Surgeon at Work

Simplified Technique for Antegrade ContinenceEnemas for Fecal Retention and Incontinence

Eric W Fonkalsrud, MD, FACS, James CY Dunn, MD, PhD, and Akemi I Kawaguchi, BA

Fecal incontinence and chronic constipation occurwith annoying frequency after reconstructive colo-rectal operations for Hirschsprung’s disease and im-perforate anus in childhood.1 Chronic constipationis a frequent occurrence that complicates the care ofchildren with spina bifida and of neurologically im-paired patients of all ages.2-4 Fecal incontinence isdevastating to the self-esteem of a child, deprivinghim or her from socializing with peers and limitingparticipation in most vigorous sports activities.

A bowel-management program with use of adaily enema, manipulation of the diet, and use ofsome medications has been helpful in reducing in-continence in several children after repair of imper-forate anus.4,5 Chronic use of rectal enemas, suppos-itories, laxatives, or lubricants, however, is oftenuncomfortable, poorly accepted, and intolerable tothe patient, and cumbersome and disruptive to othermembers of the family who are responsible for thechild’s care.

Since its first description by Malone and associ-ates in 1990,6 the antegrade continence enema(ACE) has been used with increasing frequency bysurgeons for the management of children with fecalincontinence or retention. The technique entailsconstruction of a permanent, nonrefluxing appen-diceal stoma in the abdominal wall through which acatheter can be inserted to deliver enema solutions inan antegrade manner on a daily basis, as desired. Thisoperative procedure is somewhat extensive for thepatient who requires only the instillation of enemasolutions into the proximal colon and has caused skin

irritation, granulation tissue with stenosis, and occa-sional fecal leakage in five of the children in whom itwas used in our hospital. Griffiths and Malone7 re-ported that 80% of their patients had some type ofcomplication, either minor or major, and that 5 of 21patients required a colostomy. Other investigatorshave noted several late complications after the Ma-lone procedure.8 To reduce these complications, sev-eral modifications of the continent appendicostomyhave been reported by other groups.9,10

To simplify the operation, Webb and associates11

recommended laparoscopic construction of a cutane-ous appendicostomy for antegrade enemas. Chaitand associates4 have performed percutaneous inser-tion of a low-profile cecostomy catheter or “button”under local anesthesia as a two-stage procedure forantegrade colonic cleansing in several children, withgood success.

The present study summarizes our clinical expe-rience at the University of California, Los AngelesMedical Center in the management of 24 childrenwith fecal incontinence or constipation using a sim-plified surgical technique. In this procedure, aBroviac silicone elastomer intravenous (IV) catheterwas placed in the cecum for ACE infusions.

METHODSBetween November 1995 and March 1998, 24 chil-dren between the ages of 7 months and 15 years(mean, 5.7 years) underwent placement of a siliconececostomy catheter for management of chronic fecalretention or incontinence. Eleven of the children hadHirschsprung’s disease and seven had undergone pre-vious abdominoperineal pull-through procedures; infour children the cecostomy catheter was placed atthe time of the pull-through procedure. Five other

Received March 24, 1998; Revised May 13, 1998; Accepted June 4, 1998.From the Department of Surgery, University of California, Los Angeles Schoolof Medicine, Los Angeles, CA.Correspondence address: Eric W. Fonkalsrud, MD, FACS, Department of Sur-gery, UCLA School of Medicine, Los Angeles, CA 90095.

457© 1998 by the American College of Surgeons ISSN 1072-7515/98/$19.00Published by Elsevier Science Inc. PII S1072-7515(98)00189-6

patients had pull-through operations for anomaliesof high imperforate anus. Two children had low im-perforate anus anomalies with rectal distention andchronic fecal incontinence despite having a well-functioning anorectal sphincter complex. Two chil-dren had fecal retention and incontinence related tosacral and spinal anomalies with incomplete neuro-genic innervation to the perineum. Two children hadsevere cerebral palsy or neurologic impairment, andtwo others had idiopathic fecal retention. None ofthe patients had uncorrected rectal strictures.

Perioperative IV antibiotics (gentamicin 75 mg/kg/d and clindamycin 25 mg/kg/d) were given for 2days. Two preoperative cleansing enemas were givento most patients during the 24 hours before opera-tion. In 20 of the patients, we performed a minilapa-rotomy under general anesthesia through a midlinelower abdominal incision. The remaining four pa-tients had the cecostomy catheter placed at the sametime that an abdominoperineal pull-through opera-tion was performed for Hirschsprung’s disease or im-perforate anus. In three children, the appendix was

removed and the catheter was placed through apurse-string suture at the base of the inverted appen-diceal stump. Eight patients had had the appendixremoved during previous operations. In the remain-ing patients, the catheter was placed through a purse-string suture of Prolene (Ethicon, Somerville, NJ)placed on the taenia of the cecum, leaving the appen-dix in place.

