Cecostomy Tube Placement Research Articles

LAPAROSCOPIC CECOSTOMY PLACEMENT FOR ANTEGRADE ENEMA ACCESS IN THE PEDIATRIC POPULATION

AimUse of the appendix for an antegrade continence enema (ACE) is not always possible. Various methods exist for creating cecostomy tubes, including percutaneous, endoscopic, or surgical placement. We describe our laparoscopic cecostomy technique and review short- and long-term outcomes. MethodsSingle institution retrospective review of children who underwent laparoscopic cecostomy placement from June 2016 – June 2023. The cecum is secured to the abdominal wall with trans-fascial sutures and placement of an enterostomy button under direct vision. Half-volume flushes begin after 48 hours; after two weeks, patients transition to full flushes. Demographic, intraoperative, and postoperative variables were analyzed. ResultsForty patients were included [24 (60%) female; 31 (77.5%) Caucasian]. Twenty-one (52.5%) had myelomeningocele, 15 (37.5%) had an anorectal malformation and 4 (10%) had functional constipation. Twenty-five (62.5%) underwent laparoscopic cecostomy placement alone, while 15 (37.5%) had it performed with another procedure.Median operative time was 1.12 (IQR 0:93-1.45) hours for isolated cecostomy placement, with median post-operative stay of 2.0 days (2.2 - 3.1) days. Post-operatively, one patient had severe withholding, ultimately requiring a diverting ileostomy. No other 30-day complications (surgical site infection, tube removal) were identified. One patient required revision four months post-op due to inadvertent placement in the sigmoid. At one-year follow-up, 11/36 (30.6%) children noted granulation tissue, and 11 (30.6%) noted superficial leakage. Two (6%) patients had transitioned to oral laxatives. ConclusionLaparoscopic cecostomy tube placement is a safe and alternative method of developing ACE access that can be done concurrently with other procedures.

What Happens Post-Malone? An Investigation of Long-Term Postoperative Management of Antegrade Continence Enemas

BackgroundAn option for medically refractory fecal incontinence and/or constipation is the antegrade continence enema (ACE). We investigated ACE usage and its perceptions, including whether patients were able to discontinue use of the appendicostomy/cecostomy tube. MethodsPatients who underwent appendicostomy creation or cecostomy tube placement at two institutions between 2012 and 2021 were reviewed. Patients or parents/guardians were contacted for completion of a survey. Summary statistics for clinical data were tabulated and associations were evaluated with chi-square analysis. ResultsA total of 165 patients were included, including 92 (55.8%) males. Eighty-two (49.7%) surveys were completed. Most patients (51.5%) presented with fecal incontinence; 38 (23.3%) presented with constipation. More patients had a primary underlying diagnosis of anorectal malformation (39.4%), followed by functional constipation (21.2%), Hirschsprung disease (18.8%), and spinal malformation (17.6%). Thirty-six (21.8%) patients discontinued flushes by time of contact, with switch to laxatives being the most common reason (19%), followed by appendicostomy stricture/obstruction/closure (17%), switch to ileostomy/colostomy (17%), and patient preference (14%). There was no difference in patients’ ability to stop using flushes based on underlying diagnosis (p = 0.31). The majority (84.1%) of respondents were “very likely” to recommend antegrade enemas to other children with similar diagnosis and 76.8% reported being “very satisfied” that the operation was done. ConclusionsThere remains a high degree of satisfaction with antegrade continence enemas for children with constipation and fecal incontinence; some children may be able to stop using antegrade enemas with varied mechanisms including patient/family weaning versus with assistance and laxative trials. Type of StudyRetrospective cohort study. Level of EvidenceIII.

Late Diagnosis of Hirschsprung Disease: Clinical Presentation and Long-Term Functional Outcomes

