M 7 HS SC RS 24 5</p><p>15 M 26 SL SC RS 25 2</p><p>16 M 4 MMC IC RI 20 7</p><p>17 M 11 MMC SC RS 7 15</p><p>18 F 4 MMC SC RS 26 5</p><p>19 M 34 MMC SC RS 15 15</p><p>MMC indicates meningomyelocele; SC, sigmoidocystoplasty; IC, ileocys</p><p>lipoma; CA, cloacal anomaly; HS, Hinman syndrome; ARM, anorectal ma Left colonic antegrade continence enema stoma function checkup atb Retubularized ileum was closed and changed to retubularized sigmoTable 1 Characteristics of 19 patients who underwent LACE p</p><p>Patient</p><p>no.</p><p>Sex Age</p><p>(y)</p><p>Original</p><p>diagnosis</p><p>Urologic</p><p>procedure</p><p>LACE Follow-up</p><p>(mo)</p><p>Vo</p><p>(m</p><p>1 M 8 MMC IC RSb 18 10</p><p>2 M 7 MMC SC RS 23 9</p><p>3 M 12 MMC SC RS 25 5</p><p>4 M 5 MMC SC RS 37 2</p><p>5 M 10 ARM RS 11 7</p><p>6 F 9 MMC SC RS 19 5</p><p>7 F 6 MMC SC RS 4 5</p><p>8 F 19 MMC SC RS 31 10</p><p>9 M 3 MMC SC RS 30 6</p><p>10 F 7 CA RS 25 9ure</p><p>Duration</p><p>(min)</p><p>Interval</p><p>(d)</p><p>Soilinga Regurgitationa Stenosisa Paina</p><p>30 0.3 + + 15 2 +/30 2 20 2 + 30 3 30 1 30 1 +/ 20 3 60 2 + 15 2 15 3 +/ +20 2 +/ 30 1 30 2 30 1 20 3 +/30 1 30 1 +/60 2 + + </p><p>ty; RS, retubularized sigmoid colon; RI, retubularized ileum; SL, spinal</p><p>ation.</p><p>follow-up.</p><p>lon because of stomal obstruction.</p></li><li><p>(time from enema fluid administration to bowel move-</p><p>ments). The degree of social continence and complications</p><p>after LACE procedure were also evaluated.</p><p>2. Results</p><p>2.1. Demographic data of the patients</p><p>The male-to-female ratio was 11:8, with a mean age of 10</p><p>years (range, 3-34 years). Diagnoses were of meningomye-</p><p>locele in 15 (78.9%) patients, anorectal malformation in 2</p><p>(10.5%) patients, Hinman syndrome in 1 patient, and spinal</p><p>lipoma in 1 patient. Sigmoidocystoplasty was performed by</p><p>a urologist concomitantly with LACE in 13 (68.4%)</p><p>patients, followed by ileocystoplasty in 4 (21.1%) of these</p><p>patients. Operations other than LACE were not performed in</p><p>2 (10.5%) patients.</p><p>2.2. Volume, transit time, and interval of LACE</p><p>After a period of adjustment, all 19 patients were able to</p><p>perform LACE regularly without any problems with an</p><p>average of once every 2 days (range, 0.3-3 days). These</p><p>patients received regular follow-up care every 2 or 3 months</p><p>after the LACE procedure. The median total follow-up</p><p>period was 23 months (range, 3-37 months), the median</p><p>LACE volume requirement was 600 mL (range, 250-1500</p><p>.5 to</p><p>nd-se</p><p>) wit</p><p>ltiple</p><p>catheter (C). One end of the retubularized bowel was anastomosed to th</p><p>inci</p><p>leocy</p><p>S.M. Kim et al.1752stoma into the umbilicus and anastomosed to an umbilical stab</p><p>performed with several sutures in the serosa of sigmoid colon. I</p><p>simultaneously as a bladder augmentation procedure.Fig. 1 Segments of ileum (A) or sigmoid colon (B) with a length 2the remaining bowel was anastomosed in an end-to-end fashion (ha</p><p>the antimesenteric border using a Bovie coagulator (detubularization</p><p>Foley catheter. The detubularized bowel was retubularized with mu3.0 cm were made with care to preserve their vascular arcades, and</p><p>wn). A previously made ring of bowel segments was opened along</p><p>h the rectangular bowel flap plate wrapped lengthwise around a 16F</p><p>interrupted absorbable sutures under the guidance of a 16F Foley</p><p>e sigmoid colon and the other end was exteriorized as a cutaneous</p><p>sion. Witzel-type anti-refluxing seromuscular reinforcement was</p><p>stoplasty (D) or sigmoidocystoplasty (E) was usually performed</p></li><li><p>mL), and the median LACE transit time was 30 minutes it should be noted that 2 of them received LACE procedure</p><p>Left colonic antegrade continence enema 1753Patients with dilated ascending and transverse colons, as</p><p>well as those with neurogenic bowels, often require</p><p>excessive fluid installation and require more ACE transit</p><p>time than other patients [7]. Considering this, LACE is more</p><p>physiologically sound than right colonic antegrade conti-</p><p>nence enema (RACE) because the enema is less likely to</p><p>impair water absorption, which occurs predominantly in the</p><p>ascending colon. What is more, delivery of enemas into the</p><p>descending colon targets the stool where it is hardest,</p><p>benefits from gravity, and results in timely and effective</p><p>bowel evacuation. Our experience with LACE suggests that</p><p>it is not only comparable to RACE, but also quite</p><p>satisfactory for children and their caregivers.</p><p>The most important parameter of success of the ACE</p><p>procedure is bfecal continence.Q Unfortunately, anatomicallyand physiologically, these patients remain without conti-</p><p>nence (or the ability to control bladder or bowel function).