Cecostomy Research Articles

Anal Sphincter Reconstruction Using the Posterior Sagittal Approach for Pediatric Perineal Trauma

Objectives: Traumatic perineal injuries are rare but can result in significant morbidity, particularly when the anal sphincter is injured. The management of such injuries in the pediatric population is rarely noted in the literature. We aimed to describe reconstruction in such patients using lessons learned in reoperative anorectal malformation surgery. Materials and Methods: This is a single institution retrospective case series of three pediatric patients who were referred to our institution with pelvic trauma who underwent anal sphincters reconstruction. Results: Three patients aged 5 (female), 12 (male), and 13 (female) years were referred for reconstruction following pelvic trauma involving the anal sphincter, perineal body, and genitourinary system. All three underwent multidisciplinary evaluation with urology and gynecology (for females)and a subsequent repair with anal sphincter reconstruction utilizing a posterior sagittal approach. Two patients had ostomy reversal with appendicostomy for antegrade continence enemas and regained voluntary fecal control. The third patient is awaiting colostomy reversal but has regained volitional urinary control after urethral reconstruction. Comments: The experience gained from using the posterior sagittal anorectoplasty approach in reoperations for patients with anorectal malformations can be applied to cases of rectal trauma. Key aspects include mobilizing the rectum, repairing the sphincters and placing them around the anus, and in females, reconstructing the perineal body. Conclusions: Pediatric pelvic trauma can cause devastating disruptions of physiology and are difficult to treat. Experience from reoperations for anorectal malformations can be applied to these cases, including the use of a multidisciplinary team and posterior sagittal approach.

Long-term outcome of transanal irrigation for individuals with spina bifida: a 12-year experience study.

Transanal irrigation (TAI) effectively addresses fecal incontinence and improves quality of life in individuals with spina bifida. Given the scarcity of follow-up studies lasting > 5years and reports of numerous TAI discontinuations, we assessed the enduring effectiveness and impact of TAI > 10years after its initiation on the quality of life in individuals with spina bifida. We recruited individuals with spina bifida enrolled in a bowel management program who initiated TAI in 2010 and participated in 4-month and 3-year follow-up studies at a spina bifida clinic. Raw data on bowel-related characteristics at baseline and after 4months and 3years of TAI were collected, and new survey-based demographic information, bowel-related characteristics, and the Fecal Incontinence Quality of Life scale scores were analyzed alongside extant datasets. Among 34 participants (age, mean [standard deviation] 17.7 [3.2] years), the mean follow-up was 11.8 (0.3) years; 21 participants persistently used TAI (persistent users), 12 discontinued TAI (discontinued users), and 1 used TAI and antegrade continence enema at the time of analysis. The fecal incontinence rate among persistent users decreased from 76.2% at baseline to 14.3% at the time of analysis; 11 (91.7%) discontinued users had fecal incontinence before TAI initiation, and the majority of discontinued users (66.7%) discontinued TAI because of improved bowel function. The fecal incontinence rate and quality of life did not differ significantly between discontinued users and persistent users. TAI effectively alleviated fecal incontinence among persistent users. One-third of users discontinued TAI but had improved fecal continence. We recommend periodic bowel function evaluation in TAI users and to reevaluate the necessity for TAI maintenance.

Medical Alert Cards for Pediatric Patients With Antegrade Continence Enemas to Enhance Awareness

IntroductionThe antegrade continence enema (ACE) is a surgical technique that establishes a route for colonic irrigation, necessitating a detailed comprehension of the procedural methodology, including the conduit construction, the catheters selection, and the administration of irrigation solutions. It is critical to disseminate comprehensive information regarding ACE procedures to health-care professionals and caregivers to enhance their understanding and support management of patients undergoing this intervention. This study aims to evaluate the efficacy of a novel educational tool designed to augment the knowledge base of physicians and caregivers regarding ACE procedures. MethodsMedical alert cards were conceptualized for patients managed with ACEs via an appendicostomy, neoappendicostomy, or cecostomy. These cards included essential information such as (1) contact details of the health-care team, (2) specifics of the surgical procedure, (3) criteria for emergency department referral, and (4) bespoke patient-specific information. A single-institution survey was conducted to assess the cards’ role in improving awareness of ACE procedures among health-care providers and caregivers and guiding management of patients with ACEs. The study adhered to Consensus-Based Checklist for Reporting of Survey Studies guidelines. ResultsTwenty-seven responses were collected from 18 health-care providers and nine caregivers. A significant majority (n = 24, 88%) affirmed the cards’ effectiveness in providing detailed information about individual patients. The design and layout of the card were well-received by 93% (n = 25) of respondents, with a median readability score of 8 (interquartile range 7-10). Additionally, some providers (n = 3, 17%) highlighted the card’s utility in facilitating patient referrals to specialized care centers. Suggestions for improvement included adding information about different types of tubes, enhancing readability, and optimizing the visual representation of the conduit. ConclusionsMedical alert cards demonstrated a significant potential to improve understanding of ACEs among health-care providers and caregivers. The cards aid in informing stakeholders about the ACE procedure, guiding the child’s management, and referring the patients to specialized care facilities when necessary.

