title: Laparoscopic antegrade continence enema in situ appendix procedure for refractory constipation and overflow fecal incontinence in children with spina bifida.
abstract: OBJECTIVE
  The antegrade continence enema procedure allows patients with neurogenic bowel to administer large volume enemas through a right lower quadrant stoma to flush the colon every other day. This procedure results in freedom from refractory constipation and diapers required by unexpected episodes of overflow fecal incontinence. We present a simplified laparoscopic technique using in situ appendix.
  
  
  METHODS
  A total of 6 male and 10 female children with a mean age of 12 years (range 4 to 21) and neurogenic bowel secondary to myelomeningocele underwent the antegrade continence enema in situ appendix procedure. The procedure was done with laparoscopic assistance, and associated with other bladder and bladder outlet reconstructive surgery in 5 patients. In 3 patients, a purely laparoscopic antegrade continence enema in situ appendix procedure was performed. The appendix and cecum were mobilized, and the tip of the appendix was anastomosed directly to the skin of the right lower quadrant through 1 of the 5 mm. lower quadrant port sites. The continence mechanism is simply a function of the appendix length and the mucosal coaptation of the appendiceal lumen. A 6Fr silicone Foley catheter is used to stent the mucocutaneous anastomosis. Concomitant procedures included ileocystoplasty, ileovesicostomy, sigmoidovesicostomy or ureterovesicostomy, and/or pubovaginal sling done through a low Pfannenstiel incision after laparoscopic mobilization of the appendix and cecum.
  
  
  RESULTS
  The 3 patients treated with the laparoscopic antegrade continence enema procedure ate the day of surgery and were discharged home the next morning. Constipation and fecal incontinence resolved in all cases. All antegrade continence enema stomas were catheterized easily with a 6 or 8Fr feeding tube and were continent. Complications in the 8 laparoscopic and laparoscopic assisted cases included stomal stenosis requiring dilation in the office and obstructive volvulus associated with malrotation requiring segmental resection. Patient mothers in particular were gratified by this procedure at a mean followup of 11/2 years.
  
  
  CONCLUSIONS
  The simplified antegrade continence enema in situ appendix procedure works well for refractory constipation and overflow fecal incontinence in children with neurogenic bowel secondary to spina bifida. Coaptation of the appendiceal lumen and use of small catheters allow for persistent continence without a formal surgically constructed valve mechanism. The combined antegrade continence enema and either ileovesicostomy or sigmoidovesicostomy continent urinary diversion procedures allow children to control bowel and bladder evacuation programs. A laparoscopic approach is reasonable particularly in cases requiring no other procedures.
authors.affiliation: Division of Pediatric Urology, Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky, USA.
authors.forename: J G
authors.initials: JG
authors.lastname: Van Savage
authors.forename: P
authors.initials: P
authors.lastname: Yohannes
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D002675:Child, Preschool; D003248:Constipation / Q000628:therapy*; D004733:Enema / Q000379:methods*; D004766:Enterostomy; D005242:Fecal Incontinence / Q000209:etiology / Q000628:therapy*; D005260:Female; D006801:Humans; D008297:Male; D016135:Spinal Dysraphism / Q000150:complications*; D013536:Suture Techniques