Cecostomy Research Articles

Functional constipation refractory to medical management: The anal sphincters are the problem

AimMost patients with functional constipation (FC) improve with medical treatment. For those with refractory symptoms, we propose a comprehensive and multidisciplinary work-up and decision-making approach to therapy. MethodsWe retrospectively reviewed patients referred to our center between 2019-2022 with suspected FC who had failed medical management. All patients underwent a contrast enema, anorectal manometry, examination under anesthesia, rectal biopsy (if needed), and botulinum toxin injection (as indicated). Results54 patients were evaluated using our algorithm. One was found to have anal stenosis on exam. The rectoanal inhibitory reflex (RAIR) was normal in 41(76%) patients and unable to be elicited in 12(22%). Two (17%) patients without a RAIR had Hirschsprung Disease (HD) and underwent a pull-through. 10(83%) with no RAIR had normal biopsies and were managed successfully with laxatives. Of the 41 patients with a normal RAIR, 14(34%) had high resting pressures (external sphincters) or non-relaxing (internal) sphincters and received botulinum toxin. 8(57%) of them were emptying well after one month. 24 patients failed laxatives (with or without botulinum toxin injections) and then underwent a Malone procedure. 23(96%) of these patients improved with antegrade flushes. One patient (1/21, 4.1%) did not undergo Malone and instead underwent colonic manometry and a sigmoid resection, after which he emptied well. ConclusionWe propose a systematic multidisciplinary approach for constipated patients who failed medical management starting with assessment of anal sphincters. This allows for targeted adjustment of laxative regimen, use of botulinum toxin to the internal and/or external anal sphincter and antegrade flushes via a Malone. Level of evidence levelIV

State of the Art Bowel Management for Pediatric Colorectal Problems: Anorectal Malformations.

Up to 79% of patients with anorectal malformations (ARMs) experience constipation and/or soiling after a primary posterior sagittal anoplasty (PSARP) and are referred to a bowel management program. We aim to report the recent updates in evaluating and managing these patients as part of the manuscript series on the current bowel management protocols for patients with colorectal diseases (ARMs, Hirschsprung disease, functional constipation, and spinal anomalies). The unique anatomic features of ARM patients, such as maldeveloped sphincter complex, impaired anal sensation, and associated spine and sacrum anomalies, indicate their bowel management plan. The evaluation includes an examination under anesthesia and a contrast study to exclude anatomic causes of poor bowel function. The potential for bowel control is discussed with the families based on the ARM index calculated from the quality of the spine and sacrum. The bowel management options include laxatives, rectal enemas, transanal irrigations, and antegrade continence enemas. In ARM patients, stool softeners should be avoided as they can worsen soiling.

MP53-07 INTERNAL HERNIA WITH VOLVULUS AFTER MAJOR ABDOMINAL RECONSTRUCTIONS IN PEDIATRIC UROLOGY–A POTENTIALLY DEVASTATING COMPLICATION

