Management of pediatric patients with refractory constipation who fail cecostomy

doi:10.1016/j.jpedsurg.2012.12.034

Journal of Pediatric Surgery

Volume 48, Issue 9, September 2013, Pages 1931-1935

https://doi.org/10.1016/j.jpedsurg.2012.12.034 Get rights and content

Abstract

Background

Antegrade continence enema (ACE) is a recognized therapeutic option in the management of pediatric refractory constipation. Data on the long-term outcome of patients who fail to improve after an ACE-procedure are lacking.

Purpose

To describe the rate of ACE bowel management failure in pediatric refractory constipation, and the management and long term outcome of these patients.

Methods

Retrospective analysis of a cohort of patients that underwent ACE-procedure and had at least 3-year-follow-up. Detailed analysis of subsequent treatment and outcome of those patients with a poor functional outcome was performed.

Results

76 patients were included. 12 (16%) failed successful bowel management after ACE requiring additional intervention. Mean follow-up was 66.3 (range 35–95 months) after ACE-procedure. Colonic motility studies demonstrated colonic neuropathy in 7 patients (58%); abnormal motility in 4 patients (33%), and abnormal left-sided colonic motility in 1 patient (9%). All 12 patients were ultimately treated surgically. Nine patients (75%) had marked clinical improvement, whereas 3 patients (25%) continued to have poor function issues at long term follow-up.

Conclusions

Colonic resection, either segmental or total, led to improvement or resolution of symptoms in the majority of patients who failed cecostomy. However, this is a complex and heterogeneous group and some patients will have continued issues.

Section snippets

Materials and methods

We conducted a retrospective analysis of a cohort of patients with chronic refractory constipation that underwent cecostomy for administration of ACE at The Floating Hospital for Children at Tufts Medical Center between April 2003 and January 2011. The technique has been described previously [3]. Detailed analysis of the subgroup of patients who failed to improve after cecostomy was performed including demographic variables, medical history, symptoms, subsequent treatment and clinical outcome.

Results

Seventy six patients underwent cecostomy during the study period. Twelve patients (16%) failed successful bowel management after cecostomy and were included in the study (Table 1). This subgroup of patients did not differ from the patients that succeeded in regards to demographic variables, clinical presentation and manometric findings in our series. The mean age for this subgroup of patients was 14.7±1.2 SEM (range 11–23 years). The mean follow-up time was 66.3 months (range 35–95 months) after

Discussion

Since its first description in 1990 [13], the ACE procedure has become a recognized therapeutic option in the management of children with intractable constipation who fail medical regimen and who have Hirschsprung's disease ruled out by rectal biopsy. In this paper, we describe the long term outcome of a cohort of pediatric patients with chronic constipation who failed to achieve successful bowel management after cecostomy placement. Only a small percentage of pediatric patients fail to respond

References (28)

A. Rasquin et al.
Childhood functional gastrointestinal disorders: child/adolescent
Gastroenterology
(2006)
R. van Ginkel et al.
Childhood constipation: longitudinal follow-up beyond puberty
Gastroenterology
(2003)
L. Rodriguez et al.
Laparoscopic-assisted percutaneous endoscopic cecostomy in children with defecation disorders (with video)
Gastrointest Endosc
(2011)
J.I. Curry et al.
The MACE procedure: experience in the United Kingdom
J Pediatr Surg
(1999)
E.B. Yerkes et al.
The Malone antegrade continence enema procedure: quality of life and family perspective
J Urol
(2003)
H.Y. Kim et al.
Is the outcome of the left colon antegrade continence enema better than that of the right colon antegrade continence enema?
J Pediatr Surg
(2009)
B. Jaffray
What happens to children with idiopathic constipation who receive an antegrade continent enema? An actuarial analysis of 80 consecutive cases
J Pediatr Surg
(2009)
L.T. Hoekstra et al.
The Malone antegrade continence enema procedure: the Amsterdam experience
J Pediatr Surg
(2011)
P.S. Malone et al.
Preliminary report: the antegrade continence enema
Lancet
(1990)
S.L. Lee et al.
Surgical management of chronic unremitting constipation and fecal incontinence associated with megarectum: a preliminary report
J Pediatr Surg
(2002)

M.M. Vandenberg et al.

Colonic manometry as predictor of cecostomy success in children with defecation disorders

Journal of pediatric surgery

(2006)

P.G. Chait et al.