Analysis of direct costs of trans anal saline irrigation to pharmacological measures for bowel dysfunction

BackgroundManagement of bowel dysfunction in children is expensive. Pharmacological measures (PM) are the most commonly used treatment option which has shown to have varying outcomes. The next option after failed PM involves invasive surgical procedures like the Malone Antegrade Continence Enema (MACE). Trans Anal Irrigation (TAI) is an efficacious treatment modality between failed medical therapy and invasive surgeries. As no cost analysis of TAI in children has been conducted, this study evaluated the direct costs involved with TAI in comparison to PM from the health care provider perspective. MethodsChildren >4 years with persistent bowel dysfunction despite PM, were divided into three groups: Constipation, Pseudoincontinence and Incontinence group. The costs of existing PM and number of diapers used daily were noted for each patient. In all patients, PM was stopped and TAI was initiated. Improvement in symptoms and reduction in daily diaper usage over six months was recorded. The direct costs of TAI versus the costs that would be involved had PM been continued, were compared using paired ‘t’ test. Results34 patients (20 male, 14 female) with an average age of 76.7 months were divided into three groups: Constipation:12, Pseudoincontinence:15 and Incontinence:7. In all groups, there was a significant reduction in direct costs with TAI in comparison to PM. ConclusionIn children with bowel dysfunction, TAI is an effective and significantly economical treatment modality in comparison to PM and should be considered early on in the management therapy.

The Transition of Patients with an ACE: Referral Pathway and Outcomes

AimsTransition of paediatric patients is challenging. This study aimed to assess the transition pathway for patients who underwent an ACE procedure as a child and to understand ongoing support requirements. MethodsA retrospective review was conducted of all patients on the Pelvic Floor Clinical Specialist Nurse’s (PFCNS) database from a tertiary adult hospital. Patients receiving their ACE as an adult or patients who did not attend any outpatient appointments (OPAs) were excluded. Data was gathered on complications, additional procedures and outcomes. ResultsSixty-three patients met the inclusion criteria. The median age at referral to an appropriate team was 18 years but the median age of referral to the PFCNS was 23 years. Only 7(11 %) were referred to the PFCNS by Paediatric Services. Patients experienced a variety of problems including change in equipment (n = 38, 60 %), change in washout regime (n = 28, 44 %), ACE leakage (n = 15, 24 %), stenosis (n = 15, 24 %) and ineffective washouts (n = 11, 17 %). Of those where data was available, there was a median of 7 PFCNS and 2.5 Colorectal Consultant (CC) OPAs per patient. Surgical intervention was common including procedures to the ACE (n = 8, 13 %), excision of ACE (n = 5, 7.9 %) manual evacuation (n = 5, 7.9 %) and formation of a stoma (n = 1%). 35 (56 %) were still using their ACE with a median time since transition of 11 years. ConclusionPatients with an ACE need considerable ongoing support yet few are appropriately transitioned. There needs to be a clear transition pathway for these patients to the PFCNS and if appropriate a CC.

Malone Antegrade Continence Enema Procedure in the Management of Chronic Constipation.

Malone Antegrade Continence Enema Procedure in the Management of Chronic Constipation.

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.