PurposeHirschsprung Disease (HD) is typically diagnosed in the neonatal period. A small subset of patients have a prolonged course of abdominal distention and constipation prior to diagnosis. Late HD is defined as having been diagnosed at greater than or equal to one year of age. The literature is limited and offers conflicting data on the implications of a late diagnosis. We aim to investigate the presentation, operative approach, and functional outcomes of a large cohort of patients with a late HD diagnosis. MethodsAll patients with a late diagnosis of HD (after 1 year of age) at our institution between 1997 and 2021 were included. ResultsTwenty-eight patients were diagnosed with HD at a median age of 3.4 years. Chronic constipation, failure to thrive, and enterocolitis occurred in 100 %, 31 %, and 14 %, respectively. All patients underwent contrast enema and biopsies during their workup, identifying primarily rectosigmoid disease (n = 27) and total colonic aganglionosis (n = 1). Surgical intervention was performed in 27 patients, with 4 patients (15 %) needing a stoma (3 with plan for staged pull-through, 1 long-term stoma) and 23 patients (85 %) undergoing a single-stage pull-through. Postoperative complications included Hirschsprung-associated enterocolitis (n = 5), ostomy prolapse and revision (n = 2), abdominal distention requiring ileostomy creation (n = 2), redo pull-through (n = 2), retroperitoneal hematoma (n = 1), and cecostomy tube placement (n = 1). At a median follow-up of 5.4 years, 83 % of eligible patients achieved fecal continence with 43 % needing laxatives for persistent constipation. ConclusionRecognizing a late presentation of HD requires a high index of suspicion. Patients with a late diagnosis did not experience an increased rate of permanent stoma, complications, or redo surgery compared to rates reported for the larger HD population. Similar long-term functional outcomes were achieved compared to the larger HD population. Level of EvidenceIV.

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.

Commentary to ‘in-hospital resource utilization, outcome analysis and radiation exposure in children undergoing appendicostomy vs cecostomy tube placement’

Commentary to ‘in-hospital resource utilization, outcome analysis and radiation exposure in children undergoing appendicostomy vs cecostomy tube placement’

In-hospital resource utilization, outcome analysis and radiation exposure in children undergoing appendicostomy vs cecostomy tube placement

Continence enemas for the purpose of bowel management may be delivered via trans-anal retrograde irrigations, and via antegrade conduits including surgical appendicostomy or placement of cecostomy tube (CT). An appreciation of the relative advantages and disadvantages of each antegrade continence enema (ACE) procedure allows clinicians, parents and children to make an informed decision regarding which procedure is most appropriate in individual cases. The objective of this study was to evaluate the differences in in-hospital resource utilization, surgical outcomes and radiation exposure between children undergoing appendicostomy creation and CT placement at our institution. We conducted a retrospective chart review of children undergoing these procedures at our institution over a 10-year period. All patients 0-18 years of age undergoing either procedure for any indication were included. Data on demographics, length of stay (LOS), radiation exposure events (REE), and surgical outcomes were collected. One hundred fifteen (63 appendicostomy/52 CT) patients were included. Those undergoing CT placement had significantly increased post-procedural LOS, catheter exchanges and REE compared to those undergoing appendicostomy (see Table). Reported rates of bowel control were similar between the two groups, and there was no significant difference in rates of surgical complications, although each group had unique, procedure-specific complications. In our study, appendicostomy holds a clear advantage over CT in terms of post-procedural LOS, as well as REE. In general, children with CTs require more planned and unplanned device maintenance procedures than those with appendicostomy. These findings aside, the rates of success for bowel control between the two groups are similar, and the incidence of complications does not differ significantly between the two groups. CT remains a safe and effective conduit for delivery of ACEs, and is a particularly good option in patients whose appendix has been lost or used for another conduit. However, patients wishing to avoid repeated procedures and radiation exposure may find the option of appendicostomy more attractive.

Primary placement of a skin-level Cecostomy Tube for Antegrade Colonic Enema Administration Using a Modification of the Laparoscopic-Assisted Percutaneous Endoscopic Cecostomy (LAPEC)

PurposeChildren failing medical management for severe constipation and/or fecal incontinence may undergo surgical intervention for antegrade enema administration. We present a modification of the laparoscopic-assisted percutaneous endoscopic cecostomy (LAPEC) procedure that allows primary placement of a skin-level device. MethodsA single-institution retrospective review was performed from 2009 to 2015. In the modified technique the colonoscope is advanced to the cecum, cecal suspension sutures are placed under laparoscopic visualization, and percutaneous needle puncture of the cecum is performed under direct laparoscopic and endoscopic visualization. A skin-level cecostomy tube is then placed over a guide wire. Patient characteristics and 30-day results were analyzed by Fisher's exact test. ResultsFifty-two patients underwent attempted LAPEC. Successful LAPEC using both laparoscopic and endoscopic guidance was achieved in 46 (88.5%). A MIC-KEY device was placed in 38. Corflo PEG tube placement was necessary in 14 due to high BMI (mean 28.4). Colonoscopy failed to reach the cecum in 6 and laparoscopy alone was utilized to achieve successful tube placement. Cecostomy site infections occurred in 3 (5.8%), only in those undergoing PEG placement using a pull technique (p < 0.05). ConclusionPrimary placement of a skin-level device was successful in the majority of patients undergoing cecostomy tube placement for bowel management utilizing antegrade colonic enemas. This technique avoids a second anesthesia for tube conversion. Visualization via colonoscopy with the use of cecal suspension sutures is recommended. High BMI necessitates initial placement of a PEG tube and complications exclusively occurred in this group. Type of StudyClinical. Level of EvidenceIV Case series study.

