Hypothesis / aims of study
In the United States, the prevalence of fecal incontinence in otherwise healthy children is estimated at 4%; this rate is much higher in patients with congenital abnormalities such as myelomeningocele, cloacal anomalies and anorectal malformations. While many of these children can be managed with medical therapy alone, a significant minority will continue to have incontinence. In 1990, Malone and Ransley published an operative technique to allow for antegrade enemas to optimize bowel management, improve colonic emptying and decrease fecal incontinence. This procedure, known as the Malone Antegrade Continence Enema (ACE), involves use of the appendix as a continent catheterizable channel through which to administer enemas. Since the initial description, there have been various adaptations of the procedure in an attempt to improve outcomes and decrease complications. There remain, however, wide variations in outcomes and complications. In the literature it has been suggested that besides improvements in technique, another key factor to success is dedicated team of practitioners with a particular focus on these procedures and their long-term outcomes. Prior work has shown that inpatient multidisciplinary teams improve outcomes and decrease complications. Currently, work across surgical specialties is underway to examine if multidisciplinary surgical clinics have similar benefit.
We hypothesized that creation of a multidisciplinary pediatric colorectal clinic would improve surgical outcomes in patients with ACEs and decrease unanticipated post-operative healthcare utilization.
Study design, materials and methods
A multidisciplinary clinic was implemented at our institution in 2011. Patients undergoing ACE in the year prior (2010) and the year following (2012) establishment of clinic were identified and medical records reviewed. Patients under the age of 18 undergoing appendicostomy or cecostomy for antegrade continence enemas were included. Patients without follow-up were excluded. Characteristics and outcomes were compared between groups using chi-squared test and descriptive analysis performed.
28 patients were identified (2010, n=14; 2012, n=14). Baseline characteristics were similar (see Table). Seven patients discontinued ACE use (2010, n=3; 2012, n=4). All from 2010 had poor ACE outcomes and were not adherent with bowel regimen treatment recommendations. Two from 2012 had success with a laxative program; one patient was non-adherent and one had her ACE taken down during another procedure. Two patients from each group required operative fecal disimpaction. Five patients (35.7%) from 2012 had a Chait tube placed, compared to six patients (42.9%) from the 2010 cohort. Three of the six patients from the 2010 cohort had a Chait tube placed due to difficulty with catheterizations; whereas all of the 2012 patients had the tube placed at surgeon or family preference.
Five patients (17.8%) had infectious complications (peristomal cellulitis or abscess) requiring treatment; 2 from 2012 and 3 from 2010. One patient (7.1%) from each year had problems with granulation tissue. Four (28.6%) patients from 2010 had persistent stomal leakage; only 1 (7.1%) from 2012 did. Three patients from 2010 (21.4%) had stomal stenosis or difficulty catheterizing, only 1 (7.1%) from 2012 did. Three (10.7%) patients had small bowel obstructions requiring exploration (2010, n=1; 2012, n = 2). All p values were > 0.05.
Overall operative times were higher in the second group, owing to a few patients undergoing multiple concurrent procedures including augmentation cystoplasty and appendicovesicostomy. Patients from 2010 had a median of 6.5 [IQR 6] follow-up visits to date; whereas patients from 2012 had a median of 10.5 [IQR 6.5].
Interpretation of results
There is a trend towards decreased stomal leakage, stenosis and difficulty with catheterization after implementation of our multidisciplinary colorectal clinic. This may be due to more consistent follow-up, which would lead to early identification of issues, as well as education on proper ACE care. There did not appear to be an effect on infectious complications or granulation tissue and we would not necessarily expect these to be affected by close follow-up. Due to a small sample size, statistical significance was not detected.