Cecostomy Research Articles

15 P Percutaneous endoscopic caecostomy for antegrade continence enemas in children with fecal incontinence or chronic constipation

15 P Percutaneous endoscopic caecostomy for antegrade continence enemas in children with fecal incontinence or chronic constipation

Appendicostomy for antegrade enema: effects on somatic and psychosocial functioning in children with myelomeningocele.

To assess changes in somatic variables, psychosocial functioning, mental health and self-esteem after appendicostomy for antegrade enema (MACE) in children with myelomeningocele (MMC). We performed the MACE procedure in 20 children, aged 6.3 to 17.0 years. Twelve patients had an open and 8 had a laparoscopic operation. Somatic function was assessed preoperatively and 6 and 16 months postoperatively. Psychosocial functioning and mental health were assessed preoperatively and 6 months postoperatively by a structured clinical interview and standardized questionnaires, Youth Self-Report, Child Behavior Checklist, and Harter's Self-Perception Profile for Adolescents. Preoperatively, 9 patients had fecal leaks several times a week, 7 had leaks 1 to 4 times per month, and 4 were continent. The corresponding numbers 6 and 16 months postoperatively were 0, 6, and 14 and 0, 3, and 16. Six patients have had postoperative stoma complications that required surgery; 5 had a well-functioning stoma thereafter, and 1 had a colostomy 7 months later. Preoperatively, 14 patients reported considerable, 4 moderate, 2 minor, and 0 no psychosocial problems related to bowel control and emptying regimen. Six months postoperatively, the corresponding numbers were 1, 2, 6, and 11. The standardized questionnaires revealed substantial psychopathology in the MMC patients. The Child Behavior Checklist and Youth Self-Report scores were not significantly changed postoperatively, but global self-esteem score and close friends score from the Self-Perception Profile for Adolescents were significantly improved. Fecal incontinence and constipation were greatly reduced by MACE. Children with MMC often have psychological and psychosocial problems, but important improvements in self-esteem and psychosocial function were observed 6 months after the MACE procedure.

APPENDICEAL VERSUS ILEAL SEGMENT FOR ANTEGRADE CONTINENCE ENEMA

To assess outcomes after the antegrade continence enema procedure, we present our results with an ileal segment or the appendix in children with severe bowel dysfunction. A retrospective review of 45 children who had undergone the creation of a continent cecostomy for severe chronic constipation and fecal incontinence was performed. The appendix was used to create the continent cecostomy in 28 patients (group 1) and ileum 17 (group 2). Of 16 patients who underwent simultaneous construction of appendiceal Mitrofanoff neourethra, including continent catheterizable stoma, the appendix was split and used for the cecostomy and neourethra in 11. Overall, acceptable continence was achieved in 39 (87%) patients and total continence 31 (69%). No significant difference was noted in the rate of continence between groups 1 and 2. Nonstomal postoperative complications occurred in 5 patients in group 1 and 3 group 2. Complications that required reoperation related to the continent cecostomy occurred in 10 patients, including stomal stenosis in 8, with 6 group 1 and 2 group 2 (p >0.05), and stricture in 2, with 1 group 1 and 1 group 2. There were 2 patients who had previously undergone colostomy for intractable constipation who were undiverted at the time of the creation of continent cecostomy. Both were continent postoperatively. There were 3 patients, including those 2 who presented with chronic severe constipation of unclear etiology, who underwent colostomy for unrecoverable colonic dys-motility, of whom 1 subsequently required total colectomy. The creation of a continent cecostomy for antegrade continence enema is a successful management option in children with debilitating fecal incontinence, and may enable undiversion of an existing colostomy. The appendix and ileal segment are viable options for the procedure, with no significant difference noted in continence or complication rates.

Improvement in neurogenic bladder after the antegrade continence enema procedure

A child with neurogenic bladder and bowel underwent an antegrade continence enema procedure for fecal incontinence and severe constipation. She subsequently demonstrated an improvement in her neurogenic bladder and urinary incontinence.

TAP WATER AND THE MALONE ANTEGRADE CONTINENCE ENEMA: A SAFE COMBINATION?