V7-02 ROBOTIC ASSISTED ILEOVESICOSTOMY & CECOSTOMY TUBE

You have accessJournal of UrologyPediatrics1 Apr 2017V7-02 ROBOTIC ASSISTED ILEOVESICOSTOMY & CECOSTOMY TUBE Christina Ching, Molly Fuchs, Christopher Brown, and Daniel DaJusta Christina ChingChristina Ching More articles by this author , Molly FuchsMolly Fuchs More articles by this author , Christopher BrownChristopher Brown More articles by this author , and Daniel DaJustaDaniel DaJusta More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.1920AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Robotic surgical techniques have been adopted for procedures in pediatric urology but reconstruction for neurogenic bladder has been an area where it is underutilized. The reasons for this may include the need to create a bowel anastomosis, relative inexperience with robotics or perceived limitations of the technology. Our objective is to demonstrate the successful use of robotics in creating an ileovesicostomy incontinent urinary diversion with a complete intra corporeal bowel anastomosis and cecostomy tube placement. METHODS A 15 year-old female with myelomeningocele and neurogenic bladder had multiple failed attempts at compliance with clean intermittent catheterization program. She developed acute kidney injury and it was recommended that she undergo incontinent urinary diversion. We utilized the Intuitive Surgical DaVinci® Si robotic surgery system for the operation. Prior to port placement, we performed cystoscopy and injected 300 units of botox into the detrusor muscle. We used a 12mm camera port just superior to the umbilicus and three 8mm robotic ports. A 12mm accessory port was also placed for additional assistance. A cecostomy tube was also placed robotically to manage the patient's neurogenic bowel. The ileovesicootomy stoma was created in the left lower quadrant by extending the left arm robotic port site. RESULTS The patient was admitted the day prior to the procedure for mechanical bowel prep. The next morning she was taken to the operating room for the procedure. Total operative time was 406 minutes. Anesthesia induction was 17 minutes, cystoscopy and botox injection was 10 minutes and port placement and laparoscopic dissection took 22 minutes. Total console time was 244 minutes and closure time was 14 minutes. The remaining 96 minutes was for patient positioning and preparation. A foley catheter was placed per her urethra temporarily to keep her bladder decompressed to aid in wound healing and was removed prior to discharge. She was started on a clear liquid diet on post-operative day #2 and advanced as tolerated. The patient was discharged home on post-operative day #4 with no surgical drainage tubes except for her urostomy. At 5-month follow-up her creatinine remains at her baseline of 0.9 and her ultrasound shows no hydronephrosis. She has no leakage per urethra. CONCLUSIONS Robotic assisted ileovesocostomy is technically feasible in the pediatric population. As experience increases with such techniques, these authors expect that robotic surgery can be utilized in more complex reconstruction and patients can experience the benefits that minimally invasive techniques offer. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e823 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Christina Ching More articles by this author Molly Fuchs More articles by this author Christopher Brown More articles by this author Daniel DaJusta More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Complementary roles of interventional radiology and therapeutic endoscopy in gastroenterology.

Acute upper and lower gastrointestinal bleeding, enteral feeding, cecostomy tubes and luminal strictures are some of the common reasons for gastroenterology service. While surgery was initially considered the main treatment modality, the advent of both therapeutic endoscopy and interventional radiology have resulted in the paradigm shift in the management of these conditions. In this paper, we discuss the patient’s work up, indications, and complementary roles of endoscopic and angiographic management in the settings of gastrointestinal bleeding, enteral feeding, cecostomy tube placement and luminal strictures. These conditions often require multidisciplinary approaches involving a team of interventional radiologists, gastroenterologists and surgeons. Further, the authors also aim to describe how the fields of interventional radiology and gastrointestinal endoscopy are overlapping and complementary in the management of these complex conditions.