Treatment of Persistent Soiling in Hirschsprung Disease With Antegrade Continence Enemas

IntroductionPatients with Hirschsprung disease (HD) can experience soiling after their pull-through. We evaluated the use of antegrade continence enema (ACE) for this patient population and investigated the timing and factors associated with getting the patient clean. MethodsWe performed a single-institution retrospective review (from January 2020 to January 2023) of patients with HD and prior pull-through who had persistent soiling, failed laxative treatment or rectal enemas, and were treated with antegrade enemas. The primary outcome was time to become “clean of stool” which was defined as at least one bowel movement per day, no more than one stool accident per week, and no significant stool burden radiographically. Kaplan–Meier survival analysis was performed, and univariate cox proportional hazard regression was used to assess factors associated with time to continence. ResultsThirty patients who met the criteria underwent ACE creation at a median age of 6.5 y (interquartile range 5.3-9.8) with a median follow-up time of 11.5 mo (interquartile range 5.6-16.5). Most patients became clean by 4 mo (13 of 20, 65%) with similar results at 1-y follow-up (16 of 21, 76%). The median time to becoming clean was 4.3 mo (95% confidence interval: 1.7-15.0. Patients with hypermotility were more likely to continue to soil at 1 y (80% versus 13%, P = 0.01). There were no additional factors significantly associated with time to cleanliness. ConclusionsACE is a useful modality for HD patients with soiling. Most became clean of stool in 4 mo. The presence of hypermotility was associated with a higher incidence of persistent soiling at 1 y.

Functional Outcome in Patients With Anorectal Malformation With Recto-prostatic or Recto-bulbar Urethral Fistula and Comparison Between Different Surgical Approaches: A Multi-center Study

PurposeTo analyze and compare the outcomes in patients with anorectal malformation with rectoprostatic and rectourethral fistula between laparoscopic-assisted anorectoplasty (LAARP) versus posterior sagittal anorectoplasty (PSARP). MethodWe performed a retrospective review on all males with anorectal malformation (ARM) with recto-prostatic (ARM-RP) or recto-bulbar urethral fistula (ARM-RB) treated in five tertiary paediatric surgical centres in the past 25 years. Defecative function was assessed using the Krickenbeck classification and Kelly's score. Functional outcomes between patients with LAARP and PSARP were compared. ResultsThere were a total of 136 males with ARM-RP and ARM-RB for analysis, among which 73 (53.7%) had ARM-RP and 63 (46.3%) had ARM-RB. The median age of the patients was 9.4 years (range 0.8–24.7 years) and the median age at operation was 0.4 years (0 day–3.1 years). 57 (41.9%) and 79 patients (58.1%) underwent PSARP and LAARP respectively. 34 patients (25%) had VACTERL association. 111 (81.6%) and 103 patients (75.7%) had sacral and spinal cord anomalies respectively. 19 patients (13.9%) eventually required Malone's Antegrade Continence Enema (MACE).For the comparison between PSARP and LAARP, no difference in Kelly scores (4.58 ± 1.63 versus 4.67 ± 1.36) was identified (p = 0.79). Logistic regression for voluntary bowel movement showed that VACTER association (p = 0.02) and fistula location (p = 0.01) were significant prognostic factors, whereas the operation approach (PSARP or LAARP) was not (p = 0.65). ConclusionVACTERL association and fistula location were significant prognostic factors for voluntary bowel movement, and there appeared to be no significant difference in functional outcome between PSARP and LAARP. Level of EvidenceIV.

Significance of retrograde flow with antegrade continence enemas in children with fecal incontinence and constipation.

For children with constipation and fecal incontinence treated with antegrade continence enemas (ACE), a fluoroscopic study with contrast administered via appendicostomy/cecostomy can define the anatomy of the colon and simulate the flush to investigate associated symptoms or inadequate response. These studies can at times show retrograde flow into the small intestine. Our objective was to investigate the significance of this finding. We reviewed studies at our institution with contrast administered via appendicostomy/cecostomy in children treated with ACE, identifying those demonstrating retrograde flow of contrast. We recorded demographics, medical history, interventions, and outcomes. We identified 162 studies (52% male, median age 10.7 years) with contrast via appendicostomy (76%) or cecostomy (24%). Diagnoses included anorectal malformation (38%), spinal cord anomaly (26%), functional constipation (24%), colonic dysmotility (18%), and Hirschsprung disease (12%). Fifty-nine (36%) studies showed retrograde flow: 28/59 children (48%) were not responding adequately and 21/59 (36%) had symptoms with ACE. Children with retrograde flow were more likely to have symptoms with ACE than those without (36% vs. 15%, p < 0.01). Fourteen children underwent interventions for this finding, including administering flushes more distally (4/8 responded), changing positioning of the child during flush administration, (1/2 responded), and slowing administration (1/1 responded). Retrograde flow was associated with younger age (p < 0.01), not sex or underlying diagnosis. Identifying retrograde flow during studies with contrast administered via appendicostomy/cecostomy can be useful for children with a poor response or symptoms associated with ACE, as adjustments to the mechanics of the flush can alleviate those symptoms. Prognostic study, Level III.

