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Preliminary report: the antegrade continence enema

The principles of antegrade colonic washout andthe Mitrofanoff non-refluxing catheterisablechannel were combined to produce a continentcatheterisable colonic stoma. The intention wasthat antegrade washouts delivered by this routewould produce complete colonic emptying andthereby prevent soiling. The procedure has beensuccessfully carried out in five patients withintractable faecal incontinence.

Introduction

Congenital abnormalities, such as spina bifida, imperforateanus, and Hirschsprung’s disease, and abnormalities thatfollow spinal injury, repeated pelvic surgery, or any

operation on the rectum or anus have the potential toproduce faecal incontinence. Treatment consists of trainingto establish a regular bowel habit, control of stool

consistency by diet and drugs, and the use of purgatives orenemas to produce regular colonic emptying. Operativemeasures, such as sphincter reinforcement with muscleslings, are also used but they are of little benefit forincontinence of neuropathic origin. Shandling andGilmourl reported high success rates with an enemacontinence catheter which administers large-volume salineenemas retrogradely. A small number of patients remainincontinent despite all attempted treatments and opt for apermanent colostomy.We describe here a new operative technique that

facilitates the administration of antegrade washouts to

empty the colon and thus prevent soiling-the antegradecontinence enema (ACE). The principle of the procedure isthat the appendix is reimplanted in a non-refluxing mannerinto the caecum and the other end is brought out on theabdominal wall as a continent stoma. This procedureprovides a catheterisable channel through which antegradewashouts are given to produce colonic emptying (see figure).

Patients and methods

Since October, 1989, ACE has been used in five patients, who havebeen followed up for 2-8 months (table I). In four patients (1,2,4,5)the procedure was carried out in conjunction with bladderreconstructive surgery for urinary incontinence. Every effort hadbeen made to control faecal incontinence, including repeat pull-through procedures and pelvic floor surgery for the two patientswith anorectal malformation. The new technique was used as thelast resort in patients who would otherwise have undergonecolostomy formation.

Preoperative bowel preparation and prophylactic antibiotics arerecommended. A right iliac fossa gridiron incision is used, but ifadditional procedures are to be done, a laparotomy is required. Thecaecum and appendix are delivered from the wound, and the bloodsupply to the appendix is carefully preserved. The appendix is thenresected on its vascular pedicle, with a generous cuff of caecum leftat its base. The caecal defect is closed and the distal end of theappendix is amputated. At this stage it is important to check thepatency of the appendix lumen by passage of a catheter through it. A5 cm long submucosal tunnel is fashioned by sharp dissectionthrough one of the taenia on the caecum, and the mucosa of the

bowel is opened at its distal end. The appendix is reversed and itsdistal end is anastomosed to the mucosal opening in the caecum bymeans of absorbable sutures. The appendix is placed in thesubmucosal tunnel and the seromuscular layers of the caecum areclosed over it, thus creating a non-refluxing channel (figure,A)—the Mitrofanoff principle The site of the stoma is marked onthe abdominal wall before operation and the appendix is nowdelivered through this site. The caecum is anchored to the anteriorabdominal wall, with no kinking of the appendix. The stoma isfashioned by means of a broad-based lateral skin flap that is madeinto a tube and anastomosed to the cuff of caecum on the base of the

appendix. This flap serves to bury the appendix and minimisedischarge on the abdominal wall. The resulting non-refluxingcontinent stoma provides access to the proximal colon by way of anarrow catheterisable channel. A catheter is left in situ for 2-3 weeksto prevent kinking of the channel, but washouts can be started after10 days without removal of the catheter (figure, B).

Non-refluxing appendicocaecostomy (A) and ACE principle (B).

For washout a bag of irrigation saline is hung above the toilet andis delivered by way of an intravenous giving set. It is also possible touse tap water with one (5 ml) teaspoonful of salt per pint (0-5 1)

ADDRESSES: Wessex Regional Centre for Paediatric Surgery,Southampton General Hospital (P S Malone, FRCSI), and

Departments of Urology (P. G. Ransley, FRCS) and Paediatric

Surgery (E. M Kiely, FRCS), Hospitals for Sick Children, GreatOrmond Street, London, UK. Correspondence to Mr P. S. Malone,Wessex Regional Centre for Paediatric Surgery, General Hospital,Tremona Road, Southampton SO9 4XY, UK.

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TABLE I-CLINICAL DETAILS OF PATIENTS

TABLE II-WASHOUT REGIMENS AND RESULTSI I I

administered by means of sets used to give barium enemas. Thepatient sits on the toilet and catheterises the caecum and the ACE isthen given. The regimens used by our patients are described intable u.