You have accessJournal of UrologyCME1 Apr 2023MP53-07 INTERNAL HERNIA WITH VOLVULUS AFTER MAJOR ABDOMINAL RECONSTRUCTIONS IN PEDIATRIC UROLOGY–A POTENTIALLY DEVASTATING COMPLICATION Jennison N. Cull, Cynthia A. Sharadin, Deborah L. Jacobson, Glen A. Lau, Patrick C. Cartwright, M. Chad Wallis, David E. Skarda, Robert A. Swendiman, and Anthony J. Schaeffer Jennison N. CullJennison N. Cull More articles by this author , Cynthia A. SharadinCynthia A. Sharadin More articles by this author , Deborah L. JacobsonDeborah L. Jacobson More articles by this author , Glen A. LauGlen A. Lau More articles by this author , Patrick C. CartwrightPatrick C. Cartwright More articles by this author , M. Chad WallisM. Chad Wallis More articles by this author , David E. SkardaDavid E. Skarda More articles by this author , Robert A. SwendimanRobert A. Swendiman More articles by this author , and Anthony J. SchaefferAnthony J. Schaeffer More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003301.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Enterocystoplasty (EC), appendico- or ileovesicostomy (APV), and antegrade continence enema (ACE) creation may create a space between the reconstruction and the anterior/posterior abdominal wall. This can result in internal herniation, closed loop obstruction, and volvulus. We aim to determine the incidence and describe the presentation, mechanism, and outcome of this complication. METHODS: This single-institution, retrospective cohort study identified patients who underwent EC, APV, and/or ACE between 1/2011 and 4/2022. Operative records for any subsequent exploratory laparotomy were reviewed. The primary outcome was internal herniation of bowel into the potential space between the reconstruction and the anterior/posterior abdominal wall. RESULTS: 143 patients received 241 procedures and were followed for a median of 68 (SD: 38) months. 19 patients underwent a subsequent exploratory laparotomy. The primary outcome occurred in 4 patients (including one patient who received their index procedure elsewhere) for a complication rate of 1% (3/241). Patients presented with bowel obstruction; two patients also had sudden pain following an ACE flush. These complications occurred between 19 months and 9 years (median 5 years) after the index procedure. One complication was caused by small bowel sliding under the mesentery of the EC. A second was caused by bowel herniating through/around the APV mesentery and a third by herniation through/around the ACE mesentery; these two hernias also volvulized. The etiology of one internal herniation is unknown (Table 1). 3 patients required resection of ischemic bowel and 2 required takedown of the involved urologic reconstruction. One patient died intraoperatively from cardiac arrest. CONCLUSIONS: Internal herniation caused by small or large bowel sliding through a defect between the mesentery and abdominal wall or twisting around a channel occurred in 1% of 241 reconstructions over 11 years. The ischemia resulted in bowel resection and takedown of the urologic reconstruction or death. If possible, the surgeon should close these potential spaces. Source of Funding: Dr. Schaeffer is supported in part by NIH K08DK119535 © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e714 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jennison N. Cull More articles by this author Cynthia A. Sharadin More articles by this author Deborah L. Jacobson More articles by this author Glen A. Lau More articles by this author Patrick C. Cartwright More articles by this author M. Chad Wallis More articles by this author David E. Skarda More articles by this author Robert A. Swendiman More articles by this author Anthony J. Schaeffer More articles by this author Expand All Advertisement PDF downloadLoading ...

MP53-12 LONG-TERM FOLLOW-UP IN PATIENTS WITH CONTINENT URINARY AND FECAL CATHETERIZABLE STOMAS IN PEDIATRIC PATIENTS WITH NEUROGENIC BLADDER

