Tube cecostomy versus appendicostomy for antegrade enemas in the management of fecal incontinence in children: A systematic review

doi:10.1016/j.jpedsurg.2020.01.011

Journal of Pediatric Surgery

Volume 55, Issue 7, July 2020, Pages 1196-1200

https://doi.org/10.1016/j.jpedsurg.2020.01.011 Get rights and content

Abstract

Background

Few studies have directly compared between cecostomy and appendicostomy for the management of fecal incontinence in pediatric population. This systematic review of the literature describes outcomes and complications following both procedures. We also reviewed studies reporting impact on quality of life and patient satisfaction.

Methods

MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), and Google Scholar were searched for chronic constipation pediatric patients who underwent cecostomy or appendicostomy. Two reviewers independently screened studies, extracted data, and assessed quality.

Results

An initial literature search retrieved 633 citations. After review of all abstracts, 40 studies were included in the final analysis, assessing a total of 2086 patients. The overall rate of complications was lower in the cecostomy group compared to the appendicostomy group (16.6% and 42.3%, respectively). Achievement of fecal continence and improvement in patient quality of life were found to be similar in both groups, however the need for revision of surgery was approximately 15% higher in the appendicostomy group.

Conclusion

Cecostomy has less post procedural complications, however rates of patient satisfaction and impact on quality of life were similar following both procedures.

Level of evidence

III

Section snippets

Methods

A comprehensive literature review was undertaken, with an initial electronic search of MEDLINE (1966 onwards), EMBASE (1980 onwards), the Cochrane Central Register of Controlled Trials (CENTRAL), and Google Scholar, using a series of keywords (antegrade continence enema, percutaneous cecostomy, laparoscopic cecostomy, button cecostomy, Malone antegrade continence enema). Gray literature was not searched as only evidence-based, peer-reviewed literature was included. To be eligible for inclusion,

Results

An initial literature search retrieved 633 citations following deduplication. After review of all abstracts, 144 papers were retrieved for detailed evaluation of inclusion and exclusion criteria.104 papers were excluded after title and abstract screening, leaving 40 studies included in the final analysis (Fig. 1). Studies included 31 case reviews on patients undergoing appendicostomy procedures [[6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22],

Discussion

This study was designed to compare outcomes and complications following cecostomy and appendicostomy procedures for the treatment of fecal incontinence in the pediatric population. Since it originated, modifications to the MACE procedure have been described, including the tubularization of intestinal conduits including the small bowel [7,8], cecum [22,30], and ascending colon [16,36] to permit antegrade continence enema creation in patients who have previously undergone appendectomy or in whom

Acknowledgment

We thank Nicole Travis for her help with data extraction.

Funding

This research did not receive any specific grants from funding agencies in the public, commercial, or not-for-profit sectors.

Conflict of interest

The authors do not have any conflicts of interest to declare.

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Cited by (19)