Results

We encountered no serious operative difficulties or

postoperative morbidity as a result of ACE. For the first twopatients we did not make a skin tube (as described above) forthe stoma. Both were troubled with mucous discharge. Onerequired stomal dilatations and, though she may require arevision of the stoma in the future, she is continuing tocatheterise. The remaining three patients have skin tubesand have had no difficulties with mucous discharge orstomal complications. All stomas are continent of faeces andflatus. It was difficult to establish appropriate regimens forwashout, but by a process of trial and error each patientdeveloped her own individual protocol (table 11). Althoughsome patients still have slight rectal leakage of faecal fluidthere is unanimous agreement that the ACE has had a majoreffect in controlling their incontinence and in changing theirlives for the better.

Discussion

This operative technique has its foundation in acceptedsurgical practice. Hewitt and colleagues3 described wholegut irrigation as the preparation of choice for large-bowelsurgery and Muir4 described colonic preparation byintraoperative antegrade colonic washouts delivered by wayof a tube caecostomy. Dudley and Radcliffes,6 reassessed thetechnique of "on-table" antegrade colonic washouts anddescribed successful bowel cleansing in 64 patients.Shandling and Gilmour’ reported high success rates with anenema continence catheter for delivery of large-volumesaline washouts in a retrograde manner to patients withspina bifida. This experience supports the concept that theadministration of large-volume total colonic washouts’canproduce complete bowel emptying and thus prevent soiling.However, in our experience some patients with spina bifidaare unable to cope with retrograde enemas because ofimmobility and lax perineal muscles. Many patients withfaecal incontinence undergo repeated operations for

imperforate anus and the scarred, sensitive perineum and

anal canal make the use of retrograde enemas difficult. It is inthese groups that antegrade washouts would be particularlyvaluable but no technique for their administration has beenavailable.

In 1980 Mitrofanoff2 described the use of the appendiximplanted in a non-refluxing fashion into the bladder toprovide a continent catheterisable channel through whichthe bladder could be emptied. This technique has gainedwidespread acceptance for the management of urinaryincontinence. We could see no reason why the sameprinciples could not be applied to faecal incontinence.Our initial experience of the technique in five patients is

encouraging. Only one patient has had difficulties withstomal stenosis that required dilatation and will probablyneed a revision in the future. The other problem associatedwith the stoma was mucous discharge, but it has largely beencontrolled by the skin tube technique described here, as isfound in urological practice with larger numbers of patients.We would not expect serious stoma troubles based on the

long-term experience of patients with urinary tract

Mitrofanoff reconstructions. We encountered many earlydifficulties with the large-volume antegrade washouts as thecolon was cleared of residual faecal masses which had notbeen dislodged by conventional bowel preparation. In onepatient who was severely constipated, saline refluxed

through the ileocaecal valve and caused abdominaldistension and pain. With the use of washouts alone mostpatients had leakage of faecal fluid from the rectum for longperiods after administration. We have now adopted anindividal approach for each patient through trial and error.Each individual regimen largely consists of the initial

antegrade administration of a phosphate enema followed bysmaller volumes of saline lavage.The technique was used only when all other attempts to

control incontinence had failed and the only remainingoption was colostomy. Each patient is delighted with theresult. They fmd the technique of catheterisation acceptableand easy to carry out. The enemas and washouts are givenwhile the patient is sitting on the toilet so a wheelchair-bound patient can carry out the procedure alone and thusbecome completely independent. The maximum time takenin our experience is 30 min every other day-a small price topay to be clean and to avoid a permanent colostomy. As ourexperience grows and long-term results become availablethe indications for this operation may become less restrictedand the ACE may replace other methods as the treatment ofchoice for faecal incontinence. The ACE can be carried out

by itself or in combination with surgery for urinaryincontinence, as in four of our patients. It is important thatthis surgery is carefully planned in advance.Though the numbers are still small and our follow-up is

short, we believe the ACE offers hope to people withintractable faecal incontinence, whether children or adults.

REFERENCES

1. Shandling B, Gilmour RF. The enema continence catheter in spinabifida: successful bowel management. J Pediatr Surg 1987; 22: 271-73.

2. Mitrofanoff P. Cystostomie continente trans-appendiculare dans letraitement des vessies neurologiques. Chir Pediatr 1980; 21: 297-305.

3. Hewitt J, Rigby J, Reeve J, Cox AG. Whole gut irrigation in preparationfor large-bowel surgery. Lancet 1973; ii: 337-40.

4. Muir EG. Safety in colonic resection. Proc R Soc Med 1968; 61: 401-08.5. Dudley HAF, Radcliffe AG, McGeehan D. Intraoperative irrigation of

the colon to permit primary anastomosis. Br J Surg 1980; 67: 80-81.6. Radcliffe AG, Dudley HAF. Intraoperative antegrade irngation of the

large intestine. Surg Gynecol Obstet 1983; 156: 721-23.