You have accessJournal of UrologyCME1 Apr 2023MP53-12 LONG-TERM FOLLOW-UP IN PATIENTS WITH CONTINENT URINARY AND FECAL CATHETERIZABLE STOMAS IN PEDIATRIC PATIENTS WITH NEUROGENIC BLADDER Esteban Tresgallo, Mario Garcia, Marcos Perez-Brayfield, and Carla Marin Esteban TresgalloEsteban Tresgallo More articles by this author , Mario GarciaMario Garcia More articles by this author , Marcos Perez-BrayfieldMarcos Perez-Brayfield More articles by this author , and Carla MarinCarla Marin More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003301.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Catheterizable stomas have revolutionized the management of neurogenic bladder. Long-term follow up is required due to high complication rates. There is concern with long term usage of the stoma during the transition to adulthood period. The aim of the study was to evaluate long-term functional outcomes and degree of satisfaction in pediatric patients and their caregivers after undergoing Continent Catheterizable Channel (CCC) and/or Malone Antegrade Continence Enema (MACE) procedure. METHODS: We retrospectively reviewed the charts of 32 pediatric patients who had undergone 53 CCC's between 2007 and 2022. Data was analyzed including indication, type of channel, and complications. Patients and caregivers were contacted via telephone and a survey assessing frequency of usage, presence of urinary/fecal incontinence, factors limiting or preventing channel use, and overall degree of satisfaction was conducted. This study was approved by our local IRB committee. RESULTS: 81% (26) patients had a Mitrofanoff channel and 19% (6) a Monti channel. 21 patients also underwent a concomitant MACE procedure. The average age at surgery was 10.4 years, ranging from 5-19 years. The average length of follow up was 6.9 years, with 9 patients followed for more than 10 years. 10 patients underwent revision surgery, 8 due to channel stenosis (5 sub-fascial, 3 supra-fascial). 90% of patients reported the CCC is still in use. In 65% of cases, it is the patient performing CIC. 6 reported incontinence through the CCC, which was mild in all cases. In terms of satisfaction, 84% reported to be “very satisfied” with the procedure/outcomes. In terms of the MACE procedure, 89% reported to still be using the channel and 78% of patients reported complete fecal continence. 3 patients underwent MACE revision due to stenosis (15%). The main performer of ACE is the patient in over 60% of cases and it takes on average 30-40 minutes to perform. 95% of patients reported to be “very satisfied” with the procedure. CONCLUSIONS: Continent catheterizable stomas are feasible and reliable in long term follow up. Despite a high revision rate (33%) associated with CCC, our data shows that functional outcomes and patient/caregiver satisfaction remain high even after transition into early adulthood. Source of Funding: none © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e716 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Esteban Tresgallo More articles by this author Mario Garcia More articles by this author Marcos Perez-Brayfield More articles by this author Carla Marin More articles by this author Expand All Advertisement PDF downloadLoading ...

MP18-16 DECISION REGRET IN ADULTS WITH SPINA BIFIDA FOLLOWING CHILDHOOD MACE CREATION

You have accessJournal of UrologyCME1 Apr 2023MP18-16 DECISION REGRET IN ADULTS WITH SPINA BIFIDA FOLLOWING CHILDHOOD MACE CREATION Ashley W. Johnston, Konrad M. Szymanski, Rosalia Misseri, and Joshua D. Roth Ashley W. JohnstonAshley W. Johnston More articles by this author , Konrad M. SzymanskiKonrad M. Szymanski More articles by this author , Rosalia MisseriRosalia Misseri More articles by this author , and Joshua D. RothJoshua D. Roth More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003238.16AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Our objective was to assess decision regret (DR) among adults with spina bifida (SB) regarding Malone antegrade continence enema channel (MACE) creation in childhood. METHODS: In our SB clinic, we surveyed consecutive adult patients (≥18 years old [y]) who underwent MACE creation at <18y (6/2018-1/2020). Utilizing the Decision Regret Scale, DR was categorized as: none (0), mild (1-25), moderate (26-50), strong (51-75), very strong (>75). We analyzed whether bowel management habits (catheterizations, flushing toilet time, and stool evacuation), bowel symptoms (fecal incontinence and leakage per MACE), or symptom bother impacted DR. Patient factors were assessed on exploratory analysis. Non-parametric tests and logistic regression were used. RESULTS: Of the 71 patients (52% male, 90% White) who met inclusion criteria, the median ages at survey participation was 24y and MACE creation occurred at 7y. Eighty-six percent had a ventriculoperitoneal shunt and 45% used a wheelchair. Median DR score was 0 and 58% without any DR. Of those with some DR, the majority were mild (28%) and moderate (11%) with few strong (1%) or very strong (1%).The majority of patients, 73%, were independently flushing a median 7 times/week and spending a median 1 hour on the toilet. DR was significantly associated with both time on the toilet >1 hour (p=0.02, OR 3.7, 95%CI [1.3-10.8]) and bother waiting for stool evacuation (p=0.02, OR 3.2, 95%CI [1.2-8.5]) (Table 1). Difficulty catheterizing was also associated with DR (p=0.02, OR=3.3, 95%CI [1.2-9.5]). On multivariate logistic regression, only catheterization difficulty was significantly associated with DR (p=0.05, OR 3.3, 95%CI [0.99-10.9]). Forty-six percent of patients experienced some degree of fecal incontinence and the majority (88%) were bothered by it. Neither incontinence nor MACE leakage increased DR (p≥0.22). On exploratory analysis, patient demographic factors were not associated with increased DR (p>0.3). CONCLUSIONS: The majority of adults with SB do not regret undergoing MACE creation as children. Those with DR have mild to moderate levels. Time on the toilet exceeding an hour, self-reported bother related to the time needed for flushing, and catheterization issues contribute to post-MACE DR. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e229 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ashley W. Johnston More articles by this author Konrad M. Szymanski More articles by this author Rosalia Misseri More articles by this author Joshua D. Roth More articles by this author Expand All Advertisement PDF downloadLoading ...

