Malone technique for antegrade enema in children with ... ?· 1 Pediatric Urology Coordinator, UMAE,…

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  • ORIGINAL ARTICLE

    Rev Mex Urol 2012;72(4):178-181178

    Corresponding author: Dr. Jos Manuel Garca de Len Gmez. Tarascos 3469-511, Fraccionamiento Monraz. CP 44670. Telephones: (33) 3813 3011, (33) 3813 3012. Guadalajara, Jal., Mxico. E-mail: gagm@prodigy.net.mx

    1 Pediatric Urology Coordinator, UMAE, Hospital de Pediatra, Centro Mdico Nacional de Occidente, Instituto Mexicano de Seguro Social. Guadalajara, Jal., Mexico.

    2 Urologist and Alumnus of the Hospital General de Hermosillo Sonora. Hermosillo, Son., Mexico.

    Malone technique for antegrade enema in children with neurogenic, intestinal, and urinary disorders: experience with 10 patients Garca-de Len Gmez Jos Manuel,1 Landero-Orozco Marco Antonio.2

    Resumen

    Introduccin: Anomalas congnitas como espina bfida, ano imperforado, enfermedad de Hirschprung y cirugas plvicas repetidas pueden causar incontinencia fecal y constipacin. Los enemas retrgrados a travs del ano no siempre son efectivos para el manejo de la constipacin severa e incontinencia fecal.

    Material y mtodos: Describimos 10 pacientes en un periodo de nueve aos con historia de suboclusin intestinal secundaria a constipacin crnica. Cinco fueron mujeres y cinco hombres. La tcnica para enemas antergrados consiste en localizar el apndice cecal sin despegarla del ciego, se abre la punta y se lleva sta a la pared abdominal para formar un estoma.

    Resultados: La patologa de base en los pacientes fue la vejiga neurognica por mielodisplasia. En ocho pacientes se realiz ampliacin vesical simultnea, en seis con leon y en dos con sigmoides. Se elabor un estoma de Monti para cateterismo vesical y un estoma de Malone para los enemas antergrados. El estoma de Malone como nica ciruga sin ampliacin vesical se realiz en dos pacientes. La estancia hospitalaria en promedio fue de

    AbstRAct

    Background: Congenital anomalies such as spina bifida, imperforated anus, Hirschsprungs disease, as well as repeat pelvic surgeries can cause fecal incontinence and constipation. Retrograde enemas via the anus are not always effective as severe constipation and fecal incontinence management.

    Material and methods: We describe 10 patients (five boys and five girls) seen over a period of nine years with a medical history of partial bowel obstruction secondary to chronic constipation. The antegrade enema technique consists of localizing the cecal appendix without detaching it from the cecum, opening the tip, and moving it to the abdominal wall to form a stoma.

    Results: Neurogenic bladder due to myelodysplasia was the underlying pathology. Simultaneous bladder enlargement was carried out in eight patients - in six of them with ileum, and in two of them with the sigmoid colon. A Monti stoma was made for bladder catheterization and a Malone stoma for the antegrade enemas. Malone stoma as the only surgery and without bladder enlargement was carried out in two patients. Mean

  • Rev Mex Urol 2012;72(4):178-181

    Garca-de Len Gmez JM, et al. Malone technique for antegrade enema in children with neurogenic, intestinal, and urinary disorders: experience with 10 patients

    179

    IntRoductIon

    Congenital abnormalities such as spina bifida, imperforated anus, Hirschsprungs disease, and repeat pelvic surgeries can cause fecal incontinence. Treatment consists of establishing intestinal habits and softening the feces with diet, drugs, and enemas. Sphincter reinforcement has been attempted but its effectiveness is limited in fecal incontinence of neuropathic origin.

    Retrograde enemas are not always effective in the management of severe constipation and fecal incontinence.

    The technique of antegrade enema described by Malone in 1990 consists of the antegrade administration of enemas in order to empty the colon and prevent constipation. The principle of the procedure involves reimplanting the appendix to the cecum with the antireflux technique and taking the other end to the abdominal wall to form a catheterization stoma (Figure 1).

    In this review, we describe the progression of 10 pediatric patients treated with the Malone antegrade continence enema (MACE) procedure over a 9-year period from October 2001 to December 2010.

    methods

    A descriptive study of the progression of pediatric patients in a mean six-year follow-up period after MACE surgery was carried out. We describe the complications and the degree of patient satisfaction that was established, correlating the results with the international medical literature.

    Ten patients that had a past medical history of partial intestinal obstruction symptoms with severe chronic constipation that was refractory to conservative medical management, with fecal incontinence, and more than four hospitalizations per year due to fecal impaction, within the time frame of October 2001 to December 2010, were included in the study. Five patients were boys and five were girls, with a mean age of 12.6 years.

    The surgical technique is an appendectomy without detaching the base of the appendix from the cecum, taking the tip to the abdomen and opening it so that it serves as an abdominal stoma (Figure 2).

    The enema technique introduces an 8 F feeding catheter through which plain water or saline solution instillation is carried out, starting with 100 mL and reaching up to a maximum of 1 000 mL through a 50 mL syringe in a period of approximately 15 minutes, with an expected evacuation within the following 30 minutes. This procedure is carried out every day, or every two or three days, according to patient response.

    ocho das. Se present una complicacin que fue estenosis de la estoma de Malone, en un paciente que requiri reintervencin quirrgica para su resolucin, y slo un paciente abandon los enemas debido a que le causaba dolor.