The Malone antegrade continence enema provides independence and improved quality of life in patients with fecal incontinence or intractable constipation. However, isolated reports of fatal hypernatremia after irrigation with normal saline have raised safety concerns about frequent colonic irrigation in children. Significant electrolyte abnormalities have also been reported with hypertonic phosphate and high colonic tap water enemas. Because our patients routinely use tap water for Malone antegrade continence enema irrigations, we examined the safety profile of this practice In the last 3.5 years 71 patients at our institution have used antegrade tap water enemas for managing fecal incontinence or intractable constipation. Standard serum electrolytes were measured We obtained 101 sets of serum electrolyte measurements in 71 patients at a mean of 8.4 months postoperatively (range 1 to 33). A girl who presented with severe hyponatremia and hypochloremia had not used the Malone antegrade continence enema for several days. The most interesting finding was significantly elevated sodium and chloride in 1 case 6 weeks after surgery that was associated with tap water treated with a home softening system. Electrolytes reverted to normal 1 week after using untreated tap water We did not detect significant hyponatremia or hypochloremia in any patient using tap water for Malone antegrade continence enema irrigation. Although dangerous electrolyte abnormalities are rare, potential morbidity in those cases warrants periodic evaluation. Due to the elevated sodium content in softened tap water families should be alerted to use untreated tap water for preparing enemas.

Bowel management with antegrade colonic enema using a Malone or a Monti conduit--clinical results.

During this last decade, major surgical improvements have been proposed for the treatment of patients suffering from faecal incontinence or intractable constipation. Between 1996 and 1999, 12 patients mainly presenting with spina bifida were operated for antegrade colonic enema (ACE). In seven cases, a Malone procedure was performed. In 5 cases we used a Monti plasty to create a continent catheterisable conduit. In 4 cases the neoconduit was placed between the transverse colon and the umbilicus. The mean follow-up was 15 months. Bowel control and continence were obtained in 11 cases, postoperatively. One early complete stenosis of the cutaneous stoma occurred, after which the patient did not wish to carry on. Another patient stopped using his ACE stoma after several months because he was able to manage his bowel evacuation voluntarily without requiring an enema. The other ten patients have greatly improved their quality of life. Complications included principally stomal stenosis which can be regularly dilated by the patient himself using the Hegar dilator. Patients with umbilical stoma have a result comparable to patients with Malone procedure. Our series shows that ACE can be performed without an appendix using a Monti plasty. Implantation of the continent conduit in the caecum or in the transverse colon does not modify the overall results of ACE.

CONCEALED UMBILICAL STOMA: LONG-TERM EVALUATION OF STOMAL STENOSIS

The technique of forming a concealed umbilical stoma has been described previously and includes a posterior umbilical flap for improved cosmesis and stenosis prevention. We assessed long-term stomal stenosis. We reviewed retrospectively the charts of 46 patients (mean age at surgery 14 years) of whom 35 had undergone concealed umbilical stoma creation and 11 the Malone antegrade continence enema procedure for continent urinary diversion. Urinary stomas were created from appendix in 20 cases, ileum in 8, sigmoid colon in 5, bladder in 1 and stomach in 1. Malone antegrade continence enema stomas were constructed from appendix in 10 cases and sigmoid colon in 1. A total of 21 patients underwent urinary diversion and augmentation cystoplasty. At followup of 12 to 84 months (median 3.4 years) 93.5% of patients had an intact stoma with no need for surgical revision. Of the remaining patients 3 (6.5%) required revision of the stoma at skin level for stomal stenosis at 1, 4 and 38 months after initial surgery and 2 had a brief period of indwelling catheterization for correction of stenosis. The concealed umbilical stoma technique provides an excellent cosmetic result with a low rate of stomal stenosis in patients requiring intermittent bladder or bowel catheterization.

Antegrade continence enemas in the treatment of slow-transit constipation

Background/Purpose: Children with anorectal dysfunction can now be treated by antegrade continence enema (ACE), as described Malone et al. Those with idiopathic constipation, however, are not thought to be suitable for this treatment. Over 150 children attend the authors' department with proven slow transit constipation (mostly proven on nuclear transit/X-ray study), and the authors reviewed the outcome in the 40 of these who have had the ACE procedure. Families completed a questionnaire and attended interview with an independent assessor. Methods: Of the 40 patients, 32 patients were assessed. Follow-up ranged from 3 to 54 months (median, 18 months) and age ranged from 5 to 17 years (median age, 10 years). Three of 32 stomas were no longer in use. Frequency of soiling was reduced significantly in 20 patients, and a further 6 patients were clean (P <.01). Abdominal pains were relieved significantly (P <.05), and appetite and mood improved. Results: Stomal complications were frequent, (stenosis in 16 of 29, mucus leak in 20 of 29, fecal leak 3 of 29, catheter-related pain in 20 of 29). Slow evacuation (12 of 29) and pain with enema (17 of 20) also were common. Conclusion: Malone appendicostomy does improve the well being of patients with slow transit constipation, but the advantages are less dramatic than in children with normal motility. J Pediatr Surg 36:1227-1230. Copyright © 2001 by W.B. Saunders Company.