People with spina bifida use their MACE on long-term follow-up: A single institutional retrospective cohort study

While the Malone antegrade continence enema (MACE) facilitates bowel movements in patients with spina bifida (SB) and neuropathic bowel, little is known about its long-term use. We aimed to assess long-term MACE use and potential risk factors for disuse. All patients with SB who underwent MACE procedures at our institution were retrospectively reviewed. Main outcome was MACE disuse (no longer catheterizing the MACE for antegrade enemas) based on self-report on a clinic questionnaire, or medical record for patients last seen before introducing the questionnaire 5 years ago. Survival analysis used two timeframes: time after surgery (Analysis 1) and chronological age: accounting for older children reaching adulthood earlier (Analysis 2). Overall, 411 patients (54% female, 78% shunted, 65% augmented) underwent a MACE procedure at median 7.9 years old (median follow-up: 8.4 years). Thirty-three (8%) patients no longer used their MACE. Most common reasons for doing so were channel/stomal stenosis (61%) and excision at colostomy or other abdominal surgery (12%). Bowel management afterwards included oral agents±enemas (55%), Chait tube (30%), colostomy (12%). After correcting for differential follow-up, 90% of participants used their MACE at 10 years and 87% at 15 years after surgery. Based on chronological age, 97% used their MACE at 15 years old, 92% at 20 and 81% at 30 (Summary Figure). On multivariate analysis, umbilical MACEs were 2.4 times more likely to be disused than right lower quadrant MACEs (p=0.04). Without correcting for chronological age (Analysis 1), patients undergoing MACE surgery at older ages were more likely to stop MACE use (p=0.03). However, after accounting for chronological age (Analysis 2), patients undergoing a MACE procedure at older ages were no more likely to stop its use (p=0.47, Figure). Gender, SB type, shunt status, mobility status, bladder augmentation or a urinary catheterizable channel were not associated with stopping MACE use (p≥0.10). Participants were regularly followed in multi-disciplinary SB clinics. We did not assess continence, satisfaction or long-term urinary channel use, making it premature to recommend optimal stomal locations. Most patients with SB followed by a multi-disciplinary team continue using their MACE; 1% stopped MACE use annually, particularly after adolescence. This strongly suggests it is an effective bowel management method and transitioning to self-care plays a role in maintaining long-term MACE use. Umbilical MACEs may be at high risk of disuse, but all people with a MACE can benefit from support as they transition to adult care.

Pediatric robotic urologic procedures: Indications and outcomes.

Robotic-assisted laparoscopic surgery (RALS) has revolutionized minimally invasive surgery in pediatric urology. The robotic platform allows surgeons to maintain the benefits of laparoscopic surgery while having enhanced three-dimensional view, dexterity, range of motion, and control of high-resolution cameras. In this review, we summarize the indications and recent outcomes for various pediatric urologic RALS procedures to illustrate the current state of robotics in pediatric urology. We systematically searched the PubMed and EMBASE databases. We extrapolated and summarized recent evidence on RALS in pediatric urology patients, with an emphasis on indications and outcomes, with regard to the following procedures and search terms: pyeloplasty, kidney stone surgery, partial nephrectomy, nephroureterectomy, ureteral reimplantation, appendico-vesicostomy, augmentation cystoplasty, bladder neck reconstruction, and Malone antegrade continence enema. Additional Medical Subject Headings terms used to augment the search included "Treatment Outcome" and "Robotic Surgical Procedures." Increasing usage of RALS has shown many benefits in perioperative and postoperative outcomes. In addition, there is growing evidence that robotic procedures in pediatric urology result in similar or better surgical outcomes when compared to the standard of care. RALS has shown considerable effectiveness in pediatric urologic procedures and may achieve surgical outcomes comparable to the standard approaches of open or laparoscopic surgery. However, larger case series and prospective randomized controlled trials are still necessary to validate the reported outcomes, in addition to cost analyses and studies on the surgical learning curve. We believe that the continuous evolution of robotic platforms will allow for enhanced care and quality of life for pediatric urology patients.

