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Antegrade Continence Enema: Which Bowel Segment Is Better?

Sunday, October 21, 2012: 2:42 PM
Grand Ballroom B (Hilton Riverside)
Jonathan S. Ellison, MD, A. Neil Haraway and John M. Park, Urology, University of Michigan, Ann Arbor, MI

Purpose

Antegrade continence enemas (ACE) are utilized for refractory fecal dysfunction in the pediatric neuropathic population.  Various bowel segments have been used for ACE, including the original description by Malone of appendicocecostomy.  Depending on the overall colonic motility and redundancy, the optimal bowel segment for achieving efficient enemas remains unknown.  We reviewed our experience of the ACE procedure, investigating patient factors, functional outcomes, and complications associated with the use of various bowel segments. 

Methods

An IRB-approved retrospective chart review of 109 consecutive ACE procedures by a single-surgeon from 2000-2011 was performed.  The choice of colon segment used for ACE reconstruction was determined by the surgeon's discretion intra-operatively.  Pre-operative patient characteristics, intra-operative techniques, and post-operative outcomes were reviewed and statistical analysis performed.

Results

A total of 90 patients undergoing 109 ACE procedures were included for analysis.  Average age at operation was 13.8 years.  Myelomeningocele was the most common pre-operative diagnosis.  Most patients underwent simultaneous urinary reconstruction.  Stomal complications (49%) were most common.   A sub analysis compared outcomes of proximal (cecal, N = 48) and distal (sigmoid colon, N = 55), excluding those sited at the transverse colon (N =6).  Left sided distal ACE stomas were associated with shorter flush times compared to the right-sided proximal stomas (37.2  vs. 61.2 minutes, p < 0.001).  Eight patients underwent conversion from an original cecal ACE to a more distal location due in part to protracted flush times and abdominal colic, while 3 patients underwent conversion of a distal sigmoid colonic ACE to a cecal location for stomal complications.  Use of appendix was associated with a higher, though not statistically significant, stomal complication rate (42%) as compared to colon (25%) channels.  

Conclusion

Use of either cecal, transverse or colonic location for ACE results in acceptable and comparable stoma outcomes, although left sided colonic ACE is associated with significantly shorter flush times and may have lower stomal complications.  Stomal complications, especially stomal stenosis, remain a frustrating reality of the ACE procedure. 

Table: Comparison of sigmoid versus cecal location for ACE reconstruction.

ACE Location

Sigmoid

(N = 55)

Cecal

(N = 48)

Demographics

AGE at Operation

14.9 ± 7.9

12.1 ± 6.2

BMI at Operation

21.5 ± 5.5

21.6 ± 7.7

Admission for Bowel Preparation

46 (84%)

46 (98%)

Urinary reconstruction

46 (84%)

42 (88%)

Functional Outcomes

Fecal continence

54 (98.2%)

46 (95.8%)

Not Using ACE

3 (5.5%)

3 (6.3%)

Flush time

37.2 ± 16.4

61.2 ± 35.8

Enema volume

937 ± 625

815 ± 328