Laparoscopic Cecostomy Tube Placement.

Fecal incontinence is a debilitating problem for many children, especially those with anorectal malformations. Historically, surgical options have included the Malone antegrade continence enema, using an appendicostomy for antegrade colonic enemas. Since the development of this procedure, multiple alternatives have been developed, including the Chait cecostomy tube. Here, we present our technique for laparoscopic cecostomy tube placement. We find that this approach has several advantages, including mobilization of the cecum to allow the tube to be placed below the waistline for optimal cosmesis and comfort, increased safety provided by direct vision of needle access to the cecum, and increased security of the cecum to the abdominal wall allowing for safer tube replacement should it become dislodged in the early postoperative period.

Percutaneous Cecostomy in Adult Patients: Safety and Quality-of-Life Results

PurposeTo assess the safety and quality of life in adult patients undergoing cecostomy tube placement. Materials and MethodsPercutaneous cecostomy was performed in 23 adults (10 men and 13 women) with neurogenic bowel for whom noninvasive therapeutic approaches for chronic refractory constipation or fecal incontinence had failed. Mean patient age was 41 years (range, 19–74 y). A retrospective, standardized questionnaire evaluated satisfaction and quality of life before and after cecostomy. ResultsAll 23 cecostomy procedures were technically successful with no intraprocedural complications. At a mean follow-up of 42 months (range, 1–160 mo), there was one (5%) major complication, a pericecal abscess. One or more minor complications in 11 of 23 (48%) patients included leaking around the tube (5 of 23; 22%) and partial or complete dislodgment of the tube (3 of 23; 13%). In all cases, the cecostomy tube was exchanged successfully. Satisfaction scores improved from a mean of 2.2 points (range, 0–6 points; median, 1.5) to 7.6 points (range, 4–10 points; median, 8). The percentage of patients using laxative softeners decreased from 74% to 40%, and patients requiring assistance decreased from 52% to 35% after cecostomy placement. ConclusionsPercutaneous cecostomy is a safe procedure for the management of adult patients. Patients are able to achieve greater independence in their activities of daily living and are highly satisfied with the outcomes.

V7-06 ROBOTIC CONVERSION OF CECOSTOMY TUBE TO MALONE ANTEGRADE CONTINENCE ENEMA (ACE), SURGICAL TECHNIQUE.

You have accessJournal of UrologyPediatrics1 Apr 2015V7-06 ROBOTIC CONVERSION OF CECOSTOMY TUBE TO MALONE ANTEGRADE CONTINENCE ENEMA (ACE), SURGICAL TECHNIQUE. Mourad Abouelleil, Raju Chelluri, and Jonathan Riddell Mourad AbouelleilMourad Abouelleil More articles by this author , Raju ChelluriRaju Chelluri More articles by this author , and Jonathan RiddellJonathan Riddell More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1937AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To our knowledge no previous report has described conversion of cecostomy tube or a Mic-key button (usually in the cecum) to an antegrade continence enema (ACE). Several reports have described the procedure in both open and laparoscopic fashion using the appendix, but it has never been described as a conversion procedure. In general ACE is preferred over cecostomy in achieving continence, decreasing stool leakage and being free of appliances. Several of our patients present to our clinic requesting a conversion from cecostomy tube to ACE METHODS In this paper, we will describe surgical techniques in converting cecostomy to ACE laparoscopic robotic assisted. This approach appears to be simple and safe in achieving the above listed goals. It carries minimal morbidity to patient; quick recovery period and outcome have been satisfactory to this point in our small co-hort. RESULTS In our small cohort we were able to perform this operation on three patients, 8-14 years of age. These patients all had spina bifida with neurogenic bladder and bowel as an underlining diagnosis. Two of these patients had bladder augmentation in the past for a neurogenic bladder. One patient had no other abdominal operations aside from cecostomy tube placement. All patients were discharged home on POD one. Two patients presented with superficial wound infections at the ACE site and were treated with antibiotics. No patients required revision of the stoma or the ACE up to this point. No stool leakage around the ACE was documented on their postoperative visits. Importantly, all three patients were happy with the outcome. CONCLUSIONS Conversion of cecostomy button to ACE robotically is a safe, simple operation without any major complications in this case series. General patient satisfaction is high with good fecal continence. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e660-e661 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mourad Abouelleil More articles by this author Raju Chelluri More articles by this author Jonathan Riddell More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