Analysis of the potential risk factors for defecation problems and their bowel management based on the long-term bowel function in patients with persistent cloaca: results of a nationwide survey in Japan

We conducted a nationwide survey of persistent cloaca (PC) to determine its current status in Japan. This study clarifies the potential risk factors for defecation problems in patients with PC. Patient information was obtained via questionnaire, and a total of 213 PC patients who responded to a questionnaire on defecation problems and their bowel functions were enrolled in this study. We evaluated the constipation, incontinence, and soiling as bowel functions. Univariate and multivariate analyses were performed using a logistic regression analysis to clarify the risk factors for defecation problems. Of 213 patients with PC, 55 (25.8%) had defecation problems. A multivariate logistic regression analysis showed that sacral agenesis, as an associated anomaly, was significantly associated with defecation problems (odds ratio [OR] 3.19, 95% confidence interval [CI] 1.11-9.16, p = 0.03). The other multivariate logistic regression analysis showed that the PC patients who underwent antegrade continence enema and regularly took laxatives after anorectoplasty had defecation problems (OR 12.4, 95% CI 2.35-65.6, p = 0.003, OR 2.84, 95% CI 1.24-6.55, p = 0.01). Sacral agenesis is the potential risk factor of defecation problems in the patients with PC who underwent anorectoplasty. Those patients require vigorous defecation management.

Repurposing an ACE Malone Channel for Continent Intermittent Catheterization During Re-augmentation Cecocystoplasty: The MACEtrofanoff Procedure

ObjectiveTo describe a surgical alternative option in select patients with neurogenic bladder and a history of Malone antegrade continence enema (MACE) who now require revision augmentation of the bladder, and/or creation of a new continent catherizable urinary channel (CCC). MethodsHerein, we describe a novel surgical approach for patients who have had prior MACE creation who subsequently require surgical revision and creation of a new CCC. Rather than the traditional approach of creating a new CCC utilizing bowel, we perform a cecocystoplasty and leave the previously created MACE intact. The prior MACE channel becomes repurposed as the new Mitrofanoff, which we have termed the MACEtrofanoff channel. Concomitant cecostomy tube placement for bowel management can be performed at the time of surgery. ResultsWe have successfully performed this procedure in 2 patients with good outcomes to date. This technique does not require the sacrifice of the prior appendix channel, nor require the formation of a new stoma and channel. Patients are able to adapt easily to clean intermittent catheterization through a channel they are already familiar with for their prior antegrade enemas. ConclusionIn select patients, surgeons should consider the MACEtrofanoff procedure to avoid the added morbidity of further bowel mobilization.

Is an Antireflux Procedure Necessary for a Successful Appendicostomy? The Simplified Malone Antegrade Continence Enema Procedure.

The aim of this study was to present the long-term institutional experience and outcomes of our Malone antegrade continence enema (MACE) procedure using the proximal appendix without any antireflux procedure. A single-center prospective study of 29 children undergoing a simplified Malone antegrade continence enema (SMACE) procedure from 2006 to 2017 was conducted using the appendix, whole or split. The mean follow-up period was 11.5 years (ranging from 5 to 16 years). In 25 children, the proximal appendix was used, and in 4 cases, the whole appendix was used as a conduit. On follow-up, the MACE channel has been working well in 29/29 patients. Among the complications, seven patients had stomal stenosis, which was managed by home dilatation. There was no reflux of stools seen in any of the patients. The SMACE procedure, without incorporating an antireflux mechanism, is technically simpler and saves operative time. Most importantly, the results are satisfactory and comparable with procedures using antireflux techniques.

