Laparoscopic-Assisted Percutaneous Cecostomy for Antegrade Continence Enema

Abstract

The antegrade continence enema (ACE) is an option in the management of fecal incontinence and chronic constipation. We report our experience with a simple laparoscopic technique. Data were collected on 16 children (8 boys) who underwent laparoscopic cecostomy for ACE. Success was defined as cessation of fecal soiling with no need for diapers. Mean age at laparoscopic cecostomy was 11 years (range, 6-16 years). Mean follow-up after initial cecostomy was 22 months (range, 6-51 months). Diagnoses in 16 patients were functional constipation with soiling (n=14), incontinence after surgery for Hirschsprung's disease (n=1), and constipation secondary to mitochondrial disease (n=1). Seven had significant developmental or psychiatric problems. Three patients had primary placement of a trapdoor device (Chait); 13 had placement of a long tube, with later replacement by a skin-level device. We have evolved a laparoscopic-assisted percutaneous technique, using metallic anchor sutures on the cecum, and a dilator and peel-away sheath for introduction of the catheter. Complications occurred in 5 patients; 3 returned to the operating room: 1 for tube occlusion, 1 for suture granuloma, and 1 for a dislodged tube at 7 months postoperatively. One patient received intravenous antibiotics because of suspected peritonitis on the first postoperative day. One was re-admitted with abdominal pain. Five of 16 patients have failed therapy (four tubes removed and one tube in situ). Three have had only minor improvement. Eight have had successful ACE management, of whom 1 patient has had his tube removed after resolution of symptoms. Of 8 patients with no or minimal improvement with ACE, 5 have significant psychiatric problems. Laparoscopic-assisted percutaneous cecostomy has an excellent safety profile and patient comfort. The procedure is simple, secure, and reversible. Results were excellent in half of the patients. Associated psychiatric or behavioral problems may predict poor response to ACE.