Management of the child with refractory constipation.

Caring for children with constipation refractory to conventional treatment can be challenging and management practices vary widely. To review recent advances in the evaluation and treatment of children with refractory constipation and to propose an algorithm that incorporates the latest evidence and our institutional experience. We performed a literature review on diagnostic tests and treatment options for children with refractory constipation. Evaluation of a child with refractory constipation seeks to better understand factors contributing to an individual child's presentation. Anorectal manometry evaluating for a rectal evacuation disorder and colonic manometry evaluating for colonic dysmotility can guide subsequent treatment. For the child who has not responded to conventional treatment, a trial of newer medications like linaclotide can be helpful. Transanal irrigation offers a safe and effective alternative for families able to administer daily rectal treatment. Despite mixed evidence in children, pelvic floor biofeedback therapy can help some children with pelvic floor dyssynergia. For younger children unable to cooperate with pelvic floor therapy, or older children with refractory symptoms, internal anal sphincter botulinum toxin injection can be beneficial. Antegrade continence enema treatment can be effective for children with either normal colonic motility or segmental dysmotility. Sacral nerve stimulation is generally reserved for symptoms that persist despite antegrade continence enemas, particularly if faecal incontinence is prominent. In more severe cases, temporary or permanent colonic diversion and segmental colonic resection may be needed. Recent advances offer hope for children with refractory constipation.

Current practice in the care of children with functional constipation: What is the hold up?

For children with intractable functional constipation (FC), there are no evidence-based guidelines for subsequent evaluation and treatment. Our objective was to assess the practice patterns of a large, international cohort of pediatric gastroenterologists. We administered a survey to physicians who attended the 2nd World Congress of Pediatric Neurogastroenterology and Motility held in Columbus, Ohio (USA) in September 2023. The survey included 29 questions on diagnostic testing, nonpharmacological and pharmacological treatment, and surgical options for children with intractable FC. Ninety physicians from 18 countries completed the survey. For children with intractable FC, anorectal manometry was the most commonly used diagnostic test. North American responders were more likely than Europeans to use stimulant laxatives (97% vs. 77%, p = 0.032), prosecretory medications (69% vs. 8%, p < 0.001), and antegrade continence enemas (ACE; 83% vs. 46%, p = 0.009) for management. Europeans were more likely than North Americans to require colonic transit testing before surgery (85% vs. 30%, p < 0.001). We found major differences in management practices between Americans and the rest of the world, including use of prosecretory drugs (73% vs. 7%, p < 0.001), anal botulinum toxin injections (81% vs. 58%, p = 0.018), ACE (81% vs. 58% p = 0.018), diverting ileostomies (56% vs. 26%, p = 0.006), and colonic resections (42% vs. 16%, p = 0.012). No differences were found when respondents were compared by years of experience. Practice patterns in the evaluation and treatment of children with intractable FC differ widely among pediatric gastroenterologists from around the world. A clinical guideline regarding diagnostic testing and surgical decision-making is needed.

