Y-Appendicoplasty: A Technique to Minimize Stoma1 Complications in Antegrade Continence Enema

By Paul K.H. Tam Hong Kong, China

Purpose:The antegrade continence enema (ACE) is an effec- tive method of treatment of fecal incontinence and constipa- tion. However, the original procedure described is not easy to perform and is associated with a high complication rate, especially stoma1 stenosis-necrosis (55%). Even with introduc- tion of orthotopic appendicostomy, composite series still report an incidence of 30% with stoma1 problems. The authors report a virtually complication-free simple modifica- tion, the Y-appendicoplasty.

Methods:The base of the appendix is imbricated into cecum by 2 successive rows of interrupted seromuscular stitches. A

small Y-shaped incision is made on the abdominal wall at McBurney’s point, and 3 triangular skin flaps are raised. The appendix is brought out of the skin incision. The tip is excised, and 3 vertical cuts are made 120” apart. The 3 appendiceal

flaps thus created are interdigitated with the skin flaps using interrupted sutures.

Results: Twelve children underwent Y-appendicoplasty and orthotopic appendicostomy. Mean operating time was 1 hour. None experienced stoma1 complications that required intervention. Control of fecal continence with ACE ranged from excellent to good.

Conclusion: Y-appendicoplasty and orthotopic appendicos- tomy minimizes complications for ACE and is easy to per- form. J Pediatr Surg 34:1733-1735. Copyright o 1999 by W. B. Saunders Company.

INDEX WORDS: Antegrade continence enema, orthotopic appendicostomy, Y-appendicoplasty, stoma1 stenosis, fecal incontinence, intractable constipation.

M ANAGEMFBT of fecal incontinence and intrac- table constipation has been transformed by the

introduction of the antegrade continence enema (ACE) by Malone et al in 1990.’ The principle involves the construction of a catheterizable, nonrefluxing channel using the appendix to allow regular antegrade colonic washouts. With proper patient selection and a comprehen- sive management program, a major improvement in the patients’ quality of life can be achieved.2 However, despite the proven efficacy, ACE has not been practiced as widely as it could be. Until 1998, only about 200 cases have been reported in literature.2-16 Part of the reason is that, technically, the procedure is not straightforward, involving reimplantation of the transected, vascularized appendix into the cecum and construction of a funnel- shaped anastomosis between the appendix and a skin flap.6J7 More importantly, the originator of the procedure reported a high rate of complications (81%), most of which were related to surgical technique.6 We report a new and simple modification of the procedure, the Y-appendicopiasty and orthotopic appendicostomy, which is associated with minimal morbidity.

MATERIALS AND METHODS

Between January 1993 and April 1998, 16 children underwent the ACE procedure for persistent soiling. The first 2 children underwent the original ACE procedure. Two children underwent a cecostomy button

because the appendix had previously been removed. Twelve children underwent the new modified procedure as follows.

The procedure consists of a continent appendicocecostomy without reversal of the appendix and a simple 3-flap appendicoplasty to prevent stomal complications. Cefuroxime and metronidazole are given intrave- nously on induction of anesthesia. To avoid kinking of the catheteriz- able conduit, the most direct course is adopted by planning the exit site of the appendix at the McBumey’s point on the abdominal wall (Fig 1A). A minilaparotomy is performed via a transverse incision placed a short distance above the McBurney’s point. The base of appendix is imbricated into the cecum by 2 successive rows of interrupted seromuscular stitches using nonabsorbable sutures (Fig 1B). A small Y-shaped skin incision is made, centered on the McBumey’s point, and 3 triangular skin flaps are raised (Fig 1C).

The appendix is brought out through the abdominal wall. The tip of the appendix is excised, and 3 vertical cuts are made 120” apart to create 3 appendiceal flaps (Fig 1D) for interdigitation with the triangular skin flaps. The cecum is tacked to the peritoneum with 30 Vicryl sutures.8 A size 8 SILASTIC@ (Dow Corning, Midland, MI) Foley catheter is inserted to ensure smooth passage in the conduit. The tips of the skin flaps (A, B, C) are sutured to the proximal ends of the appendiceal incisions (A’, B’, C’). The tips of the appendiceal flaps (X, Y, Z) are

From the Department @Surgery, University of Hong Kong Medicaf Centel; Queen Mary Hospital, Hong Kong SAR, China.

Presented at the 32nd Annual Meeting of the Pacific Association of Pediatric Surgeons, Berj‘ing, China, May 9-14, 1999.

Address reprint requests to Professor Paul K.H. Tam, Department of Surgery, University of Hong Kong Medical Centec Queen Mary Hospital, Hong Kong SAR, China.

Copyright @ 1999 by N!B. Saunders Company 0022-3468/99/3411-0035$03.00/O

Journal of Pediatric Surgery, Vol34, No 11 (November), 1999: pp 1733-1735 1733

1734 PAUL K.H. TAM

Fig 1. (A) Planned incision. Transverse incision for laparotomy and Y-shaped incision at McBurney’s point. (B) lmbrication of base of appendix into cecum by seromuscular sutures. (C) Three vertical incisions 120’ apart, 1 cm long each, in amputated appendix. This creates 3 appendiceal flaps. (D) Y-shaped skin incision, each limb 1 cm long, 120’ apart. This creates 3 triangular skin flaps. (E) Tips of skin flaps (A, a, c) anastomosed to base of appendiceal flaps (A’, E’, c’) and bases of skin flaps (x, Y, z) anastomosed to tips (x’, Y’, z’) of appendiceal flaps. (F) Completed stoma1 anastomosis.

similarly sutured to the bases of the triangular skin flaps (X’, Y’, Z’); Fig 1E). The z&zag cutaneo-appendicular anastomosis is completed with intervening sutures (Fig 1F).

