0022-5347/95/1542-0759$03.00/0 THE JOUKNAL UF UHOL(X:Y Copyright 0 1995 by AMERICAN UROUXIICAL ASSOClATION, INC.

Vol. 154, 759-761, August 1995 Printed an U S A .

THE MALONE ANTEGFU.DE CONTINENCE ENEMA FOR NEUROGENIC AND STRUCTURAL FECAL INCONTINENCE AND CONSTIPATION

MARTIN A. KOYLE,* DEVONNA M. KAJI, MANUEL DUQUE, JODI WILD AND STANLEY H. GALANSKY

From the Section of Pediatric Urology, Children's Hospital and Department of Surgery, University of Colorado School of Medicine, Denver, Colorado

ABSTRACT

Problems of fecal elimination are commonly encountered by the pediatric urologist and sur- geon. The Malone antegrade continence enema has been described as a means to administer a large volume enema via a continent catheterizable appendicocecostomy, resulting in reliable fecal elimination. Of 22 patients undergoing this procedure 16 reported total continence 4 months or longer after surgery. Complications are relatively minor and tap water appears to be a safe solution for the antegrade continence enema. A nonrefluxing, imbricated appendicocecostomy is preferable to prevent cutaneous fecal or gas leaks.

Kn! WORDS: enema, cecum, cecoatomy, appendix

Mitrofanoff first popularized the concept of appendicocys- tostomy as a continent, catheterizable cutaneous conduit to the bladder.' In 1990 Malone et a1 adapted this concept to children with fecal incontinence by describing the continent cutaneous appendicocecostomy.2 The principle that they used was the administration of an antegrade enema via a cutane ous appendiceal conduit and the right colon to allow total emptying of the large bowel with the functional outcome of fecal continence. Although it was initially used for fecal in- continence only, the Malone antegrade continence enema procedure was expanded for uae in children with intractable constipation.3 We report our experience with the Malone antegrade continence enema procedure.

MATERIALS AND METHODS

We reviewed the records of 22 children who underwent the antegrade continence enema procedure at our facility be- tween June 1991 and February 1994. In these candidates intensive dietary and medical therapies andor high rectal washouts had failed previo~ely.4 All children had been fol- lowed for a minimum of 4 months after surgery to determine the success of the procedure. Subsequent information regard- ing the outcome of the procedure and patient satisfaction was obtained by patienuparent interview or telephone.

The technique of cutaneous appendicocecoetomy or its vari- ation was derived from patient records. A series of Merent operative approaches was used, including the initial tech- nique described by Malone et al of a dismembered reh- planted appendicocecostomy and, most recently, plicated and nonplicated orthotopic cutaneous appendi~ocecostorny.~*~ When appendix was not available, a tubularized cecal tube based on the Boari-Ockerblad principle or a piece of defunc- tionalized ureter was used.5.6

A 12F silicone catheter was left in the appendiceal stoma for a minimum of 21 days postoperatively. However, irriga- tions were instituted as soon as patients were able to take oral feedings in the early postoperative period. Irrigations were started with 50 cc tap water and were then increased by 50 cc increments every 2 to 3 days. Continence was moni- tored by the patient or parent since trial and error with respect to volume and frequency are necessary to determine what works best for each patient. Creatinine, blood urea

uesta for re r i n k Department of Pediatric Urn1 Chil- drzn%ospital. 10dEast 19th Ave., B 463, Denver, Colom~80218.

nitrogen and electrolytes were monitored closely during the first 3 months postoperatively.

Of our 9 male and 13 female patients (age 5 to 23 years, mean 13) 19 underwent simdtaneous and 2 had undergone previous urological reconstruction. One patient required only an antegrade continence enema. The cause of incontinence or constipation included myelodysplasia with newgenic etiol- ogies in 18 patients, imperforate anus in 3 (2 with the verte- bral, anal, cardiac, tracheal, esophageal, renal and limb syn- drome, and 1 with cloacal exstrophy) and cerebral palsy in 1. Reversed reimplanted appendicocecostomy was done in 3 patients and orthotopic appendicocemstomy was done in 16, of whom 11 underwent cecal imbrication as a secondary continence mechanism and 5 underwent nonimbricated pro- cedures. Of 3 patients with surgically absent appendixes 2 underwent construction of tubularized cecal tubes and in 1 a dismembered piece of nonfunctional ureter was used as the catheterizable limb.