The Percutaneous Cecostomy Tube in the Management of Fecal Incontinence in Children

PurposeTo retrospectively evaluate experience with percutaneous cecostomies and their long-term outcomes. Materials and MethodsBetween June 1994 and March 2009, 290 patients (mean age, 10.1 y) with fecal incontinence underwent percutaneous cecostomy tube placement and subsequent tube management. Technical success, procedural complications, and long-term follow-up until March 2012 were evaluated. ResultsA cecostomy was successfully placed in 284 patients (98%), and 257 of 280 patients (92%) underwent a successful exchange to a low-profile tube. A total of 1,431 routine exchanges to low-profile tubes were reviewed in 258 patients (mean, 1.6 ± 1.3 routine tube changes per 1,000 days). Eighty-five patients (29%) experienced one or more early problems after cecostomy, and 10 (3%) had major complications. In the total 463,507 tube-days, 938 late problems were noted: 917 (98%) minor and 22 (2%) major. Forty patients had the cecostomy catheter removed and 141 “graduated” to an adult health care facility. ConclusionsThe percutaneous cecostomy procedure provides a safe management option for fecal incontinence in the pediatric population.

Minimally Invasive Approach for Treatment of Urinary and Fecal Incontinence in Selected Patients with Spina Bifida

At our institution, the use of cecostomy tubes has provided a successful method for managing severe constipation in patients with spina bifida, with good patient and caretaker satisfaction and minimal morbidity. We have developed a modified technique to allow placement of the cecostomy tube under direct vision during laparoscopic appendicovesicostomy. We present our initial experience and technique. Patients with a normal bladder capacity and compliance who were scheduled for creation of an appendicovesicostomy and who also had refractory constipation were offered concurrent cecostomy tube placement. At the laparoscopic procedure, we performed percutaneous placement of the cecostomy tube through the abdominal wall under direct visualization. Subsequently, dissection of the appendix with its mesentery was performed. The detrusor muscle was dissected and a trough for the appendix created. Laparoscopic anastomosis of the appendix to the bladder mucosa and approximation of the detrusor over the appendix created a nonrefluxing channel. Three patients have undergone concurrent cecostomy tube placement at appendicovesicostomy. No complications have been encountered thus far. On follow-up, the cecostomy tube scar has been well concealed and appears no different from the ones placed under radiologic guidance. The patients have been using the catheterizable channel to access the bladder and dry performing intermittent catheterization without difficulties. In patients with a neurogenic bladder who do not qualify for major bladder reconstructive procedures, such as augmentation cystoplasty or bladder neck repair, social continence and independence can be achieved with minimally invasive surgery. Concomitant laparoscopic appendicovesicostomy and cecostomy tube placement may be a suitable surgical option.

Use of A Monti Channel For Administration of Antegrade Continence Enemas

Use of A Monti Channel For Administration of Antegrade Continence Enemas

Fecal incontinence in children: treatment with percutaneous cecostomy tube placement--a prospective study.

To evaluate the technique used for and long-term results of percutaneous cecostomy tube placement for the treatment of fecal incontinence in children. After an initial pilot study in 15 patients, 42 additional patients with fecal incontinence aged 2-20 (mean, 11.5) years and weighing 9.9-109.0 (mean, 39.2) kg underwent percutaneous cecostomy tube placement. Twenty-nine patients had spina bifida, nine had imperforate anus, three had cloacal anomalies, and one had Hirschsprung disease. Mean follow-up was 265 days (range, 8-503 days). Tube placement was successful in all patients. One patient developed local inflammation after accidental early retention-suture removal, which was treated with suture replacement and intravenous antibiotics. Another developed postprocedural ileus, which resolved. Late complications included constipation in one patient (treated with diet alteration), granulation tissue in seven patients (treated with silver nitrate cautery), and accidentally dislodged tubes in three patients (two successfully replaced at home and one replaced at the radiology suite). Vomiting related to the phosphate enema occurred in two patients. Resolution of soiling was achieved in all patients. Percutaneous cecostomy and antegrade enemas are very successful in achieving fecal continence and patient independence and acceptability, with minimal early and late complications.