TRANSVERSE RETUBULARIZED SIGMOIDOVESICOSTOMY CONTINENT URINARY DIVERSION TO THE UMBILICUS

Purpose: The most widely used conduit when creating continent urinary diversion based on the Mitrofanoff principle has been appendicovesicostomy. However, appendix is not always available and it is increasingly used for the antegrade continence enema in situ appendix procedure. In 1993 the technique of transverse retubularization of the ileum to create a continent catheterizable conduit for an ileal reservoir was described and in 1997 this technique was studied in an animal model. Larger patients may need 2 ileal segments in series to bridge the distance between the umbilicus and bladder. To avoid using 2 segments we used transverse retubularized sigmoid colon to create a catheterizable sigmoidovesicostomy to the umbilicus.Methods and Methods: In 5 children 6 to 19 years old (mean age 15) with neurogenic bladder secondary to spina bifida a transverse retubularized sigmoidovesicostomy to the umbilicus was performed. In all patients an antegrade continence enema procedure was done for refractory constipatio...

Transverse retubularized sigmoidovesicostomy continent urinary diversion to the umbilicus.

The most widely used conduit when creating continent urinary diversion based on the Mitrofanoff principle has been appendicovesicostomy. However, appendix is not always available and it is increasingly used for the antegrade continence enema in situ appendix procedure. In 1993 the technique of transverse retubularization of the ileum to create a continent catheterizable conduit for an ileal reservoir was described and in 1997 this technique was studied in an animal model. Larger patients may need 2 ileal segments in series to bridge the distance between the umbilicus and bladder. To avoid using 2 segments we used transverse retubularized sigmoid colon to create a catheterizable sigmoidovesicostomy to the umbilicus. In 5 children 6 to 19 years old (mean age 15) with neurogenic bladder secondary to spina bifida a transverse retubularized sigmoidovesicostomy to the umbilicus was performed. In all patients an antegrade continence enema procedure was done for refractory constipation and overflow fecal incontinence secondary to neurogenic bowel. Laparoscopy was performed to mobilize the appendix in patients who requested a low Pfannenstiel incision for better cosmesis. Additional procedures included the pubovaginal sling placement and sigmoid colocystoplasty. Mean length of the sigmoidovesicostomy, which was equal to the circumference of the sigmoid before retubularization, was 13 cm. (range 10 to 15). This sigmoid conduit reached the umbilicus easily in all cases. All sigmoidovesicostomies were easily catheterized and all were continent. One patient with morbid obesity (body mass index 40.4) had a mucocutaneous anastomotic breakdown 3 months postoperatively. Minimum followup was 1 year (mean 1.5). Transverse retubularized sigmoidovesicostomy is effective for creating a continent urinary diversion to the umbilicus in patients with neurogenic bladder secondary to spina bifida. Dilating the sigmoid colon from neurogenic bowel creates a long conduit based on the Yang-Monti principle and 2 ileal segments with an anastomosis are not required. Additional benefits are that the sigmoid colon is readily accessible via a low Pfannenstiel incision and may also be used for augmentation in select cases.

Catheterisable continent urinary diversion (Mitrofanoff principle)--clinical experience and psychological aspects.