Medium-Term Outcomes of Antegrade Continent Enema (ACE): Cairo University Specialized Pediatric Hospital (CUSPH) Experience

Aim of the studyTo assess the medium-term outcomes of ACE in children with fecal incontinence (FI). MethodEligible 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. Result24 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). ConclusionACE 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.

A patient- and parent-centered approach to urinary and fecal incontinence in children and adolescents with spina bifida: understanding experiences in the context of other competing care issues

Despite significant and known challenges to urinary and fecal incontinence (UI and FI, respectively) among children with spina bifida (SB) and their families, few studies have identified patient-centered measures and approaches to assessing them. This study represents the first stage of a larger study to develop a patient-centered goal-setting tool to guide incontinence management (Figure). Our aim was to understand patient experiences of UI and FI, and what goals should be included in the tool. We used a qualitative research approach integrated with human-centered design methods. We recruited, in clinic and online, children with SB (8-17 years old) and parents (>=18 years old) of children with SB (8-17 years old). Online activities were analyzed by four experienced design researchers using affinity diagramming, group analysis and modeling activities (mind maps, challenge maps, experience maps). Recruitment and thematic qualitative analysis continued until saturation was reached. Seventeen children with SB participated (9 female, 12 shunted, 13 using bladder catheterizations, 6 using Malone antegrade continence enema, median age: 15 years old). Fifteen parents participated (13 mothers/2 fathers, median age: 42 years old), including six mother-child dyads. Five major themes each were identified for UI and FI experiences: (1) negative emotional impact of incontinence, (2) unpredictability of incontinence, (3) challenging/unpleasant incontinence management, (4) inconvenient/unreliable incontinence management, (5) UI management having unpleasant complications and FI putting much responsibility on parents. We identified six UI goal domains and five FI goal domains. Four overlapping domains included: accidents, independence, interruptions at school and social/friends. Unique domains were: urinary tract infections (UI), catheterizations (UI) and enemas (FI). Findings of our study improve our understanding of children's and parents' experiences associated with incontinence in SB and potential continence goals. Children with SB experience incontinence as distressing and unpredictable. Incontinence management can be challenging and unreliable. Patient-centered continence goals cluster in domains, indicating how incontinence intermeshes with other life areas and offering potential approaches to structure continence goals in a goals-selection tool.

Single institution experience of cloacal malformation

IntroductionThe aim of this study is to report on the outcomes of patients born with cloacal malformation, managed at a single institution more than the last 28 years. The focus of this study is the long term renal and colorectal outcomes. MethodsPatients were identified from the departmental database from 1994 to 2021. The medical records and operative notes were retrospectively reviewed. ResultsTwenty-one patients fulfilled the inclusion criteria. Eleven long common channel (LCC) and ten short common channel (SCC) cloacae patients were identified. Median age at the time of primary reconstruction was 11 months in both groups. In the LCC group, seven (63.6%) patients underwent a Total Urogenital Mobilisation (TUM), and 4 (36.4%) required a vaginal replacement. 6/11 (54.5%) of patients required drainage of a hydrocolpos. In the SCC group, four patients required a TUM, two patients underwent mobilisation of the rectum and vagina alone, and three underwent rectal mobilisation alone. Two patients have required renal transplant for congenital renal dysplasia, and two have developed chronic renal failure associated with the sequalae of vesicoureteric reflux. Eleven (52.3%) of the patients manage their bowels with an antegrade continent enema (ACE), and two of the LCC cloaca are defunctioned with a colostomy. Clean intermittent catheterisation is performed by 12 (57%) of the patients, either per urethra or via a Mitrofanoff channel. ConclusionThe urinary and faecal continence are the main challenges in the management of cloaca patients. Many require surgical intervention to achieve social continence. Level of evidenceLevel IV.

