M. Zeidan1, D. W. Kays1, J. A. Taylor1, S. Larson1, S. Islam1 1University Of Florida,Gainesville, FL, USA
Introduction: Severe constipation and encopresis or soiling are significant problems for a number of children and may lead to physical, social, and psychological issues if they persist. Medical management including laxatives and dietary modification usually succedds, but there is a cohort of patients whose problems remain refractory and surgical options are considered such as the Antegrade Colonic Enema (ACE). The purpose of this study is to assess the long-term outcomes in children following the ACE procedure.
Methods: We reviewed all patients that underwent the open and laparoscopic ACE procedure between 1999 and 2013 at a single institution. Data collected included diagnosis and indication for surgery, change in bowel movements and soiling patterns before and after surgery, admissions for clean-outs before and after surgery, flush therapy and changes to regimen, and long term complications. Comparative data was analyzed using the Fischer’s exact test.
Results: A total of 42 patients were found who had complete charts. The mean age at surgery was 10 years, with 54.8% male. Encopresis or soiling was the indication in 56% of cases. Patients suffered for a mean duration of almost 7.5 years prior to surgery, with over half having symptoms since birth (including congenital anomalies). The appendix was used as conduit in 90% of cases, and a majority were placed in the umbilicus, with over 50% performed laparoscopically. Over an average follow up of 4.5 years, 33 (79%) of the children had improvement in their bowel regimens. Number of children experiencing soiling more than three times per month decreased from 79% to 12% (p<0.0001) and admissions for cleanouts decreased from 52% to 19% (p=0.003). All cases of Hirschsprungs, functional constipation and spina bifida were successful while success rates varied for other diseases such as slow transit constipation (60%), imperforate anus (50%), and cerebral palsy (33%). The most common long-term complications were relatively minor, including leakage from the stoma site (68%) and dislodged tubes (63%), with a mean of 3.2 OR visits per patient during the study period. 85% of successful cases required a change in the enema composition for improvement. Of 10 patients that had the tube removed, 8 patients were weaned off of the ACE and remained clean, while two patients had to have it replaced.
Conclusion: We found the ACE procedure to have a high rate of success in reducing soiling, constipation, and need for disimpaction in children over a long term. Further refinement of the selection criteria would increase the success. Complications were minor and well tolerated, and a majority could not be weaned off the ACE. Enema fluid changes were very frequent and these data will be used to improve family discussion and satisfaction. This procedure should be part of a comprehensive treatment plan for encopresis and constipation in children.