48 Mitrofanoff principles (MTR) were performed on 46 patients (male : female ratio, 30 : 16) with a mean age of 9.1 years (range 2.5 to 24 years). The primary diagnoses were neurogenic bladder in 11, infravesical obstruction in 7 and bladder exstrophy-epispadias complex in 28 patients. The most common type of conduit was appendix (38 cases); other conduits were constructed from the ileum (seven) and ileocaecum (one). In two cases with bladder substitution the uterine tube and tubularised bladder stump were used as perineal MTR. 33 of the 46 children underwent augmentation cystoplasty in conjunction with the MTR procedure. The Malone procedure for antegrade colonic enema (ACE) was performed at the same stage with MTR in eight cases. To achieve continence, bladder neck reconstruction was performed in 32 patients and the bladder neck was closed in four patients during the same operation and MTR procedure. The mean follow-up period was 28.7 months (range one month to 57 months). To assess the psychological aspects of the MTR procedure, the Rosenberg Self-Esteem Scales were completed by 12 children older than eight years of age. Nine patients had problems with the MTR (19.5 %). Three appendiceal MTR had strictures at the skin level, 2 of which needed minor surgical revisions. A mucocele formation at the skin level of an appendix was removed successfully. We did not observe any complaints among the other appendiceal conduits. All the tapered ileum conduits were difficult to catheterise, and 1 of them had a leakage from the stoma. None of the three transversely tubularised ileum MTRs had problems with catheterisation or leakage. A stricture of the conduit from the uterine tube was observed. 36 of the 42 patients are now continent, giving a ratio of 86 %. The results of the Rosenberg Self-Esteem Scales revealed that there was an increase in the percentage of patients with high self-esteem, and a decrease in depressive feelings after the MTR procedure. We conclude that the MTR procedure provides excellent continence, offers good prospects of a socially acceptable life with increased self-esteem, and the appendix seems to be the ideal organ for continent urinary diversion, with the transverse tubularised ileal tube as a second choice.

SIMULTANEOUS MALONE ANTEGRADE CONTINENT ENEMA AND MITROFANOFF PRINCIPLE USING THE DIVIDED APPENDIX: REPORT OF A NEW TECHNIQUE FOR PREVENTION OF STOMA COMPLICATIONS

We determine the results and complications of continent urinary diversion and simultaneous Malone antegrade continent enema (MACE) and the Mitrofanoff principle using the divided appendix, and report on the VQQ and VQ technique for prevention of complications at the stoma level. Between June 1995 and June 1999, 40 patients 4 to 22 years old (mean age 9.5) underwent Mitrofanoff procedures in conjunction with the MACE and augmentation cystoplasty as primary (5) or salvage (35) therapy. Of the patients 35 had neuropathic bladder, and 5 had bladder and bowel dysfunction without detectable neurological abnormalities. All patients had an antireflux Mitrofanoff channel constructed using distal part of the appendix with its divided mesothelium. The proximal half of the appendix was preserved as a modified MACE. Average length of appendix was 10.3 cm. (range 9 to 15) and no correlation was found between the length of appendix and age of child. The stoma construction was performed as 2 different techniques. The 2 appendix stomas were initially anastomosed with 2 separate triangular posterior V shape skin flaps on the right lower abdominal wall. Both appendix mucosae were completely buried with a single or double quadrilateral skin flap (VQQ and VQ technique). All patients are continent day and night without diapers. Mean followup was 22 months (range 8 to 48) and the overall incidence of complications was 7.5%. Mitrofanoff stomal stenosis due to catheter false passage occurred postoperatively in 1 case, gas leakage from the MACE in 1 and partial mucosal prolapse in 1. The MACE and Mitrofanoff principle have proved invaluable for the treatment of children with urinary and fecal incontinence. The divided appendix with 2 separate mesotheliums is an ideal channel for simultaneous Mitrofanoff and MACE when the appendix length is 9 cm. or more with a suitable branching mesothelium. When the appendix is short we prefer to use it as the Mitrofanoff and create a pediculed tube flap from the cecum for the MACE. All patients with a short appendix or history of appendectomy operated on by different techniques, such as the Monti procedure, Casale technique, cecal flap or ureteral Mitrofanoff, were excluded from our study. Most of the minor complications are preventable by meticulous technique. The VQQ and VQ stomas have the lowest incidence of complications and produce the most satisfactory cosmetic appearance.

Simultaneous Malone antegrade continent enema and Mitrofanoff principle using the divided appendix: report of a new technique for prevention of stoma complications.