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

Radiology

(1997)

S. Cascio et al.

MACE or caecostomy button for idiopathic constipation in children: a comparison of complications and outcomes

Pediatr Surg Int

(2004)

Y. Soylet et al.

Antegrade continence enema—an analysis of 20 children with faecal incontinence

Eur J Pediatr Surg

(2006)

Cited by (19)

Enema-Induced spastic left colon syndrome: An unintended consequence of chronic enema use
2021, Journal of Pediatric Surgery
Citation Excerpt :
We selected the papers specifically describing the antegrade or retrograde use of enemas for the treatment of fecal incontinence, severe intractable constipation, colonic motility disorders in children and in adults. Forty-three publications were selected for review. (1–43) The type of enemas have varied in these patients, as well as the ingredients that the patients were receiving, including saline solution/glycerin (six cases), only saline solution (five), saline solution/glycerin/soap (four), plain water (three), and one case each of molasses/milk, saline solution/glycerin/soap/phosphate, saline solution/phosphate, and only phosphate (Table 1).
Enemas have become a common practice for treating fecal incontinence and severe constipation. Several patients receiving enemas complained of severe, colicky, abdominal pain during enema administration and complained that the duration for fluid to pass was progressively increasing. Contrast studies showed a startling picture of severe right colon dilatation and a spastic, narrow, left colon. An investigation was started to seek the origin and possible management of this condition.
Medical and radiologic records were reviewed retrospectively, with emphasis on the type and ingredients of enemas used, the duration the patients had been receiving enemas, and their original diagnosis. A literature review was done on previous reports of this condition and publications related to long-term use of enemas.
This series included 22 patients (average age, 19.6 years; range, 8–54) with fecal incontinence due to anorectal malformations (10 cases), myelomeningocele (5), cloaca (2), severe colonic dysmotility (2), Hirschsprung's disease (2), and sacrococcygeal teratoma (1). The average duration of enema use was 13.7 years (range, 4–45). The composition of the enemas included saline/glycerin (six cases), only saline solution (five), saline/glycerin/soap (four), plain water (three), and one case each of molasses/milk, saline/glycerin/soap/phosphate, saline/phosphate, and only phosphate. The enemas were performed in an antegrade fashion in 21 cases and rectally in 1. All patients had a dilated right colon and a narrow, spastic, left, transverse, and descending colon. Four patients underwent colonoscopy, colonic manometry, and mucosal biopsies, which did not help in explaining the etiology of the problem. In the literature, 43 reports mentioned a “long-term follow-up” for the administration of enemas, but we could not find a description of symptoms, such as in our cases.
An intriguing and, to our knowledge, previously unreported complication of chronic enema use is presented. We call attention to an overly concerning complication and report our findings in the hope that they will aid and stimulate more investigations into this condition. Several hypotheses to explain the cause are presented, as well as potential treatment options.
Intermediate and long-term outcomes of a bowel management program for children with severe constipation or fecal incontinence
2020, Journal of Pediatric Surgery
We sought to examine the long-term clinical success rates of a bowel management program (BMP) for children with severe constipation or fecal incontinence.
A single center review was conducted of children (≤ 18 years) enrolled in a BMP and followed in a colorectal specialty clinic (2011–2017). All patients who completed an initial week of the BMP were included. Patients enrolled in a BMP after 2018 were excluded. Success was defined as no accidents and < 2 stool smears per week.
A total of 285 patients were reviewed. BMP was initiated at a median age of 7 years (9 months-17 years). Primary diagnoses included functional constipation (112), anorectal malformation (ARM) (104), Hirschsprung Disease (HD) (41), rectal prolapse (14), spina bifida (6), fecal incontinence (3) and other (5; 4 sacral coccygeal teratomas and a GSW to the buttocks). Initial bowel regimen included large volume enema in 54% and high dose stimulant laxative in 46%. The initial Bowel Management Week (BMW) was successful in 233 (87% of adherent patients) patients with 17 (6%) non-adherent. One hundred twenty-two patients had follow-up at 12 months (72% success amongst adherent patients, 7% of patient non-adherent) and 98 patients had follow-up at 24 months (78% success amongst adherent patients, 10% of patients non-adherent). 21/154 (14%) patients started on enemas were later successfully transitioned to laxatives and 13/132 (10%) patients started on laxatives subsequently required enemas in order to stay clean. Clinic phone contact occurred outside of scheduled visits for adjustment to the BMP in 44% of patients. 33% of patients had surgery to aid bowel management (antegrade colonic enema (ACE) = 81, resection + ACE = 13, diverting stoma = 4). Median follow up was 2.5 years (5 weeks–7 years).