Functional constipation refractory to medical management: The colon is the problem

BackgroundManagement 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. MethodsPatients 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. ResultsOf 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. ConclusionWe 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 of evidenceLevel IV

Do preoperative factors predict success of antegrade continence enemas in children?

IntroductionAntegrade continent enemas (ACE) procedures are one treatment option in children with medically refractory constipation or encopresis and predicting success is difficult. We hypothesize that there are preoperative factors that can be identified to help with patient selection and family counseling. MethodsWe conducted a retrospective study of children who underwent a cecostomy or appendicostomy for an ACE program between 2015 and 2021. Underlying diagnosis, pre-operative bowel regimen and imaging were analyzed. Patients were reviewed for success at 3-, 6- and 12-months post-procedure. Data was analyzed with Fisher's Exact, Kruskal-Wallis and logistic regression where applicable with significance defined as p < 0.05. ResultsForty-three children were identified; 28 were male, 15 were female, mean age at time of operation was 8 years old. 76% were considered successful at 3-months, 86% at 6-months, and 87% at 12-months post- procedure. Univariate analysis showed that a pre-ACE retrograde enema program predicted success at 3-months (94% vs. 64% p = 0.03) but no difference at 6- or 12-months. At one year after ACE procedure there was a significant reduction in number of enteral medications (2 to 0, p < 0.01) and 94% of patients were on one or fewer at one year follow-up. Age, gender, weight at time of operation, contrast enema, anorectal manometry and colonic transit time results were not predictive of outcomes. ConclusionIn this study, we characterized expected time to success in our population as well as identified use of a pre-operative retrograde enema program as a potential predictor of success at 3-months in children undergoing an ACE procedure. Level of evidenceIV. Type of studyPrognosis study.

Fecal continence disparities in patients with idiopathic constipation treated at referral institutions for pediatric colorectal surgery

PurposeFecal continence is a concern for many patients with idiopathic constipation and can significantly impact quality of life. It is unknown whether racial, ethnic, and socioeconomic disparities are seen in fecal continence within the idiopathic constipation population. We aimed to evaluate fecal continence and associated demographic characteristics in children with idiopathic constipation referred for surgical evaluation. MethodsA multicenter retrospective study of children with idiopathic constipation was performed at sites participating in the Pediatric Colorectal and Pelvic Learning Consortium (PCPLC). All patients >3y of age with idiopathic constipation diagnosis were included. The primary outcome was fecal continence, categorized as complete (no accidents ever), daytime (no accidents during the day), partial (occasional incontinence day/night), and none (incontinent). We evaluated for associations between fecal continence and race, sex, age, insurance status, and other patient-level factors, employing Kruskal-Wallis and trend tests. Results458 patients with idiopathic constipation from 12 sites were included. The median age of diagnosis was 4.1 years. Only 25% of patients referred for surgical evaluation were completely continent. Age at the visit was significantly associated with fecal continence level (p = 0.002). In addition, patients with public and mixed public and private insurance had lower levels of continence (p<0.001). Patients with developmental delay were also more likely to have lower continence levels (p = 0.009) while diagnoses such as anxiety, ADD/ADHD, autism, depression, obsessive-compulsive disorder were not associated. Approximately 30% of patients had an ACE operation (antegrade continence enema) at a median age of 9.2 years at operation. Black patients were significantly less likely to undergo ACE operation (p = 0.016) when compared to white patients. ConclusionWe observed data that suggest differences in fecal incontinence rates based on payor status. Further investigation is needed to characterize these potential areas of disparate care. Level of EvidenceLevel III

The success rate of antegrade enemas for the management of idiopathic constipation.