The laparotomy wound is closed in layers. One percent chlorampheni- co1 ointment is applied to the stoma for dressing. Antibiotics are continued for 5 days postoperatively. The SILASTIP (Dow Coming) Foley catheter is retained for 1 week, after which daily catheterization is performed for antegrade colonic washouts.

RESULTS

Mean operating time was 1 hour. Most children resume feeding the next day. Analgesic requirement was mini- mal. Follow-up ranged from 1 to 3 years with an average of 1.8 years. There was no major complication. One child had mild stoma1 infection, followed by granulation formation, resulting first in reluctance and then difficulty in self-catheterization. This was overcome by catheteriza- tion with an infant feeding tube, which was kept for 2 weeks. Subsequent introduction of successive larger catheters restored normal passage. Patients report satisfac- tory control of fecal continence with none requiring nappies. One patient described the result as “unbeliev- able,” “the best thing that has ever happened.” All patients are satisfied with the cosmesis after surgery (Fig 2). Fig 2. Late appearance of stoma and wound.

Y-APPENDICOPLASTY: MODIFICATION FOR ACE

DISCUSSION

The disadvantages of the original ACE procedure include technical difficulty and high complication rates (30% to 81%). Like us, others have found reversed reimplantation of the appendix to be unnecessary and have adopted orthotopic appendicostomy.3 Imbrication of the base of appendix into the cecum results in a satisfac- tory antireflux mechanism.

By choosing the straightest and shortest route of exit to the McBumey’s point, the common problem of kinking encountered in the original procedure is avoided, en- abling easy self-catheterization by the patient. This also obviated the problem of intestinal obstruction or torsion (14% of Griffiths and Malone’s series).6

The originally described funnel-shaped skin flap mea- sures 8 to 10 cm in total length, resulting in an unsightly scar. Despite the use of this flap for anastomosis with the appendix, stoma1 stenosis is common (29%).6 Closure of

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the wound is associated with tension,17 and stoma1 breakdown is frequent (29%).6

The Y-appendicoplasty provides a simple solution to the stomal problems. It is known that circular stomas tend to stenose. Interdigiting flaps provide a lengthened zig- zag anastomosis that reduces such risks, eg, stenosis of end tracheostomy could virtually be eliminated by the adoption of cruciate skin flaps.‘* The small size of the appendix will allow creation of only 3 flaps, and, hence, corresponding tripartite skin flaps are appropriate. Our Y-appendicoplasty is tension free, avoids the commonly encountered stomal complication, and is aesthetically more pleasing. The simplicity of the procedure has reduced operating time considerably.

We believe that our new modification of the ACE procedure is simple and effective and could help to popularize this useful method of treatment of fecal incontinence.

REFERENCES 1. Malone PS, Ransley PG, Kiely EM: Preliminary report: The

antegrade continence enema. Lancet 336:1217-1218,199O 2. Toogood GJ, Bryant PA, Dudley NE: Control of faecal inconti-

nence using the Malone antegrade continence enema procedure: A critical appraisal. Pediatr Surg Int 10:37-39, 1995

3. Graf JL, Strear C, Bratton B, et al: The antegrade continence enema procedure: A review of the literature. J Pediatr Surg 33:1294- 1296,1998

4. Dick AC, McCallion WA, Brown S, et al: Antegrade colonic enemas. Br J Surg 83642~643,1996

5. Ellsworth PI, Webb HW, Grump JM, et al: The Malone antegrade colonic enema enhances the quality of life in children undergoing urological incontinence procedures. J Urol 155:1416-1418, 1996

6. Griffiths DM, Malone PS: The Malone antegrade continence enema. J Pediatr Surg 30:68-71,1995

7. Hill J, Stott S, MacLennan I: Antegrade enemas for the treatment of severe idiopathic constipation. Br J Surg 81:1490-1491, 1994

8. Kiely EM, Ade-Ajayi N, Wheeler RA: Caecal flap conduit for antegrade continence enemas. Br J Surg 81:1215, 1994

9. Koyle MA, Kaji DM, Duque M, et al: The Malone antegrade contmence enema for neurogenic and structural fecal incontinence and constipation. J Urol 154:759-761, 1995

10. Squiare R, Kiely EM, Carr B, et al: The clinical application of the Malone antegrade colomc enema. J Pediatr Surg 28:1012-1015, 1993

11. Levitt MA, Soffer SZ, Pefia A: Continent appendicostomy m the bowel management of fecally incontinent children. J Pediatr Surg 32:1630-1633,1997

12. Webb HW, Barraza MA, Crump JM: Laparoscopic appendicos- tomy for management of fecal incontinence. J Pediatr Surg 32:457-458, 1997

13. Shandling B, Chait PG, Richards HF: Percutaneous cecostomy: A new technique in the management of fecal incontinence. J Pediatr Surg 31:534-537, 1996

14. Redel CA, Motil KJ, Bloss RS, et al: Intestinal button implanta- tion for obstipation and fecal impaction in children. J Pediatr Surg 27:654-656,1992

15. Shankar KR, Losty PD, Kenny SE, et al: Functional results following the antegrade continence enema procedure. Br J Surg 85:980-982.1998

16. Meier DE, Foster ME, Guzzetta PC, et al: Antegrade continent enema management of chronic fecal Incontinence in children. J Pediatr Surg 33:1149-1152,199s

17. Tsang TM, Dudley NE: Surgical detail of the Malone antegrade continence enema procedure. Pediatr Surg Int 10:33-36, 1995

18. Lam KH, Wei WI, Wong J, et al: Tracheostome construction during laryngectomy-A method to prevent stenosis. Laryngoscope 93:212-215, 1983