We determine the results and complications of continent urinary diversion and simultaneous Malone antegrade continent enema (MACE) and the Mitrofanoff principle using the divided appendix, and report on the VQQ and VQ technique for prevention of complications at the stoma level. Between June 1995 and June 1999, 40 patients 4 to 22 years old (mean age 9.5) underwent Mitrofanoff procedures in conjunction with the MACE and augmentation cystoplasty as primary (5) or salvage (35) therapy. Of the patients 35 had neuropathic bladder, and 5 had bladder and bowel dysfunction without detectable neurological abnormalities. All patients had an antireflux Mitrofanoff channel constructed using distal part of the appendix with its divided mesothelium. The proximal half of the appendix was preserved as a modified MACE. Average length of appendix was 10.3 cm. (range 9 to 15) and no correlation was found between the length of appendix and age of child. The stoma construction was performed as 2 different techniques. The 2 appendix stomas were initially anastomosed with 2 separate triangular posterior V shape skin flaps on the right lower abdominal wall. Both appendix mucosae were completely buried with a single or double quadrilateral skin flap (VQQ and VQ technique). All patients are continent day and night without diapers. Mean followup was 22 months (range 8 to 48) and the overall incidence of complications was 7.5%. Mitrofanoff stomal stenosis due to catheter false passage occurred postoperatively in 1 case, gas leakage from the MACE in 1 and partial mucosal prolapse in 1. The MACE and Mitrofanoff principle have proved invaluable for the treatment of children with urinary and fecal incontinence. The divided appendix with 2 separate mesotheliums is an ideal channel for simultaneous Mitrofanoff and MACE when the appendix length is 9 cm. or more with a suitable branching mesothelium. When the appendix is short we prefer to use it as the Mitrofanoff and create a pediculed tube flap from the cecum for the MACE. All patients with a short appendix or history of appendectomy operated on by different techniques, such as the Monti procedure, Casale technique, cecal flap or ureteral Mitrofanoff, were excluded from our study. Most of the minor complications are preventable by meticulous technique. The VQQ and VQ stomas have the lowest incidence of complications and produce the most satisfactory cosmetic appearance.

THE MALONE ANTEGRADE COLONIC ENEMA ISOLATED OR ASSOCIATED WITH UROLOGICAL INCONTINENCE PROCEDURES: EVALUATION FROM PATIENT POINT OF VIEW

Fecal and urinary incontinence in patients with congenital or acquired spinal cord defects represents a handicap that impairs chances of integration in society. Associated with the management of urinary incontinence, the Malone antegrade colonic enema is a generally successful procedure for resolving refractory fecal incontinence. We report the results of the evaluation of this technique from the patient perspective. A survey was conducted among 19 patients who had undergone a Malone procedure, combined in 14 with urological surgical intervention for urinary incontinence. Patients completed a questionnaire either by mail or during an interview with a urotherapy nurse and/or a psychologist. Questions concerned patient opinion about the quality of preoperative information, perioperative period, stoma, functional result and overall satisfaction. The psychological impact of the procedure was also evaluated during the interviews. No complication occurred related to the Malone procedure or stomal stenosis, and a perfect functional result was achieved in 17 patients, 1 of whom had occasional leakage through the stoma. Of the 19 patients in the study 2 who have abandoned using the Malone procedure, including 1 with a poor result and 1 with a good functional result, did not return the questionnaire. The remaining 17 patients believed they had received adequate preoperative information and expressed no specific complaint about the perioperative period. The 15 with the stoma in the umbilicus were satisfied, although 3 young patients were temporarily disturbed by catheterizing the umbilicus and 2 with the stoma in the right fossa iliaca were disappointed. The 15 patients who had a perfect functional result recognized great improvement in quality of life but 13 complained of pain (12) and/or excessive duration of the procedure (9). The patient with a poor functional result and the other with occasional stomal leakage would not consider the procedure again. These 2 patients had durable postoperative depression while 3 others who ultimately achieved a good functional result experienced temporary depression. The Malone procedure generally meets the expectations of patients but it is considered by a majority as painful and lengthy. The umbilicus is the preferred stoma site but may prove to be disturbing in young patients. Abandonment of the procedure and postoperative depression experienced by some patients, despite a good functional result, deserve better prevention.

Synchronous bladder reconstruction and antegrade continence enema.

We assess the long-term outcome of synchronous bladder reconstruction and antegrade continence enema in a large series of patients. We retrospectively reviewed records of the last 50 consecutive patients treated at 1 unit in Southampton and 1 in Denver. A total of 46 patients were available for analysis, including 24 from Southampton and 22 from Denver. Median patient age at operation was 12 years (range 4 to 30), median followup was 44 months (range 7 to 100), and 80% of patients had neuropathy and anorectal malformation. A variety of bladder reconstructive procedures were performed and 58% of patients underwent a simultaneous Mitrofanoff procedure. Fecal and urinary continence was achieved in 76% of patients but the rate of revision surgery was high. The most common complication was stomal stenosis (17%). Secondary procedures consisted of refashioning urethral length, closure of the bladder neck, bladder augmentation and conduit revision. It is now possible to produce double continence in some patients with synchronous combined surgery, a goal that was not achievable without colostomy before the development of the antegrade continence enema in 1990. However, the surgery is demanding with high revision rates and we emphasize that it should only be performed in patients who are highly motivated and have reasonable dexterity and intelligence. This careful patient selection is confirmed by the fact that surgery was performed on 2 to 3 patients a year at each unit. This surgery should only be performed at facilities which can provide long-term patient followup.

