Colonoscopy-Assisted Creation of Antegrade Continent Enema Tract in a Patient With Spina Bifida

Abstract

Spina bifida is a neural tube defect that affects 33-52/100,000 live births. Bowel incontinence affects 60-70% of all patients, and is a source of significant limitation to social interactions. When first line treatment with traditional laxatives fail, an antegrade continence enema (ACE) tract can help improve quality of life. An 18-year-old woman with spina bifida and hydrocephalus was referred for neurogenic bowel characterized by severe constipation and daily fecal incontinence. She had tried several bowel regimens with inconsistent benefit. Her surgical history was complicated by hydrocephalus requiring 2 ventriculoperitoneal shunts, bladder rupture, and bladder augmentation. After discussion of possible options, she elected to undergo an ACE procedure and was referred to pediatric surgery. A plan was made to try a laparoscopic approach, with colonoscopy rescue procedure planned is this was unsuccessful. On the day of procedure, multiple attempts to gain laparoscopic access through the suprapubic and epigastric routes were unsuccessful due to thick adhesions from past surgeries. Both wounds were closed, and gastroenterology was called to proceed with a colonoscopy-assisted procedure. Colonoscopy was accomplished without difficulty with a cecal intubation time of 7 minutes. Attempts at transillumination in the cecum failed. A spot with good transillumination and good one-to-one colonic indentation was identified in mid-ascending colon. Three T-fasteners were deployed in a triangular fashion under endoscopic visualization to anchor the ascending colon to the abdominal wall. A small cruciate incision was made and a needle was passed into the ascending colon. A guidewire was placed through the needle, and the tract dilated to 11 F. A 10.2 F Chait percutaneous cecostomy catheter was deployed using an introducer over the guidewire and placed under visualization in the ascending colon, creating a tract through which antegrade enema could be administered. Procedure time from scope insertion to withdrawal was 27 minutes. The patient was discharged home the day after the procedure. On telephone follow up, she reported excellent bowel control since the procedure was completed. Our report indicates that colonoscopy-assisted creation of an ACE tract can be accomplished without difficulty when laparoscopy may be difficult due to adhesions, or where the appendix may not accessible for a traditional Mallone ACE procedure.Figure: Chait percutaneous cecostomy tube in colon.