Preliminary report: the antegrade continence enema
Abstract
The principles of antegrade colonic washout and the Mitrofanoff non-refluxing catheterisable channel were combined to produce a continent catheterisable colonic stoma. The intention was that antegrade washouts delivered by this route would produce complete colonic emptying and thereby prevent soiling. The procedure has been successfully carried out in five patients with intractable faecal incontinence.
References (7)
- B. Shandling et al.
The enema continence catheter in spina bifida: successful bowel management
J Pediatr Surg
(1987) - J. Hewitt et al.
Whole gut irrigation in preparation for large-bowel surgery
Lancet
(1973) - P. Mitrofanoff
Cystostomie continente trans-appendiculare dans le traitement des vessies neurologiques
Chir Pediatr
(1980)
Cited by (734)
Medium-Term Outcomes of Antegrade Continent Enema (ACE): Cairo University Specialized Pediatric Hospital (CUSPH) Experience
2023, Journal of Pediatric SurgeryTo assess the medium-term outcomes of ACE in children with fecal incontinence (FI).
Eligible children were recruited from the colorectal clinic between December 2016 and January 2020 and were followed prospectively for 2–6 years. A series of questionnaires were used to assess QOL, patients and parent satisfaction, and to assess the outcomes of the ACE.
24 children aged 6–12 years (mean age 8.17 ± 1.95), including 18 males (75%) and 6 females (25% were studied. Cases included anorectal malformations (45.83%)., Hirschsprung disease (25%), neural tube defects (16.66%), sacrococcygeal teratoma (4.16%), and intractable pseudoincontinence (8.33%). QOL improved from (3) [3 -3] to (16) [16-16],p < 0.05. Fecal incontinence index showed significant improvement: 20 [20-20] versus 3 [0–4],p < 0.05. Bowel symptoms demonstrated improvement in the ability to decide when to pass stools and a decrease in soiling. Stooling survey showed lower scores representing better outcome. ACE questionnaire showed that the range of irrigation volumes used by parents is wide, and that all families recommend the ACE for children with similar condition. Postoperative complications were stenosis (16.66%), stomal prolapse (12.5%), leakage (4.16%), and false passage (4.16%). Satisfaction questionnaire showed a median score of 9 (range, 5–10).
ACE is an effective method to keep the child with FI clean, more socially active, and with a better QOL and FII in the medium-term. The reported complications were stenosis, false passage, and leakage. ACE mucosa prolapse is a novel complication picked up on medium-term follow up.
Functional constipation refractory to medical management: The colon is the problem
2023, Journal of Pediatric SurgeryManagement of refractory constipation in children has not been standardized. We propose a protocolized approach which includes a contrast enema, anorectal manometry and exclusion of Hirschsprung disease (HD). For those without HD or with normal sphincters, an assessment of the colonic motility may be needed. The subgroups of dysmotility include (1) slow motility with contractions throughout, (2) segmental dysmotility (usually the sigmoid), or (3) a diffusely inert colon. We offered a Malone appendicostomy in all groups with the hope that this would avoid colonic resection in most cases.
Patients with medically refractory constipation were reviewed at a single institution (2020 to 2021). For patients without HD or an anal sphincter problem, assessment of colonic motility using colonic manometry was performed followed by a Malone appendicostomy for antegrade flushes.
Of 196 patients evaluated for constipation refractory to medical management, 22 were felt to have a colonic motility cause. These patients underwent colonic manometry and Malone appendicostomy. 13 patients (59%) had a slow colon but with HAPCs throughout, 5 (23%) had segmental dysmotility, and 4 (18%) had a diffuse colonic dysmotility. 19 (86%) responded well to antegrade flushes with 17 reporting no soiling and 2 having occasional accidents. 3 patients (14%) failed flushes and underwent a colon resection within 6-month following Malone procedure.
We propose a protocol for medically refractory constipation which provides a collaborative framework to standardize evaluation and management of these patients with antegrade flushes, which aids in avoidance of colonic resection in most cases.
Level IV
The appendix conduit with a conflict of interests – An alternate strategy
2023, Journal of Pediatric UrologyConventionally the split appendix has been used to address the need for dual conduits such as the Mitrofanoff and the ACE, however limited by its length. We present a video demonstration of an alternate solution.
Size-12 Nelaton catheter introduced via appendicular stump and skirted along the lateral wall of the caecum. Ethicon Endopath 35 mm Linear Stapler was used to create a caecal tube of about 3 cm based on the appendicular stump.
From September 2019–January 2023, 6-patients, aged 5–18 years with a diagnoses of 4-spinal dysraphisms, 1-cloacal anomaly, and 1-urogenital sinus were included. Follow up: 5–45 months. Two patients had ACE site infection which resolved with antibiotics. One developed a stomal granuloma treated effectively with silver nitrate. All are clean with no stomal leaks and experience easy intubation.