</p><p>Therefore, success of the ACE procedure should be judged</p><p>by social continence (having soilage-free interval between</p><p>ACE). Social continence was achieved in 14 (73.7%) of</p><p>19 patients, and the bowel habits of children with fecal</p><p>incontinence of various causes changed completely into</p><p>normally adjusted, timely, and predictable ones. These</p><p>children developed clean perinea without use of a bag or</p><p>nappy between ACE. The remaining 3 (15.8%) patients</p><p>experienced some fecal soiling once or twice per month, but(range, 15-60 minutes).</p><p>2.3. Function of LACE</p><p>Social continence without fecal soilage between ACE</p><p>was achieved in 14 (73.7%) patients; 5 (26.3%) patients</p><p>complained of some fecal soilage between ACE. Regurgi-</p><p>tation of fecal material through the umbilical ACE stoma</p><p>was not reported at all in 17 (89.5%) patients, whereas</p><p>2 others (10.5%) complained of some regurgitation of fecal</p><p>material through the umbilical ACE stoma. Stoma stenosis</p><p>developed in 2 (10.5%) patients and required surgical</p><p>revision (ambulatory surgery). Other patients with minimal</p><p>stenosis required just stoma dilatation with a Hegar dilator</p><p>or Foley ballooning. Although 15 (78.9%) patients did not</p><p>present abdominal pain during LACE, 1 (5.3%) patient</p><p>experienced significant abdominal pain and 3 (15.8%)</p><p>patients experienced tolerable pain only upon introduction</p><p>of the catheter at the umbilical ACE stoma.</p><p>2.4. Complications of LACE procedurerequiring rehospitalization</p><p>Six (31%) patients required rehospitalization because</p><p>of post-LACE complications. Most complications were</p><p>stoma problems.</p><p>3. Discussionjust 3 and 4 months ago, and are still likely to adapt to the</p><p>new circumstances. Two (10.5%) patients have experienced</p><p>a bplightQ with the LACE stoma because of frequent soilingbetween ACE. In this authors opinion, both patients should</p><p>be reeducated about the possibility of achieving fecal</p><p>continence with changes in their ACE regimen. One patient</p><p>had foregone further treatment after just 2 corrective</p><p>operations after LACE. The other patient, a 34-year-old</p><p>man, generally remains at home and believes that he can</p><p>endure fecal soiling without further treatment by self-</p><p>administration of anal enema. In addition to fecal soiling,</p><p>stoma stenosis or obstruction can be major problems after</p><p>ACE operations [11,12]. Stoma stenosis is frequently</p><p>reported after ACE procedure. In our study, mild stenosis</p><p>was corrected by repeated Hegar dilator or Foley balloon-</p><p>ing. However, 2 patients required stoma revision because of</p><p>severe stoma stenosis, which were managed by revision of</p><p>stoma opening in the umbilicus (V-Y plastic revision) on an</p><p>ambulatory basis. On the other hand, stoma obstruction was</p><p>quite problematic, which required laparotomy for closure</p><p>and recreation of retubularized bowels. For correction of</p><p>stoma obstruction, 2 patients required laparotomy, which</p><p>showed stricture in retubularized bowel suggestive of</p><p>previous ischemia because of inadequate blood supply or</p><p>excessive tension. Bernard et al emphasized 3 factors for</p><p>reducing the risk of stoma stenosis or obstruction. (1) There</p><p>must be adequate mobilization of the colon to avoid tension;</p><p>(2) the tubularized segment of colon must have blood</p><p>supply from at least 2 blood vessels to avoid ischemia; and</p><p>(3) the LACE stoma must remain intubated for 30 days to</p><p>facilitate healing [7].</p><p>In our study there are 3 points that should be considered.</p><p>First this is retrospective study for 19 patients who received</p><p>LACE procedure. We no longer perform the original</p><p>Malones ACE procedure (RACE) since 2001 (before that</p><p>time, we performed 4 cases of RACEprocedure), sowe do not</p><p>have any prospective data that can confirm the superiority of</p><p>LACE procedure. We have information about the treatment</p><p>outcomes of RACE procedure from other reported series</p><p>[6,13,14]. Secondly, in this study, postoperative follow-up</p><p>period was longer than any other reported series [8,9], but still</p><p>relatively short with a median of 23 months. Longer follow-</p><p>up period is required. Thirdly, although 73.4% of patients</p><p>achieved social continence and became soilage-free between</p><p>ACE, as much as 31% of the patients required reoperation</p><p>mainly because of stoma problem. However, our result is</p><p>compa...</p></li></ul>

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