Comparing binary & ordinal definitions of urinary & stool continence outcomes: Data from the National Spina Bifida Patient Registry
2024, Journal of Pediatric Urology
The National Spina Bifida Patient Registry (NSBPR) assesses bladder and bowel incontinence using ordinal categories, but prior NSBPR analyses employed binary classification. Our aims were to 1) perform the first NSBPR analysis of bladder and bowel incontinence as ordinal outcomes to compare to the binary definition and subject variables; 2) explore the correlation of incontinence with undergarment usage, and 3) assess incontinence status following continence surgeries.
Data from NSBPR participants’ most recent clinic visit from 2013 to 2020 were analyzed. Ordinal categories of incontinence were compared to previously used binary definitions. Incontinence surgical outcomes were analyzed for those with data at least three months post-operatively. Chi-square tests evaluated associations among categorical variables. Univariate and ordinal logistic regression models were used to test associations of ordinal incontinence status with patient and condition factors. Statistical tests were 2-sided; p values < 0.05 were considered significant.
Analysis of 7217 individuals using ordinal incontinence outcomes showed little difference from previously used binary outcomes. The final multivariable logistic regression models with ordinal multinomial outcomes showed that associations of incontinence with age, sex, race/ethnicity, health insurance, level of lesion, and continence management technique were similar to prior studies. Among those reporting never being incontinent of both bladder and bowel, 14% reported using protective undergarments. Of the 500 individuals who had bladder outlet surgery, 38% reported never being incontinent of urine. Of 1416 individuals who had appendicostomy (ACE) bowel surgery, 48% reported never being incontinent of stool.
Our current analysis showed that ordinal continence outcome classification had similar continence findings as previous studies using the binary definition of continence. Expanding the binary definition of continence to include monthly episodes of incontinence did not greatly increase the proportion of continent individuals and, therefore, would have not likely made meaningful differences in continence outcomes in prior NSBPR analyses. However, it is known that even mild incontinence can affect quality of life, therefore, capturing any level of incontiennce is of clinical importance. Confirmation of the association of continence outcomes with sociodemographic, condition-related, and interventional factors with both approaches further validates previous analyses using the binary definition of continence.
The previously used binary definition of bladder and bowel continence appears robust. Undergarment choice was a poor surrogate for reported incontinence. After bladder and bowel continence surgeries, 38% and 48%, respectively, reported never being incontinent.
Long-Term outcomes of cecostomy tube insertion for patients with bowel dysfunction: A retrospective review
2023, Journal of Pediatric Urology
Constipation is common in the pediatric population and in severe forms it can lead to debilitating fecal incontinence which has a significant impact on quality of life. Cecostomy tube insertion is a procedural option for cases refractory to medical management, however there is limited data investigating the long-term success and complication rate.
A retrospective review was performed evaluating patients at our centre undergoing cecostomy tube (CT) insertion between 2002 and 2018. The primary outcomes of the study were the rate of fecal continence at 1-year, and the incidence of unplanned exchanges prior to annual scheduled exchange. Secondary outcomes include the frequency of anaesthetic requirements and length of hospital stay. Descriptive statistics, t-test, and chi-square analysis was performed where appropriate using SPSS v25.
Of 41 patients, the average age at the time of initial insertion was 9.9 years with the average length of stay in hospital being 3.47 days. The most common etiology of bowel dysfunction was spina bifida, which was present in 48.8% (n = 20) of patients. Fecal continence was achieved in 90% (n = 37) of patients at 1 year and the average rate of cecostomy tube exchange was 1.3/year with an average of 3.6 general anaesthetics being required by patients and the average age of no longer requiring one being 14.9 years.
Analysis of patients undergoing cecostomy tube insertion at our centre has further supported the use of cecostomy tubes as a safe and effective option for management of fecal incontinence refractory to medical management. However, a number of limitations exist in this study including its retrospective design and failure to investigate changes in quality of life using validated questionnaires. Additionally, while our research provides greater insight to practitioners and patients what degree of care and types of complications or issues they may encounter with an indwelling tube over the long-term, our single-cohort design limits any conclusions that could be made regarding optimal management strategies for overflow fecal incontinence through direct comparison with other management strategies.
CT insertion is a safe and effective method for managing fecal incontinence due to constipation in the pediatric population, however, unplanned exchange of tube due to malfunction, mechanical breakage, or dislodgment occurs frequently and may impact quality of life and independence.
IV.
Pediatric neurogenic bowel dysfunction: ICCS review document
2023, Journal of Pediatric Urology
The International Children's Continence Society (ICCS) aims to improve the quality of life in children with lower urinary tract dysfunction. A substantial portion of children also have problems with bowel dysfunction. There is a lack of evidence-based information on managing neurogenic bowel dysfunction (NBD) in children.
The ICCS aimed to provide an up-to-date, selective, non-systematic review of NBD's definitions, assessment, and treatment.
Specific definitions and terminology are defined within the document. Recommendations and considerations for physical assessment, history taking, and diagnostic studies are made. Management updates, both surgical and non-surgical, are provided as well as recommendations for follow-up and monitoring of individuals with NBD.
This review of the current literature will help guide NBD management and research to improve NBD care.
Do preoperative factors predict success of antegrade continence enemas in children?
2023, Journal of Pediatric Surgery
Citation Excerpt :
It is important for patients and parents to understand the procedure options, how success is defined, and how each operation can treat constipation. Recently papers comparing outcomes between appendicostomy and cecostomy have shown similar success rates but increased complications with appendicostomy tubes [15–17]. Our study was not designed as a comparator of complications, and we only had three patients receive a cecostomy, however, the complication rate for appendicostomy in our patients was 23%, lower than the 42.3% reported in a recent systematic review [17].
Antegrade 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.
We 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.
Forty-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.
In 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.
IV.
Prognosis study.
Robotic-assisted laparoscopic Malone appendicostomy: a 6-year perspective
2024, Pediatric Surgery International
2023 Canadian Urological Association/ Pediatric Urologists of Canada guideline: Pediatric patients with neurogenic lower urinary tract dysfunction
2023, Canadian Urological Association Journal

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Review ArticleTube cecostomy versus appendicostomy for antegrade enemas in the management of fecal incontinence in children: A systematic review

Abstract

Background

Methods

Results

Conclusion

Level of evidence

Section snippets

Methods

Results

Discussion

Acknowledgment

Funding

Conflict of interest

Lancet

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Urol

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Urol

J Pediatr Urol

J Pediatr Surg

Surgery

J Urol

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Urol

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Urol

J Urol

Review Article
Tube cecostomy versus appendicostomy for antegrade enemas in the management of fecal incontinence in children: A systematic review