Variation in Practice Surrounding Antegrade Colonic Enema Channel Placement

PurposeAntegrade colonic enemas (ACE) can be an effective management option for defecation disorders and improve quality of life. Best practice regarding channel placement is unclear and variation may exist around preferred initial type of channel, age at placement, and underlying diagnoses. We aimed to describe practice patterns and patient characteristics around ACE channel placement. MethodsWe conducted a multicenter retrospective study of children with an ACE channel cared for at sites participating in the Pediatric Colorectal and Pelvic Learning Consortium (PCPLC) from 2017 to 2022. Kruskal–Wallis test was utilized to test the age at surgery by site with significance level of 0.05. Results500 patients with ACE channel were included. 293 (58.6%) patients had their ACE procedure at a PCPLC center. The median age at surgery was 7.6 [IQR 5.3–11.0] years for the overall cohort and 8.1 [IQR 5.3–11.5] years for placement at PCPLC centers. For PCPLC centers, median age at placement varied significantly across centers (p = 0.009). 371 (74.2%) patients received Malone appendicostomy, 116 (23.2%) received cecostomy, and 13 (2.6%) received Neo-Malone appendicostomy. Median age of patients by channel type was 7.7 [IQR 5.3–11.0], 7.5 [IQR 5.7–11.0], and 9.8 [IQR 4.2–11.6] years, respectively. The most common indication for cecostomy was idiopathic/refractory constipation (52.6%), whereas anorectal malformation was the most common indication for Malone (47.2%) and Neo-Malone (61.5%). Among ACE channels placed at PCPLC centers, there was variation across institutions in preferred initial channel type. The 4 highest volume centers favored Malone appendicostomy over cecostomy. ConclusionThere is variation in practice of ACE channel placement. At specialty pediatric colorectal centers, age at time of placement and type of channel placed varied across institutions. Further work is needed to better characterize diagnosis- and age-focused patient centered outcomes to clarify recommendations for our patients who benefit from these procedures. Type of StudyRetrospective comparative study. Level of EvidenceLevel III.

Antegrade Continence Enema Alone for the Management of Functional Constipation and Segmental Colonic Dysmotility (ACE-FC): A Pediatric Colorectal and Pelvic Learning Consortium Study.

The purpose of the study was to determine if antegrade continence enema (ACE) alone is an effective treatment for patients with severe functional constipation and segmental colonic dysmotility. A retrospective study of patients with functional constipation and segmental colonic dysmotility who underwent ACE as their initial means of management. Data was collected from six participating sites in the Pediatric Colorectal and Pelvic Learning Consortium. Patients who had a colonic resection at the same time as an ACE or previously were excluded from analysis. Only patients who were 21 years old or younger and had at least 1-year follow-up after ACE were included. All patients had segmental colonic dysmotility documented by colonic manometry. Patient characteristics including preoperative colonic and anorectal manometry were summarized, and associations with colonic resection following ACE were evaluated using Fisher's exact test and Wilcoxon rank-sum test. p-Values of less than 0.05 were considered significant. Statistical analyses and summaries were performed using SAS version 9.4 (SAS Institute Inc., Cary, North Carolina, United States). A total of 104 patients from 6 institutions were included in the study with an even gender distribution (males n = 50, 48.1%) and a median age of 9.6 years (interquartile range 7.4, 12.8). At 1-year follow-up, 96 patients (92%) were successfully managed with ACE alone and 8 patients (7%) underwent subsequent colonic resection for persistent symptoms. Behavioral disorder, type of bowel management, and the need for botulinum toxin administered to the anal sphincters was not associated with the need for subsequent colonic resection. On anorectal manometry, lack of pelvic floor dyssynergia was significantly associated with the need for subsequent colonic resection; 3/8, 37.5% without pelvic dyssynergia versus 1/8, 12.5% (p = 0.023) with pelvic dyssynergia underwent subsequent colonic resection. In patients with severe functional constipation and documented segmental colonic dysmotility, ACE alone is an effective treatment modality at 1-year follow-up. Patients without pelvic floor dyssynergia on anorectal manometry are more likely to receive colonic resection after ACE. The vast majority of such patients can avoid a colonic resection.

Evaluation of the safety, efficacy and feasibility of ‘at-home’ capsule endoscopy

ObjectiveThe role of small bowel capsule endoscopy (SBCE) in diagnosing gastrointestinal diseases has long been established. Recently, colon CE (CCE) has been suggested as an alternative to colonoscopy. CE has...