    Discusin: Los enemas antergrados son una excelente alternativa para el manejo de pacientes con constipacin crnica severa, que presentan periodos frecuentes de suboclusin intestinal que no han respondido a manejo conservador.

    Palabras clave: Ampliacin vesical, enema, incontinencia fecal, constipacin, Mxico.

    Figure 1. Diagram of the antegrade enema procedure described by Malone in 1990

    hospital stay was eight days. The complication of stricture in the Malone stoma presented in one patient, requiring surgical reintervention for its resolution, and only one patient discontinued the enemas due to pain.

    Discussion: When there is no response to conservative management, antegrade enemas are an excellent alternative for the treatment of patients with severe chronic constipation that frequently present with partial intestinal obstruction.

    Keywords: Bladder enlargement, enema, fecal incontinence, constipation, Mexico.

  • 180 Rev Mex Urol 2012;72(4):178-181

    Garca-de Len Gmez JM, et al. Malone technique for antegrade enema in children with neurogenic, intestinal, and urinary disorders: experience with 10 patients

    Results

    Pediatric patients that presented with urologic and intestinal problems and whose main pathology was neurogenic bladder (Table 1) were included in the study.

    The requirement was that they present with severe constipation, fewer than 3 evacuations per week, painful evacuation with straining, and hard feces or feces in balls in the majority of the evacuations. In addition to gastrointestinal surgery, the majority of the

    patients also required urinary tract surgery, such as bladder enlargement.

    Simultaneous bladder enlargement was performed in eight of the patients, six with the ileum and two with the sigmoid colon. A Monti stoma was made from a small segment of the small intestine for bladder catheterization (Figures 3 to 5).

    MACE surgery alone, with no additional procedure, was performed in only two patients.

    Mean hospital stay was eight days. Complications included one Malone stoma stricture that required reintervention, and one patient stopped the antegrade enemas due to pain caused by the instillation of the liquid. All the patients, except the one who stopped the treatment, were satisfied with the results of the surgery.

    dIscussIon

    The retrograde enemas reported by Shandling and Gilmour showed a high success rate. In this procedure a thick catheter is placed through the rectum, and large quantities of liquid are instilled for washing out the sigmoid rectum in patients with spina bifida. The experience with these enemas is that patients with neurogenic bladder are not able to keep the colon clean, possibly due to the immobility and laxness of the perineal muscles. 1,2

    Many patients with fecal incontinence have a past medical history of multiple operations, and the reduced anal sensitivity and anatomy they present with makes managing retrograde enemas difficult. MACE is indicated in these types of patients.

    In 1980 Mitrofanoff described the use of the appendix reimplanted into the bladder with the antireflux technique. It rapidly gained in popularity and today, more than 30 years later, is still widely used. 3

    Figure 2. Clinical photograph of the surgery in which the tip of the appendix is externalized to form a stoma without detaching the appendix from its base at the cecum, so that antegrade enemas may be performed later.

    Table 1. General data of the 10 patients included in the study

    Patient Sex Age Diagnosis Result Follow-up

    1 F 10 Myelodysplasia Good 90 months

    2 M 12 ARM Stricture 72 months

    4 F 13 Myelodysplasia Good 62 months

    5 F 11 Myelodysplasia Good 54 months

    6 M 13 ARM Good 42 months

    7 M 7 Myelodysplasia Abandoned (pain) 35 months

    8 F 10 ARM Good 28 months

    9 F 12 Myelodysplasia Good 17 months

    10 M 8 Myelodysplasia Good 12 monthsARM: anorectal malformations

  • Rev Mex Urol 2012;72(4):178-181

    Garca-de Len Gmez JM, et al. Malone technique for antegrade enema in children with neurogenic, intestinal, and urinary disorders: experience with 10 patients

    181

    The Malone technique uses the same principle, but without detaching the appendix from the cecum. The tip of the open appendix is taken to the abdomen to form a stoma in which a stent remains for one month and catheterization is begun for periodic washings. The advantage of this procedure is that it can be performed at the same time as bladder enlargement, and if a urinary stoma is required, a detubularized intestinal Monti segment is used.4

    This procedure of antegrade enemas is not a very conventional surgery, but it is extremely useful in the management of severe refractory constipation.

    REfERENCEs1. Malone PS, Ransley PG, Kiely EM. Preliminary report: The antegrade

    incontinence enema. Lancet 1990;336(8725):1217-1278.2. Shanding B, Gilmour RF. The enema continence catheter in spina bi-

    fida: successful bowel management. J Pediatr Surg 1987;22(3):271-273.

    3. Mitrofanoff P. Cystostomie continente trans-appendiculare dans le traitment des vessies neurologiques. Chir Pediatr 1980;21(4):297-305.

    4. Casale AJ, Metcalfe PD, Kaefer MA, et al. Rink Total continence re-construction: A comparison t stage reconstruction of neuropathic bowel and bladder. J Urol 2006;176(4 Pt 2):1712-1715.

    Figure 3. Appendiceal reinforcement at the level of the cecum, so that fecal material leakage can be avoided.

    Figure 4. Illustration showing the use of a segment of the small intestine with a Monti stoma for bladder catheterization in the cases of simultaneous bladder enlargement in which the Monti and Malone double surgery is performed.

    Figure 5. Clinical photograph of the Monti stoma using the small intestine in cases of Monti and Malone double surgery.

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