In children faecal incontinence encompasses both encopresis and soiling (Di Lorenzo and Benninga 2004). Encopresis is defined as the repeated expulsion of a normal bowel movement, whether involuntary or intentional in inappropriate places by a child aged 4 years or over. Soiling is defined as the involuntary leakage of small amounts of stool resulting in staining of underwear. Faecal incontinence is a serious problem in the paediatric population. In the USA it is estimated that at least 3 million children are affected (Kaye and Towbin 2002). Children with faecal incontinence can be classified into four main groups: children with functional faecal retention and overflow soiling; children with functional non-retentive faecal soiling; children with anorectal malformations; and children with spinal deformities. The cecostomy technique described below is primarily aimed at the last two categories.
To date the most effective therapeutic method is the use of high volume enema, as this ensures com plete evacuation of the colonic tract. This approach minimizes the risk of unwanted bowel evacuation, which is not only cumbersome but also humiliating for both patient as well as carers. The major disadvantage is the level of acceptance in patients, especially during puberty. In patients with paresis or paralysis of limbs it is impossible to perform the procedure without aid, lowering the level of compliance in this population.
In order to overcome the above mentioned problems, Malone et al. (1990) introduced an operation to perform an antegrade colonic enema (ACE). The advantage of ACE over retrograde colonic enemas is that the procedure is cleaner to perform and patients are more independent as they can more easily perform the procedure themselves (Malone et al. 1990). In this operation Malone et al. (1990) used the appendix as a conduit to irrigate the colon (see also Graf et al. 1998; Grif Fiths and Malone 1995; Squire et al. 1993). Although the procedure is effective, well tolerated and the level of acceptance in patients is high, complications have been described in a significant number of patients (GrifFiths and Malone 1995; Squire et al. 1993; Ekmark and Adams 2000; Searles et al. 2000; Cascio et al. 2004). These complications consist of stoma prolapse, stenosis of the fistula, accidental perforation of the conduit and faecal soiling at the stoma site. In a retrospective literature study Graf et al. (1998) report a prevalence of 27% of necrosis/stenosis of the stoma, 6.6% catheter leak, 3.7% difficulty in catheterization, 3% pain with enema administration and 2.9% wound infection. Besides the surgical approach, endoscopic approaches to the ACE procedure have also been described (Rivera et al. 2001). Rivera et al. (2001) described their experience with percutaneous endoscopic cecostomy (PEC) in 13 patients. In one patient the PEC could not be placed after multiple attempts. In the 12 patients in whom the PEC could be placed one child died of underlying disease 9 months after the procedure. The remaining 11 patients have all improved after PEC placement.
In 1996, Shandling and Chait were the first to describe a percutaneous approach to cecostomy placement in 15 patients. In more recent publications, Kaye et al. (2000a), Kaye and Towbin (2002) and Chait et al. (2003) describe the percutaneous ACE procedure in detail. The patient is placed on a two-day pre-admission fluid diet and Fleet (CB Fleet CO. Inc., Lynchburg, Va., Canada) phospho-soda bowel regimen (45 ml on the night before admission and a repeat dose on the day of the procedure). The bowel should be clear of stools. Within 30 minutes prior to the procedure a single dose of Cefotaxime 20 mg/kg is administered.
Ultrasound is used to identify the liver, right kidney and bladder, and possibly other masses. The procedure is quite similar to the 'push' gastrostomy technique. The colon is inflated and after confirmation of its location, the cecum is punctured and transfixed using T-fasteners (Fig. 7.5). A stiff guide-wire is inserted into the ascending colon through the puncture needle. The puncture site can be dilated over the guidewire in order to capacitate the placement of an 8-F pigtail catheter. The position of the catheter is confirmed and secured in place.
After approximately 8 days antegrade enemas can commence. To prevent clogging of the pigtail, a daily flush with 10-15 ml of saline is performed.
Fig. 7.5. a A 5-and-a-half-year-old boy with bifid spine and faecal incontinence. The image shows an overview of the abdomen with the cecum outlined in the right lower abdomen (courtesy of Dr. P.G. Chait, Image Guided Intervention, Hospital for Sick Children, Toronto, Canada). b The caecum has been punctured and the intraluminal position of the needle is confirmed using contrast medium. c A guidewire is inserted into the caecum along with two T-fasteners. d An 8.5-F pigtail catheter is placed within the lumen of the caecum. All images are from Dr. P.G. Chait
Fig. 7.5. a A 5-and-a-half-year-old boy with bifid spine and faecal incontinence. The image shows an overview of the abdomen with the cecum outlined in the right lower abdomen (courtesy of Dr. P.G. Chait, Image Guided Intervention, Hospital for Sick Children, Toronto, Canada). b The caecum has been punctured and the intraluminal position of the needle is confirmed using contrast medium. c A guidewire is inserted into the caecum along with two T-fasteners. d An 8.5-F pigtail catheter is placed within the lumen of the caecum. All images are from Dr. P.G. Chait b a d c
After 6-12 weeks the pigtail can be exchanged for a cecostomy button.
In 1997 Chait et al. (1997a) presented an improved cecostomy button that protrudes no more than 1 cm from the abdominal wall, which constitutes an enormous cosmetic improvement as the button or trapdoor can easily be hidden under garments (Fig. 7.6).
As in all procedures complications have been described. In one of the largest studies thus far, Chait et al. (1997b) report one case of local cellulites and one case of transient ileus. Minor complications consist of nausea, constipation, granulation of the puncture site, soiling and accidental dislodge-ment of the cecostomy tube. Chait et al. (2003) reported results of their 7-year experience with this technique, achieving a 100% success rate for the procedure. The majority of patients (79%) reported that the number of soiling accidents had decreased and, additionally, their independence had increased by being able to perform the antegrade enema themselves. In four cases the cecostomy tube had to be removed twice due to problems with tube maintenance and twice because of aesthetic reasons. The most impressive result in their study was that 97% of respondents stated that they would recommend the procedure to others in the same position (Chait et al. 2003). Another study, on surgical ACE procedures, also reported a high patient satisfaction, with 84% completely continent or soiling less than once a month (Dey et al. 2003).
The advantage of the percutaneous ACE procedure over the surgical approach is the fact that it can be performed without general anaesthesia (Kaye
Was this article helpful?