A308 AN UNUSUAL CASE OF MACE DYSFUNCTION: THE BENEFIT OF USING ANTEGRADE CONTRAST FOLLOW THROUGH MIMICKING HOME SETTINGS

Abstract Background Malone Antegrade Continence Enema (MACE) is indicated in cases where medical management for constipation or faecal incontinence with laxatives or enemas has failed. MACE allows the administration of flushes with and without laxatives in an antegrade manner to mechanically empty the colon. Aims The aim of this case report is to illustrate an unusual case of MACE dysfunction and how it was troubleshooted. Methods Case report and review of the literature Results 11-year-old female with neurogenic constipation and faecal incontinence for which MACE was being used. She was referred to clinic for evaluation of new-onset vomiting, abdominal distention, and abdominal pain with MACE flushes. Her flushes consisted of crushed Bisacodyl, glycerin, PEG 3350 and 300 ml of saline solution. Cone enemas were also being used to completely empty her rectum, otherwise evacuation with regular flushes was not occurring, but was causing significant abdominal pain, distention and vomiting. A contrast study was done by flushing water-soluble contrast through the MACE in an antegrade manner, while simultaneously performing a contrast enema, demonstrating good passage of contrast with no findings suggestive of obstruction. She was admitted to hospital to complete imaging studies, bowel clean out and to better understand her MACE dysfunction. Following bowel clean out in hospital, MACE flushes were resumed, causing the same symptoms. Flushes without Bisacodyl were tried in the attempt to avoid possible colonic spasms; however symptoms re-occurred. A second contrast study was performed (figure 1), mimicking home flushes in volume and time of administration, as well as patient’s position (sitting), completed in an antegrade fashion only. The patient developed symptoms 20 minutes after administering the contrast requiring cone enema. By the end of the study, there was poor passage of contrast through the proximal descending colon, suggesting a kink at the juncture between the sigmoid and descending colon. There was no reflux on contrast into the terminal ileum. An x-ray was done around 5 hours after, and contrast was still not seen in the rectum. The patient underwent diagnostic laparoscopy, finding adhesions in the left upper quadrant of the descending and sigmoid colon, causing a Z-configuration hairpin obstruction, and colostomy creation. The patient has been doing well since colostomy creation with no pain. Conclusions MACE dysfunction can be caused by colonic adhesions distal to the MACE site Simultaneous antegrade contrast through MACE and contrast enema may miss bowel obstruction Antegrade contrast study mimicking home settings may be more helpful in situations where bowel obstruction is suspected Funding Agencies None

Outcomes of children with constipation and autism spectrum disorder treated with antegrade continence enemas.

Treatment of functional constipation (FC) in children with autism spectrum disorder (ASD) is challenging due to sensory and behavioral issues. We aimed to understand whether antegrade continence enemas (ACEs) are successful in the treatment of FC in children with ASD. A single-institution retrospective review was performed in children diagnosed with ASD and FC who underwent appendicostomy or cecostomy placement from 2007 to 2019. Descriptive statistics regarding soiling and complications were calculated. There were 33 patients included, with a median age of 9.7 years at the time of ACE initiation. The average intelligence quotient was 63.6 (SD = 18.0, n = 12), the average behavioral adaptive score was 59.9 (SD = 11.1, n = 13), and the average total Child Behavioral Checklist score was 72.5 (SD = 7.1, n = 10). Soiling rates were significantly lower following ACE initiation (42.3% vs. 14.8%, p = 0.04). Behavioral issues only prevented 1 patient (3.0%) from proper ACE use. Eleven patients (36.6%) were able to transition to laxatives. There were significant improvements in patient-reported outcomes measures and quality of life. Placement of an appendicostomy or cecostomy for management of FC in children with severe ASD was successful in treating constipation and improving quality of life.

Feasibility of Enhanced Recovery After Surgery (ERAS) implementation in Pediatric Urology: Pilot-phase outcomes of a prospective, multi-center study