RESULTS

Complications included superficial wound infections in 2 patients and complete stenmis of a tubularized cecal tube in 1. Of 16 patients who underwent orthotopic appendieocecoe- tomy complications developed in 5, including cutaneous stomal stenosis requiring minor secondary surgical revisions in 2 and occasional cutaneous fecal or gas leaks in 3. The leaks occurred in the subgroup of patients who underwent orthotopic nonimbricated cutaneous a p p e n d i m s t o m y . At 3 months postoperatively patients had no significant change in serum electrolytes and renal function when compared with preoperative values (see table).

One patient who had complete stenosis refused revision and, thus, the procedure was considered to have failed. An- other patient was not evaluable because she had ceased antegrade continence enema administrations due to changes in foster care. Of the 20 patients evaluable for greater than 4 months 300 to 800 cc (mean 380) fluid were used for each antegrade continence enema administration. Some families had independently substituted saline or soapsuds enemas although the majority used tap water only. Ofthe patients 17 administered the enema once daily, 2 required twice daily instillations and 1 performed an antegrade continence enema every third day. Instillation time was less than 5 minutes in all cases and the interval until a result aecurred was 8 to 32 minutes. Of the 22 patients 17 reported complete success in

759

760 ANTEGRADE ENEMA FOR INCONTINENCE AND CONSTIPATION

Antegrade continence e n e m technique and associated complications - No. Complications

No. Pts. Wound Infections Total Slough Cutaneous Stomas FecaVGas Leak Techniques

Reversed appentllcoeecostorny 3 0 0 0 0

cecal unbncation, 11 1 0 1 0 No imbncahon, 5 0 0 1 3

1 0 0 - 0 0 Totals 22 2 1 2* 5

Orthotopic appentllcocecostomy 16

Tubulanzed c d tube 2 1 1 Ureter -

* Stenoses at umbilical flap level

that they had no further soiling whatsoever with reliable emptying. There was marked improvement in the 3 other patients although accidents occurred an average of 4 to 6 times per month.

DISCUSSION

Pediatric urologists are often involved in the care of chil- dren who have not only urinary incontinence but problems of fecal elimination as well. If standard techniques of diet ma- nipulation, drugs and laxatives or the high rectal washout as described by Shandling and Gilmour have failed, there has been little recourse for this select group.4 Surgical therapy has had poor success and, thus, many of these children are relegated to spend the rest of their lives in diapers or in some cases undergo fecal diversion via colostomy.5

The technique and rationale behind the antegrade conti- nence enema were first described in 1990 by Malone et al.2 Initially this antegrade enema technique was used for fecal incontinence. The Mitrofanoff principle of a dismembered, reimplanted appendix into the cecum was used. Further ex- perience with this initial dismembered technique as well as the orthotopic appendicocecostomy was reported in 1993 by Squire et al, who expanded the indication for the antegrade continence enema in patients with severe constipation.3 The short and long-term success in this population appeared to be excellent in the majority although, as in our series, it was not universally successful nor complication-free. As Malone et a1 previously described, the approach to each

patient must be individualized.* Success totally depends on experimentation by the patient and family, and so the ulti- mate frequency and volume of administration must be deter- mined by trial and error. Most of the patients in our experi- ence tend to use catheters that have been discarded after use for clean intermittent catheterization of the urinary tract. In general, antegrade enemas are administered with the pa- tient sitting on the commode.

Although others initially reported administering an enema containing phosphate followed by smaller volumes of saline, our patients have had success using tap water, saline andor soapsuds with no obvious metabolic problems. Our experi- ence also suggests that tap water alone as the enema solution is safe. If in the long term our success rate is maintained using tap water, the potential for hyperphosphatemia that has been described with phosphate enemas would be elimi- nated.7 Presently we are monitoring renal function and elec- trolytes every 3 months to ensure no long-term problems with free water absorption or loss of electrolytes.