Most patients with idiopathic constipation achieve daily voluntary bowel movements with stimulant laxatives after a "Structured Bowel Management Program" (BMP). A small percentage require rectal enemas. One week in a BMP to find the right enema recipe results in a success rate great than 95%. Once the enema is radiologically and clinically effective, antegrade continent enema procedures (ACE) can afford patients an alternative route of enema administration. This study summarized the outcomes of children with idiopathic constipation who receive antegrade enemas (AE) with or without a prior BMP. This was a single institution, retrospective cohort study of children with idiopathic constipation who underwent ACE procedures indicated by different providers from 2015-2020. We categorized the outcomes with AE after the ACE procedure as: "successful outcome" when the AE produced a daily bowel movement, no involuntary bowel movements, and no more fecal impactions, "unsuccessful outcome" was defined when the patient continued having involuntary bowel movements or fecal impaction requiring cleanouts despite a daily AE, and "unnecessary outcome" was defined when the patient was no longer doing AE, but had daily bowel movements, and no involuntary bowel movements or fecal impactions. Thirty-eight children with idiopathic constipation had an ACE. The most frequent indication for ACE was a failure of medical treatment. The most common medical treatment was polyethylene glycol. Before ACE, 34 (89%) patients did not have a BMP; 18 patients were on rectal enemas and 16 on laxatives. All four with BMP (100%) had a successful rectal enema. After ACE, 12 (31%) patients had successful antegrade enemas, including the four with previous successful BMP with rectal enemas. Twenty patients (52%) had unsuccessful antegrade enemas, and in 6 (15%), the ACE was unnecessary (Fig. 1). Using antegrade enemas without a previously successful formula for rectal enemas has resulted in a high rate of unsuccessful and unnecessary procedures. BMP for children with idiopathic constipation who needs rectal enemas offers a high possibility to find the proper rectal enema recipe and ensures higher rates of successful AE.

The effect of an enhanced recovery protocol in pediatric patients who undergo colostomy closure and Malone procedures.

Pediatric colorectal studies have shown enhanced recovery after surgery (ERAS) protocols can safely improve outcomes. This study sought to determine the impact of an ERAS pathway on the outcomes of children with colorectal conditions who underwent colostomy closure or Malone procedure. A single-institution, retrospective cohort study of children who underwent colostomy closure or Malone procedure between 2016 and 2020 was performed. Differences in outcomes between pre-ERAS and ERAS cohorts were tested. A sub-analysis based on procedure type was performed. There were 96 patients included: 22 prior to ERAS implementation and 74 after. Patients who underwent ERAS had shorter mean time (hours) to oral intake, mean days until regular diet, post-operative opioid volume, and median length of stay (p < 0.05). There was no difference in complication rates in the ERAS and pre-ERAS cohort (12.2 vs 9.1%, p = 0.99). Patients who underwent colostomy closure after ERAS had lower post-operative opioid use, but no differences were seen in those who underwent Malone. Implementation of an ERAS protocol resulted in quicker time to oral intake, normal diet, and decreased opioid use without increasing complication rates. Differences seen based on procedure type may reflect that the effect of an ERAS protocol is procedure specific.

Simultaneous placement of fecal and urinary continent channel stomas in the umbilicus: Single-center experience

In 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.

Antegrade continence enema stoppers: a pilot study on patient preferences.

Severe constipation can have a major impact on a child's quality of life and that of their families. Forming an antegrade continence enema (ACE) can be a transformational intervention to manage severe symptoms. However, operations can also have unpredictable negative consequences such as stomal stenosis or leaks from the ACE site. To investigate whether the choice of an ACE stopper can increase patient satisfaction and compliance. A service evaluation with a standardised questionnaire was completed to assess quality of life and explore factors that have an impact on the preference for which ACE stopper was used. In total, 17 patients completed the evaluation of all three ACE stopper devices. At least 75% of the children improved their stooling pattern with an overall satisfaction rate of 8.5 out of 10. More patients preferred a flexible stopper but no one device was strongly preferred over the others. The study shows that an ACE has a positive impact on quality of life. With regards to the choice of ACE stopper, results show that different stoppers suit different individuals, highlighting that there is a place for a choice. This is useful information for healthcare providers who wish to improve compliance and reduce the risk of complications in this patient group.