Enhanced Recovery After Surgery (ERAS) is a fundamental shift in perioperative care that has consistently demonstrated an improved outcome for a wide variety of surgeries in adults but has only limited evidence in the pediatric population. We aimed to assess the success with and barriers to implementation of ERAS in a prospective, multi-center study on patients undergoing complex lower urinary tract reconstruction. Centers were directed to implement an ERAS protocol using a multidisciplinary team and quality improvement methodologies. Providers completed pre- and post-pilot surveys. An audit committee met after enrolling the first 5 patients at each center. Pilot-phase outcomes included enrollment of ≥2 patients in the first 6 months of enrollment, completion of 90 days of follow-up, identification of barriers to implementation, and protocol adherence. A total of 40 patients were enrolled across 8 centers. The median age at surgery was 10.3 years (IQR 6.4-12.5). Sixty five percent had a diagnosis of myelomeningocele, and 33% had a ventriculoperitoneal shunt. A bladder augmentation was performed in 70%, Mitrofanoff appendicovesicostomy in 52%, Monti ileovesicostomy in 15%, and antegrade continence enema channel in 38%. The most commonly perceived barriers to implementation on the pre-pilot survey were "difficulty initiating and maintaining compliance with care pathway" in 51% followed by a "lack of time, money, or clinical resources" in 36%. The pre-pilot study experience, implementation, and pilot-phase outcomes are provided in the Table. All primary and secondary outcomes were achieved. The findings of the present study were similar to several small comparative studies with regard to the importance of a multidisciplinary team, strong leadership, and continuous audit for successful implementation of ERAS. Similar barriers were also encountered to other studies, which primarily related to a lack of administrative support, leadership, and buy-in from other services. The limitations of the present study included a relatively small heterogeneous cohort and absence of a comparative group, which will be addressed in the larger exploratory phase of the trial. The findings may also not be generaziable due to the need for sustainable processes that were unique to each center as well as an absence of adequate volume or resources at smaller centers. ERAS was successfully implemented for complex lower urinary tract reconstruction across 8 centers through a multidisciplinary team, structured approach based on the local context, and focus on a continuous audit.

The impact of antegrade continence enemas on bladder function in patients with neurogenic bladder and bowel

In neurologically intact children with constipation and lower urinary tract symptoms, treatment of constipation frequently results in improved or resolved lower urinary tract symptoms. The impact of treatment of constipation on bladder function in children with a neurogenic bowel and bladder is not well studied. The objective of this study was to evaluate the impact of antegrade continence enemas (ACE) via Chait tube on urodynamic study (UDS) parameters and urinary continence in patients with neurogenic bowel and bladder (NGB). We hypothesized that following ACE some patients would demonstrate improved UDS parameters and improved urinary continence. A review of patients with NGB who underwent a cecostomy was performed. Inclusion criteria required UDS within 12 months before and after Chait tube placement and no change in clean intermittent catheterization or anticholinergic medications. UDS parameters assessed included bladder capacity, bladder compliance, and bladder stability. In addition, the frequency of antegrade continence enemas and encopresis were reviewed as was the frequency of UTIs before and after the surgery. 8 children met inclusion criteria, including 5 girls and 3 boys, with a mean (range) age of 8.5 years (5-13). All children were on clean intermittent catheterization and 7 were on anticholinergic medications. The patients demonstrated a significant improvement in constipation and encopresis (p<0.05). All but 1 patient had resolution of encopresis, and 6 of 7 patients who had constipation before ACE management had a resolution of constipation. 2 patients (25%) developed urinary continence (i.e., dry between CIC), and 2 others had improvement in continence. 3, 2, and 2 patients had urodynamic improvement in bladder capacity, compliance, or stability, respectively. However, no significant improvement in urinary incontinence or UDS parameters was demonstrated for the group overall. Our data demonstrate that some children with neurogenic bowel and bladder will have improvement in continence and UDS parameters following the initiation of ACE. Despite significant improvement in constipation and encopresis, the frequency of bladder improvement in this population appears less than that reported in neurologically intact children following treatment of constipation. Confirmatory studies with a larger number of children are needed. However, since constipation appears to negatively impact bladder function in some children with neurogenic bowel and bladder, it is reasonable to try to eliminate significant constipation in these patients before increasing pharmaceutical management of their neurogenic bladder.

Psychosocial factors impacting antegrade continence enema outcomes in pediatric patients.

Children with constipation and encopresis are often treated with medication and behavioral approaches. When constipation persists, surgical interventions such as antegrade continence enema (ACE) procedures are considered. Many children benefit from these procedures; however, some children continue to have incontinence, experience complications, or discontinue the use of the ACE stoma. There is some evidence in the literature to indicate that psychosocial factors can have an impact on ACE outcomes; however, standardized biopsychosocial guidelines related to ACE candidacy and surgery do not currently exist. The purpose of this review is to summarize the research to date on psychosocial factors related to ACE treatment outcomes and complications. Identifying what is known and what limitations remain can support future research to inform development of guidelines for pre-procedure evaluations. Psychosocial pre-procedure evaluations could help to inform eligibility for the procedure as well as interventions to enhance outcomes for children at increased risk for poor outcomes or complications from ACE. Age, psychiatric symptoms, and adherence to the ACE flush regimen were some of the factors identified in the literature as impacting ACE outcomes; however, there is limited research in this area.