B.O. Campbell2, S. Ko2, A. Behrmann2, C. Dew1, T. Kempker1, V. Ramachandran1, A. Marwan1 1University Of Missouri, Division Of Pediatric General, Thoracic And Fetal Surgery, Department Of Surgery, Columbia, MO, USA 2University Of Missouri, School Of Medicine, Columbia, MO, USA
Introduction:
Antegrade continence enemas (ACE) are either administered via an appendicostomy or a cecostomy approach for various clinical indications including chronic constipation, anorectal malformations, and neurogenic bowel, among others. Cecostomies utilize tubes/buttons that require periodic exchanges, whereas in appendicostomies, the appendix is sutured to the skin. Numerous studies have documented complications associated with both approaches. The primary aim of our study is to evaluate long-term outcomes of those approaches in a mixed rural patient population setting.
Methods:
A retrospective cohort analysis was performed on pediatric patients at a tertiary academic hospital in mid Missouri who either underwent Malone type ACE or Laparoscopic Cecostomy (LC) between 2014 and 2024. 27 patients were included for analysis. The cohort consisted of 8 (30%) MACE and 19 (70%) LC patients.
Results:
The average age at time of procedure was significantly higher in the MACE group compared to the cecostomy group (14.6 and 8.1 years, respectively, p=0.028). 11 (57.9%) cecostomy patients underwent a single incision approach whereas 7 (36.8%) had a traditional approach and 1 (0.05%) received a Chait. Neurogenic bowel/bladder was the primary diagnosis for the MACE group (100%), whereas chronic constipation was most common in the cecostomy group (63.2%).
MACE patients had a longer length of stay compared to LC (7.5 days vs. 4.5 days, p=0.014). 30-day readmission rates were significantly higher in the MACE (5) compared to the LC group (1) (p=0.001), with an average length of stay of 4 and 2 days respectively.
There were no significant differences in persistent soiling, surgical site infections (SSI), ileus, stomal dehiscence, or bowel obstruction between groups. Stomal stenosis was only observed in MACE (37.5%) patients with none in LC patients (p=0.005). Granulation tissue was significantly more prevalent and was the most common complication seen in LC compared to MACE patients (89.5% and 13% respectively, p<0.001). MACE patients had a higher rate of surgical revision (25%) compared to none in LC patients (p=0.024).
Conclusion:In a mixed rural setting in mid-Missouri, we observe an overall low complication rate and low incidence of major complication over a 10-year period caring for those complex patients. The higher re-admission rate observed in MACE patients leads to a higher healthcare utilization impact, in addition to a financial, travel, social and academic burden to these families. Revisions of MACE were necessary when performed alongside Monti procedures. The complications of each procedure should be considered in future practice to tailor care based on patient characteristics.