Children who follow a structured BMP with readily available personnel to provide outpatient assistance can experience successful treatment of severe constipation or fecal incontinence long-term. A multi-institutional collaboration is necessary to identify factors which predict failure of a BMP and non-adherence.
Single-center retrospective chart review.
3
Functional Constipation and Fecal Incontinence
2020, Pediatric Gastrointestinal and Liver Disease, Sixth Edition
Constipation and fecal incontinence represent common problems in children. Beyond the neonatal period, only a minority of children have an organic cause for their constipation, and the etiology remains not well understood. Constipation rarely leads to life-threatening complications but can cause emotional and physical distress and concerns for children and their families, ultimately impairing health-related quality of life. The hallmarks of constipation are infrequent painful defecation and fecal incontinence often accompanied by abdominal pain. In less than 15% of cases, children have fecal incontinence without a history and physical examination that indicates underlying constipation. These latter children are classified as having functional nonretentive fecal incontinence (FNRFI) according to the Rome IV criteria. The aims of this chapter are to describe functional defecation disorders in children: functional constipation associated with or without fecal incontinence and FNRFI. The chapter will also describe diagnostic approaches and treatment regimens for this disorder and will report on treatment outcomes.
Neurogastroenterology and motility disorders in pediatric population
2019, Clinical and Basic Neurogastroenterology and Motility
Motility of the gastrointestinal tract plays a critical role in the maintenance of its many physiological functions. These motility patterns, which vary along the gastrointestinal tract, are achieved by highly coordinated interactions between the neuromusculature of the gut (smooth muscle layers, enteric nervous system, interstitial cells of Cajal), central nervous system, autonomic nervous system, hormones, peptides and the microbiome. Other external factors such as diet, and age related changes in the gastrointestinal tract also, ultimately, affect gastrointestinal motility. A subtle change in any of the above factors could significantly impact on gastrointestinal function leading to pediatric gastrointestinal motility disorders. Here, we review common motility disorders in children and provide an indepth understanding of the pathophysiology and management of these problem.
Malone appendicostomy versus cecostomy tube insertion for children with intractable constipation: A systematic review and meta-analysis
2018, Journal of Pediatric Surgery
Citation Excerpt :
The three studies reported on children with a variety of conditions and not all may respond to antegrade continence enemas. In fact, some patients may do better with a more radical surgical intervention, such as subtotal colectomy and ileorectal anastomosis [32]. In the foreseeable future, however, the choice of intervention for intractable constipation will continue to be influenced by patient and physician preferences, while taking into consideration the patient's comorbidities and psychosocial circumstances.
Children with intractable constipation are often treated with antegrade continence enemas. This requires the creation of a Malone appendicostomy in the operating room or insertion of a cecostomy tube using endoscopic, radiologic, or surgical techniques. The purpose of this study was to assess the evidence regarding these procedures.
We conducted a search of Embase, Medline, CINAHL, and Web of Science up to October 2016. We included comparative studies of children treated with Malone appendicostomy or cecostomy tube insertion. Two reviewers screened abstracts, reviewed studies, and extracted data.
We identified 166 children from three retrospective studies who underwent Malone appendicostomy (n = 82) or cecostomy tube insertion (n = 84). There were no differences in the number of patients who achieved continence (80% versus 70%, p = 0.76), but the need for additional surgery was higher in children treated with Malone appendicostomy (30% versus 12%, p = 0.01). Studies reported a variety of tube and stoma-related complications, but quality of life was not assessed using validated measures.
Malone appendicostomy and cecostomy tube insertion are comparable in terms of achieving continence. Children treated with Malone appendicostomy appear to be more likely to require additional surgery due to early or late complications.
Therapeutic, 1c.
Pain Management
2016, Smith's Anesthesia for Infants and Children, Ninth Edition

View all citing articles on Scopus

View full text

Original ArticleManagement of pediatric patients with refractory constipation who fail cecostomy

Abstract

Background

Purpose

Methods

Results

Conclusions

Section snippets

Materials and methods

Results

Discussion

Gastroenterology

Gastroenterology

Gastrointest Endosc

J Pediatr Surg

J Urol

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

Lancet

J Pediatr Surg

Journal of pediatric surgery

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

Radiology

MACE or caecostomy button for idiopathic constipation in children: a comparison of complications and outcomes

Pediatr Surg Int

Antegrade continence enema—an analysis of 20 children with faecal incontinence

Eur J Pediatr Surg

Original Article
Management of pediatric patients with refractory constipation who fail cecostomy