SYNCHRONOUS BLADDER RECONSTRUCTION AND ANTEGRADE CONTINENCE ENEMA

We assess the long-term outcome of synchronous bladder reconstruction and antegrade continence enema in a large series of patients. We retrospectively reviewed records of the last 50 consecutive patients treated at 1 unit in Southampton and 1 in Denver. A total of 46 patients were available for analysis, including 24 from Southampton and 22 from Denver. Median patient age at operation was 12 years (range 4 to 30), median followup was 44 months (range 7 to 100), and 80% of patients had neuropathy and anorectal malformation. A variety of bladder reconstructive procedures were performed and 58% of patients underwent a simultaneous Mitrofanoff procedure. Fecal and urinary continence was achieved in 76% of patients but the rate of revision surgery was high. The most common complication was stomal stenosis (17%). Secondary procedures consisted of refashioning urethral length, closure of the bladder neck, bladder augmentation and conduit revision. It is now possible to produce double continence in some patients with synchronous combined surgery, a goal that was not achievable without colostomy before the development of the antegrade continence enema in 1990. However, the surgery is demanding with high revision rates and we emphasize that it should only be performed in patients who are highly motivated and have reasonable dexterity and intelligence. This careful patient selection is confirmed by the fact that surgery was performed on 2 to 3 patients a year at each unit. This surgery should only be performed at facilities which can provide long-term patient followup.

Does anorectal manometry predict clinical outcome after laparoscopic ACE procedures in children with spina bifida?

The laparoscopic antegrade continence enema (LACE) procedure is used for the treatment of faecal incontinence in children with spina bifida. The purpose of this study was to relate the outcome of the LACE procedure to anorectal function, as determined by anorectal manometry. Eleven children with spina bifida who had the LACE procedure underwent anorectal manometry (ARM) to document their anorectal function, and its relationship to the level of continence obtained following surgery. There was a consistently high level of functional continence achieved following surgery despite wide variability in the parameters of anorectal manometry. There was no demonstrable correlation between the outcome of the LACE procedure and anorectal function as assessed by manometry. Anorectal function as determined by manometry failed to predict outcome after the laparoscopic ACE procedure in children with spina bifida.

191. NON-STARCH POLYSACCHARIDE INTAKE AND THE PREVALENCE OF CONSTIPATION IN FREE-LIVING AND INSTITUTIONALISED OLDER PEOPLE

Background: Diagnosis of functional constipation using Rome II criteria includes an assessment of stool frequency, straining and sensation of incomplete evacuation. Few studies have compared the prevalence of these bowel...

Use of bowel in laparoscopic urology

Minimally invasive urology is a rapidly expanding field. What once was thought technically impossible is now becoming a reality, especially with the advent of intracorporeal stapling and automated suturing devices. Laparoscopic assistance and pure laparoscopy improve convalescence and cosmesis in comparison with open surgical procedures. Minimally invasive continent urinary stomas, ACE procedures, bladder augmentation, urinary diversion, and urinary undiversion have all been described in clinical practice. Continent urinary diversions and ileal bladder augmentations are being developed. Eventually, even the most challenging urologic procedures will be performed in a minimally invasive manner.

Percutaneous colonoscopic cecostomy for management of chronic constipation in children

Background: Chronic constipation and encopresis are common problems in children with spina bifida and anorectal anomalies. Commonly used therapies include complicated bowel regimens and antegrade continence enemas delivered via surgically placed appendicostomies and radiologically placed cecostomies. Methods: A technique is described for percutaneous placement of cecostomies for the delivery of continence enemas or venting. Results: Percutaneous cecostomies were placed in 12 patients. Improvement in bowel management occurred in all patients. Conclusions: Percutaneous endoscopic cecostomy is a safe and effective method for the treatment of intractable constipation.