title: The appendix as a conduit for antegrade continence enemas in patients with anorectal malformations: lessons learned from 163 cases treated over 18 years.
abstract: BACKGROUND
  The antegrade continence enema (ACE) has been shown to be a safe and effective method for managing fecal incontinence in the pediatric population. The purpose of this study was to examine our experience with the ACE procedure using the appendix as a catheterizable conduit in children with anorectal malformations (ARMs).
  
  
  METHODS
  We reviewed the charts of all patients who underwent an ACE procedure using the appendix as a catheterizable conduit between January 1992 and January 2010. Preoperative diagnosis (ARM type), operative details, functional outcomes, and postoperative complications were assessed. Technical modifications over time included selective cecoplication, implementation of the umbilical V-V appendicoplasty technique, and laparoscopy for cecal mobilization.
  
  
  RESULTS
  Mean age was 9.9 ± 0.6 years, and 67% were male. The most common preoperative diagnosis was rectourethral fistula in boys (39%) and persistent cloaca in girls (61%). Forty-five complications occurred in 41 patients with an overall incidence of 25.6% (stricture, 18%; leakage, 6%; prolapse, 4%; intestinal obstruction, 0.6%). The incidence of stomal leakage was lower in patients when a cecoplication was performed (2.9% [4/138] vs 29.4% [5/17]; P < .01), and the incidence of stricture was lower in patients when the umbilical anastomosis was created using the V-V appendicoplasty technique (11% [11/100] vs 30% [18/60]; P < .01). Successful management of incontinence was reported by 96% of all patients.
  
  
  CONCLUSIONS
  The ACE procedure using the umbilical V-V appendicoplasty provides an effective and cosmetically superior means for bowel management in children with ARMs. The rate of late complications is not insignificant however, and preventative strategies should focus on careful operative technique and ensuring compliance with catheterization protocols well past the initial postoperative period.
authors.affiliation: Department of Pediatric Surgery, Children's Hospital Boston, Harvard School of Medicine, Boston, MA 02115, USA. shawn.rangel@childrens.harvard.edu
authors.forename: Shawn J
authors.initials: SJ
authors.lastname: Rangel
authors.forename: Taiwo A
authors.initials: TA
authors.lastname: Lawal
authors.forename: Andrea
authors.initials: A
authors.lastname: Bischoff
authors.forename: Kaveer
authors.initials: K
authors.lastname: Chatoorgoon
authors.forename: Emily
authors.initials: E
authors.lastname: Louden
authors.forename: Alberto
authors.initials: A
authors.lastname: Peña
authors.forename: Marc A
authors.initials: MA
authors.lastname: Levitt
mesh_terms: D000714:Anastomosis, Surgical / Q000379:methods; D000071056:Anorectal Malformations; D001006:Anus, Imperforate / Q000150:complications / Q000175:diagnosis / Q000601:surgery; D001065:Appendix / Q000601:surgery*; D002648:Child; D015331:Cohort Studies; D004733:Enema / Q000379:methods*; D005242:Fecal Incontinence / Q000209:etiology / Q000503:physiopathology / Q000628:therapy*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D017060:Patient Satisfaction; D011182:Postoperative Care / Q000379:methods; D011183:Postoperative Complications / Q000503:physiopathology / Q000628:therapy; D011788:Quality of Life; D019651:Plastic Surgery Procedures / Q000009:adverse effects / Q000379:methods*; D012189:Retrospective Studies; D012720:Severity of Illness Index; D018709:Statistics, Nonparametric; D054047:Surgical Stomas; D013997:Time Factors; D016896:Treatment Outcome