Because there have been a few instances in our series of fecal or gas leakage in patients who underwent nonimbri- cated orthotopic appendicocecostomy, we now recommend the imbricated procedure in all patients to prevent the po- tential for such reflux. We currently discard the tip of the mobilized appendix that is in continuity with the cecum appendix. A cruciate incision is made in the posterior perito- neum and fascial layer at the appropriate area where the appendix is to reside. After making a U shaped skin flap (if the right lower auadrant is to be the stomal site) or a similar

umbilical flap (if it is to be an umbilical antegrade continence enema) the anterior fascia is incised in line with the posterior fascial incisions, and a tract is created and dilated to admit the index finger easily. The appendix is brought through this path before cecal imbrication to determine the length of ap- pendix that can be safely imbricated. Complete mobilization of the cecum that will ultimately allow it to reach the poste- rior abdominal incision affords the maximum available ap- pendiceal length. The appendix is then returned to the abdo- men and an appropriate imbricated tunnel is created by flipping the appendix to lie on the anterior surface of the cecum with its tip facing cranially. With a 12F latex-free catheter passed through the appendix into the cecum to prevent compression the serosa of the cecum is brought over the appendix using Lambert 3-zero silk interrupted sutures. Two to 3 such sutures are used to create a 1.5 to 2.0 cm. tunnel. The catheter is withdrawn and reinserted to ensure easy passage. The appendix is then brought through the abdominal tract, such that the cecum lies flush with the posterior fascia and is sutured to it with 3 or 4 interrupted silk sutures. We repeat placing the catheter at this time to exclude any inadvertent torsion of the appendix. The appen- diceal serosa is then tacked to the anterior fascia a t 3 points with 25, 3-zero poligrecaprone sutures. Any excess distal appendix is discarded. The antimesenteric wall of the appen- dix is spatulated and the skin flap or umbilicus is anasto- mosed to the appendix beginning at the spatulated apex using 25, 5-zero Poligrecaprone sutures.

The 12F catheter is left in situ for 3 weeks following sur- gery. We remove the catheter 3 weeks later although irriga- tions are commenced as soon as the patient tolerates a full oral diet. The catheter used subsequently for intermittent catheterization is always nonlatex with the type left up to the patient. Some prefer the standard softer Foley balloon cath- eter since it frees the hands during enema administration with the inflated balloon. However, because instillation time is less than 5 minutes, the majority of families use 12F silicone catheters that have been discarded after 10 to 14 days of urinary clean intermittent catheterization. To date we have not found it necessary to do any additional catheter- izations in an attempt to prevent stomal stenosis. However, anecdotally we believe that our incidence of stomal stenosis is higher in our combined experience of urinary and fecal cutaneous appendicostomy when the umbilical flap group is compared to the right lower quadrant skin flap group.

When appendix is not available, our results as well those of Squire et a13 suggest that a tubularized cecal flap 1s

possible although it is probably more prone to complication than the appendix when used as a catheterizable stoma. In 2 cases we transected the appendix, such that it could be used for dual purposes simultaneously. The distal portion served as a bladder Mitrofanoff stoma and the remaining proximal orthotopic stump served as an antegrade continence enema stoma. When the appendix is long enough this option 1s

excellent in those requiring a supravesical catheterizable urinary stoma and an antegrade continence enema access

- . -. . .. . . - stoma. The Malone antegrade continence enema procedure is

ANTEGRADE ENEMA FOR INCONTINENCE AND CONSTIPATION 761 an important adjunct in the care of adults and children with problems of fecal elimination in whom standard medical therapies have failed.

REFERENCES

1. Mitrofanoff, P.: Cystostomie continente transappendiculare dans le traitement des vessies neurologiques. Chir. Ped., 21: 297, 1980.

2. Malone, P. S., Ransley, P. G. and Kiely, E. M.: Preliminary report: the antegrade continence enema. Lancet, 336: 1217, 1990.

3. Squire, R., Kiely, E. M., Cam, B., Ransley, P. G. and Due, P. G.: The clinicd application of the Malone antegrade colonic en- ema. J. Ped. Surg., 28: 1012,1993.

4. S h a d i n g , B. and Gilmour, R. F.: The enema continence cathe- ter in spina bifida: successful bowel management. J. Ped. Surg., 2 2 271, 1987.

5. Boari, A: Contributo sperimentale alla plastica dell'uretere. Atti. Acad. Sci. Med. Nat. Ferrara, 88: 149, 1894.

6. Ockerblad, N. F.: Reimplantation of the ureter into the bladder by a flap method. J. Urol., 61: 845,1947.

7. McCabe, M., Sibert, J. R. and Routledge, P. A.: Phosphate ene- mas in childhood: cause for concern. Brit. Med. J., 302: 1074, 1991.