Review Article
Malone appendicostomy versus cecostomy tube insertion for children with intractable constipation: A systematic review and meta-analysis

https://doi.org/10.1016/j.jpedsurg.2018.02.010Get rights and content

Abstract

Purpose

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.

Methods

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.

Results

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.

Conclusion

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.

Level of Evidence

Therapeutic, 1c.

Section snippets

Study design

We conducted a systematic review and meta-analysis of children with functional and pathologic causes of intractable constipation refractory to maximal medical management. Our intervention and comparison groups were those treated with Malone appendicostomy versus cecostomy tube insertion. Our primary outcomes were continence post-procedure and quality of life. Secondary outcomes included adverse events and complications. Our study design was registered with the International Prospective Register

Search results

An overview of our search results is depicted in Fig. 1 [25]. Two hundred and thirteen studies were identified from the structured search of databases and an additional 16 records from our review of the grey literature. After removal of duplicates, 139 studies underwent title and abstract review. Studies were excluded for using a technique that was neither Malone appendicostomy nor cecostomy (n = 28), non-comparative design (n = 87), non-pediatric participants (n = 11), no surgical technique studied

Discussion

This study found no significant differences between Malone appendicostomy and cecostomy tube insertion in terms of achieving fecal continence. We were concerned to see that children who underwent Malone appendicostomy were more likely to require additional surgery. This is probably because the Malone procedure is associated with increased risk of stomal stenosis, leading to higher rates of surgical revision or conversion to cecostomy. Another possibility is that some of the children who

Acknowledgements

We would like to thank Andrea McLellan for her assistance with developing and executing the search strategy.

Conflicts of interest

The authors have no conflicts of interest to report.

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