A small incision was made in the right lower ab-domen and another was made in the right upper ormidabdomen $ 7 cm distant from the first incision.A single-lumen Broviac silicone catheter (size 6.6)was drawn through the subcutaneous tunnel be-tween the incisions, placing the Dacron cuff (BardAccess Systems, Salt Lake City, UT) on the catheterapproximately 3 cm from the exit site (Fig. 1). Asmall clamp was inserted through the abdominalmuscles via the right lower-quadrant incision, andthe tip of the Broviac catheter was drawn into theperitoneal cavity. The distal end of the catheter wasresected, leaving approximately 10 to 12 cm betweenthe tip and the abdominal wall. A hollow needle was

Figure 1. The silicone elastomer (Broviac) catheter extending through the subcutaneous tunnel from the right upper tolower abdomen and then passing through the abdominal muscles and into the cecum. The cuff of the catheter is $ 3 cmfrom the exit site.

458 Fonkalsrud et al Antegrade Continence Enema J Am Coll Surg

inserted into the cecum through the pursestring su-ture, followed by a guide wire and a Cook disposablecatheter with peel-away sheath. The Broviac catheterwas passed through the peel-away sheath and ad-vanced into the upper ascending colon. The purse-string suture was tied, and the cecum was sutured tothe abdominal wall circumferentially around thecatheter with interrupted Prolene sutures.

Prolene sutures were placed through the abdom-inal muscles on each side of the catheter to reduce therisk of bacteria from the cecum contaminating thecatheter tract. The catheter was flushed with radio-graphic contrast, and fluoroscopic examination wasperformed to ensure that the catheter tip was withinthe bowel lumen and that there was no leakage.

Patients were started on oral feedings within 12hours, and most were discharged home within 48 to72 hours. Cecostomy catheter flushes using Golytelysolution (Braintree Laboratories, Inc., Braintree,MA) (200 to 500 mL, depending on the size of thepatient) were started within 24 hours after operation,performed twice daily (after breakfast and dinner).The catheters were shortened externally, leaving5 cm between the abdominal-wall exit site and theend of the catheter. A blunt-tip needle was placed inthe end of the silicone catheter. In 15 patients, theirrigation solution was switched to saline with soapsuds within 1 week.

RESULTSComplications related to the silicone cecostomycatheter have been uncommon in the 24 patients.Patients, parents, and care givers have expressed greatsatisfaction with the simplicity of use and care of thecatheter and its low profile. Five children were con-verted from a modified Malone appendicostomy tothe Broviac silicone infusion catheter because of per-sistent granulation tissue, stomal stenosis, or skin ir-ritation around the cutaneous stoma.

In 3 of the 24 patients, exit-site infections devel-oped secondary to chronic infection of the cathetercuff. Each of these children required removal of theinfected catheter and placement of a new one. In oneother child, the catheter became plugged and re-quired replacement. For each of these patients, anincision was made in the right lower abdomen at thesite where the catheter passed through the abdominalmuscles. The catheter was withdrawn from the sub-cutaneous tunnel, and a guide wire was passedthrough the catheter lumen into the cecum. A newcatheter was passed through a new subcutaneoustunnel, exiting on the upper left side of the abdomen.

The catheter was placed in the cecum through a peel-away sheath, which had been introduced over theguide wire. In each of these children, the procedurewas performed on an outpatient basis. Three otherchildren dislodged the catheter (mean, 6.4 monthsafter insertion) and required a minilaparotomy toplace a new catheter because acceptable continencehad not yet been achieved.

The volume of the catheter flushes was increasedgradually until the patient experienced the urge todefecate and had a bowel movement within 15 to 30minutes. A few patients required rectal stimulationfor approximately 2 weeks with a large Foley catheterto encourage prompt evacuation. None of the pa-tients had evidence of excessive water absorption.Catheter flushes were given after breakfast and din-ner in an attempt to coordinate with and enhance thenormal gastrocolic reflex of contractions. Once astandard pattern of twice-daily defecation was estab-lished, the volume of the catheter flushes was gradu-ally reduced. Several children learned to perform thecatheter flushes themselves.