Alternatives to the split appendix include the Monti ACE, and Caecostomy tube/caecal flap when limited by appendicular length. The technique described is easy and quick however care must be taken to keep away from the ileo-caecal junction and to keep the tube length as short as possible or needed to preserve vascularity.
The stapled caecal tube ACE is easy, quick, and safe especially when limited by appendicular length.
Stapled neoappendicostomy: A novel technique
2022, Journal of Pediatric SurgeryLong term outcome of antegrade colonic enema (ACE) stoma for treatment of constipation and fecal incontinence in children
2022, Journal of Pediatric SurgeryTo determine the long term outcome of antegrade colonic enema (ACE) stoma for treatment of chronic constipation and soiling in children.
We reviewed patients prospectively who underwent formation of ACE stoma after failure of maximum medical treatment of chronic constipation and soiling from September 2008 to October 2020. All patients had anorectal manometry, endosonography and colonic transit study. A validated symptom severity (SS) score questionnaire was used pre operatively and during follow up. The sum of SS score ranged between 0 (best) and 65 (worst). Data was expressed as median(range) and Wilcoxon rank sum test was used and p value < 0.05 was considered significant.
58 patients had formation of ACE stoma, laparoscopic appendicostomy 56, cecostomy 1, and open procedure 1. The main indications for the ACE stoma were chronic functional constipation (FC) 50(86%), anorectal malformations (ARM) 6(11%) and Hirschsprung disease (HD) 2(3%). 41(71%) of patients had previous intrasphincteric botulinum toxin (BT) treatment. Age at operation was 11(range 4–15) years and follow up was 36(3–84) months. 47(81%) patients were continent of stool within three months postoperatively. The preoperative SS score improved from 34/65 (26–47) to 8/65 (4–12) at 12 months and 5/65 (2–11) at 24 months follow up, p ≤ 0.05.
complication rate was 15(26%), wound infection 5, granulation tissue 4, stoma prolapse 4, retraction 1, abscess formation and fistula 1. 15 (26%) adolescents had transition of their care to adult services.
There is a significant improvement of constipation, soiling and general health of patients following formation of ACE stoma. Adolescents benefits an orderly transition of their care to adult services.
Level 2, Therapeutic study.
Simultaneous placement of fecal and urinary continent channel stomas in the umbilicus: Single-center experience
2022, Journal of Pediatric UrologyIn patients with urinary continent channel (UCC) and Malone Antegrade Continent Enema (MACE) procedures, two separate abdominal stomas are needed. The umbilicus is a preferred site for single channel stomas given the ability to conceal the stoma. However, there are no studies describing outcomes of both stomas being created in the umbilicus. We aimed to describe our experience in patients who underwent UCC and MACE stomas both placed in the umbilicus.
A retrospective review from 2009 to 2020 was performed in our institution for patients who underwent the creation of UCC and MACE stomas simultaneously in the umbilicus. The variation in the technique involves two V-skin shaped flaps in the umbilicus; the MACE and UCC stomas are delivered from both flaps and placed at the right and left side respectively. Patients with greater than 3 months of follow-up were included in the study.
There were 17 patients identified with the median age of 13.5 years and a median follow-up of 32.8 months. The mean BMI percentile was 89.5%. Monti technique and split appendix with cecal extension were utilized in 8 (47.1%) and 7 (41.2%) patients respectively and 13 (76.5%) patients required concurrent urological procedures. All channel-related complications occurred within a mean time of 15.7 months. Skin-level stenosis in the MACE occurred in 5 (29.4%) events, and all were successfully managed by placing an indwelling catheter for up to two weeks. There were 2 (11.8%) complications related to UCC, which required subfascial minor surgical revision. The rate of patients with symptomatic UTI decreased 35.3% postoperatively, and no new onset of UTI occurred in patients without a prior history of UTI. During follow-up, all patients remained dry between CIC, however one had occasional leakage related to delay in catheterization. Total fecal continence was achieved in 14 (82.3%) patients. Additionally, 3 (16.6%) patients experienced improvement in fecal continence with sporadic soiling episodes.
Placement of UCC and MACE stomas in the umbilicus demonstrate a percentage of complication of 7/34 (20.6%) with only 2 patients requiring surgical intervention, comparable to the standard. UTI rate decreased in patients with a prior history of UTI. We believe the patients’ perspective and degree of satisfaction will fully determine the benefits of this technique.
Simultaneous UCC and MACE stomas placed at the umbilicus showed good functional outcomes and similar complication rates to traditional approach where stomas were placed separately in the abdominal wall.