Simplified technique for antegrade continence enemas for fecal retention and incontinence

Abstract

Fecal incontinence and chronic constipation occur with annoying frequency after reconstructive colorectal operations for Hirschsprung’s disease and imperforate anus in childhood. Chronic constipation is a frequent occurrence that complicates the care of children with spina bifida and of neurologically impaired patients of all ages. Fecal incontinence is devastating to the self-esteem of a child, depriving him or her from socializing with peers and limiting participation in most vigorous sports activities. A bowel-management program with use of a daily enema, manipulation of the diet, and use of some medications has been helpful in reducing incontinence in several children after repair of imperforate anus. Chronic use of rectal enemas, suppositories, laxatives, or lubricants, however, is often uncomfortable, poorly accepted, and intolerable to the patient, and cumbersome and disruptive to other members of the family who are responsible for the child’s care. Since its first description by Malone and associates in 1990, the antegrade continence enema (ACE) has been used with increasing frequency by surgeons for the management of children with fecal incontinence or retention. The technique entails construction of a permanent, nonrefluxing appendiceal stoma in the abdominal wall through which a catheter can be inserted to deliver enema solutions in an antegrade manner on a daily basis, as desired. This operative procedure is somewhat extensive for the patient who requires only the instillation of enema solutions into the proximal colon and has caused skin irritation, granulation tissue with stenosis, and occasional fecal leakage in five of the children in whom it was used in our hospital. Griffiths and Malone reported that 80% of their patients had some type of complication, either minor or major, and that 5 of 21 patients required a colostomy. Other investigators have noted several late complications after the Malone procedure. To reduce these complications, several modifications of the continent appendicostomy have been reported by other groups. To simplify the operation, Webb and associates recommended laparoscopic construction of a cutaneous appendicostomy for antegrade enemas. Chait and associates have performed percutaneous insertion of a low-profile cecostomy catheter or “button” under local anesthesia as a two-stage procedure for antegrade colonic cleansing in several children, with good success. The present study summarizes our clinical experience at the University of California, Los Angeles Medical Center in the management of 24 children with fecal incontinence or constipation using a simplified surgical technique. In this procedure, a Broviac silicone elastomer intravenous (IV) catheter was placed in the cecum for ACE infusions.