Surgeon at Work
Simplified Technique for Antegrade Continence
Enemas for Fecal Retention and Incontinence
Eric W Fonkalsrud,
MD
,
FACS
, James CY Dunn,
MD
,
P
h
D
, and Akemi I Kawaguchi,
BA
Fecal incontinence and chronic constipation occur
with annoying frequency after reconstructive colo-
rectal operations for Hirschsprung’s disease and im-
perforate anus in childhood.
1
Chronic constipation
is a frequent occurrence that complicates the care of
children with spina bifida and of neurologically im-
paired patients of all ages.
2-4
Fecal incontinence is
devastating to the self-esteem of a child, depriving
him or her from socializing with peers and limiting
participation in most vigorous sports activities.
A bowel-management program with use of a
daily enema, manipulation of the diet, and use of
some medications has been helpful in reducing in-
continence in several children after repair of imper-
forate anus.
4,5
Chronic use of rectal enemas, suppos-
itories, laxatives, or lubricants, however, is often
uncomfortable, poorly accepted, and intolerable to
the patient, and cumbersome and disruptive to other
members of the family who are responsible for the
child’s care.
Since its first description by Malone and associ-
ates in 1990,
6
the antegrade continence enema
(ACE) has been used with increasing frequency by
surgeons for the management of children with fecal
incontinence or retention. The technique entails
construction of a permanent, nonrefluxing appen-
diceal stoma in the abdominal wall through which a
catheter can be inserted to deliver enema solutions in
an antegrade manner on a daily basis, as desired. This
operative procedure is somewhat extensive for the
patient who requires only the instillation of enema
solutions into the proximal colon and has caused skin
irritation, granulation tissue with stenosis, and occa-
sional fecal leakage in five of the children in whom it
was used in our hospital. Griffiths and Malone
7
re-
ported that 80% of their patients had some type of
complication, either minor or major, and that 5 of 21
patients required a colostomy. Other investigators
have noted several late complications after the Ma-
lone procedure.
8
To reduce these complications, sev-
eral modifications of the continent appendicostomy
have been reported by other groups.
9,10
To simplify the operation, Webb and associates
11
recommended laparoscopic construction of a cutane-
ous appendicostomy for antegrade enemas. Chait
and associates
4
have performed percutaneous inser-
tion of a low-profile cecostomy catheter or “button”
under local anesthesia as a two-stage procedure for
antegrade colonic cleansing in several children, with
good success.
The present study summarizes our clinical expe-
rience at the University of California, Los Angeles
Medical Center in the management of 24 children
with fecal incontinence or constipation using a sim-
plified surgical technique. In this procedure, a
Broviac silicone elastomer intravenous (IV) catheter
was placed in the cecum for ACE infusions.
METHODS
Between November 1995 and March 1998, 24 chil-
dren between the ages of 7 months and 15 years
(mean, 5.7 years) underwent placement of a silicone
cecostomy catheter for management of chronic fecal
retention or incontinence. Eleven of the children had
Hirschsprung’s disease and seven had undergone pre-
vious abdominoperineal pull-through procedures; in
four children the cecostomy catheter was placed at
the time of the pull-through procedure. Five other
Received March 24, 1998; Revised May 13, 1998; Accepted June 4, 1998.
From the Department of Surgery, University of California, Los Angeles School
of Medicine, Los Angeles, CA.
Correspondence address: Eric W. Fonkalsrud, MD, FACS, Department of Sur-
gery, UCLA School of Medicine, Los Angeles, CA 90095.
457
© 1998 by the American College of Surgeons ISSN 1072-7515/98/$19.00
Published by Elsevier Science Inc. PII S1072-7515(98)00189-6