Each of the patients experienced a marked de-crease in fecal soiling during the day, with 11 of the24 having no further daytime soiling within 1 weekafter operation. This factor resulted in marked im-provement in school and other social and physicalactivities. None of the children experienced limita-tion in physical activities because of the catheter.Nocturnal soiling persisted in 15 of the 24 patientsfor a few weeks, but was much less severe and fre-quent than before operation. Low-dose loperamideat night ended nocturnal soiling in seven patients.Occasional nocturnal soiling persisted in only 2 ofthe 21 patients 3 months after the cecostomy flusheshad been initiated.

The catheters remained in place for 4 to 28months (mean, 15.2 months). Four patients experi-enced marked improvement in defecatory patternswith only rare soiling, which was maintained for $ 5weeks after enema administration had been discon-tinued. Each of these patients had the catheter re-moved under local or light general anesthesia on anoutpatient basis, without sequelae (mean, 11.9months after catheter placement).

DISCUSSIONPlacement of the Broviac cecostomy ACE catheter isa short and simple technique compared with the Ma-lone continent appendicostomy and other reportedmethods for administration of antegrade colonic en-emas. The details of catheter placement are impor-

459Vol. 187, No. 4, October 1998 Fonkalsrud et al Antegrade Continence Enema

tant to minimize the risk of subcutaneous tunnel andcatheter-cuff infection. Because of careful suturing ofthe cecum to the abdominal wall around the catheter,none of our patients experienced intraabdominal in-fection. In three early patients, the abdominal mus-cles were not closely approximated around the cath-eter and bacteria from the cecum may have infectedthe subcutaneous tunnel and catheter cuff, necessi-tating catheter replacement. The absence of catheterexit-site granulomas and surrounding skin irritationwith the Broviac catheter is a marked improvementover our previous experience with the continent cu-taneous appendicostomy.

Coordination of cecostomy flushes with the pa-tient’s maximal normal gastrocolic reflex—afterbreakfast and dinner—resulted in a more rapid andcomplete bowel evacuation than when the flusheswere given at various times during the day. The vol-ume of the catheter flush was modified as necessaryto cause evacuation within 20 minutes. The volumeof the bolus flush necessary to produce evacuationhas varied widely among patients and appears to cor-relate with the size of the patient, the degree of co-lonic distention, and the presence of anorectal ob-struction. Patients were encouraged to complete thedefecation in , 20 minutes and not to remain on thetoilet for prolonged periods to encourage the devel-opment of an efficient bowel pattern and to mini-mize venous congestion in the rectum.

Children with rectal strictures or fissures maybenefit from dilatation or surgical correction to min-imize sphincter spasm with obstruction to colonicemptying. Patients with marked rectosigmoid dilata-tion and inefficient contractility have had the mostdifficulty developing satisfactory emptying with thececostomy tube flushes. Three patients had plicationof the dilated rectosigmoid at the time of cecostomycatheter placement, which we believe facilitated co-lonic emptying with the flushes. Two other patientswith Hirschsprung’s disease who had previous pull-through operations and who developed severe sig-moid distention underwent resection of the dilatedsegment and a new endorectal pull-through proce-dure together with cecostomy catheter placement.

Although the appendix was removed during ce-costomy catheter placement in three patients in ourearly experience, we currently leave the appendix inplace for patients with spinal or neurologic disorderswho have urinary incontinence; these patients maybenefit later from a Mitrofanoff appendiceal conduitfrom the bladder to the abdominal wall.

In summary, we report a larger group of childrenwith persistent fecal soiling after previous abdomino-perineal pull-through operations for Hirschsprung’sdisease who have benefited from the ACE procedurethan has been reported by other authors.12,13 Each ofthe seven children with Hirschsprung’s disease andprevious pull-through procedures with persistentsoiling became free of soiling within 5 days after be-ginning cecostomy ACE flushes (mean 3.6 days).The bowel-management program recommendedby Pena and associates,13 combined with ACEflushes, has also been highly successful in patientswith fecal neurologic incontinence or retention inour experience.

The Broviac catheter cecostomy is easier to con-struct and to close than the Malone continent appen-dicostomy. The catheter is inexpensive and is readilyavailable in most hospitals. Complications were un-common and minor in our experience. Cathetermanagement has been easy, particularly in youngchildren, and there are minimal limitations in patientactivities with the short, low-profile catheter. Thegood results with the Broviac catheter ACE flushes incorrecting fecal incontinence and constipation haveencouraged us to use this technique earlier in themanagement of children with these disorders.

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