ACE report -10 year effectiveness

More data is now available on the use of antegrade continence enema (ACE) for difficult-to-treat defecation disorders (J Pediatr 2012; 161: 700-4).

This study reports the 10-year (retrospective) experience of a single center.  In total there were 99 patients, median age 8 years.  Mean time for followup was 46 months.  Most procedures were undertaken by interventional radiology with temporary  8.5 Fr Dawson-Mueller catheter which was changed to a Chait Trapdoor catheter after six weeks.  All patients received triple antibiotics for 48 hours and then oral metronidazole for 7 days.  While ACE were not started for 10-14 days, the tube was irrigated with 10 mL of normal saline BID after placement.

Key findings:

  • 71% became symptom-free, and an additional 20% improved significantly
  • Patient population: 35 with functional constipation, 29 with spinal abnormalities, 8 with cerebral palsy, 8 with Hirschsprung’s, 7 with imperforate anus, 7 with combined imperforate anus/tethered cord, and 5 with other causes
  • Irrigations with a stimulant seemed to be more effective.  Specific stimulants included bisacodyl (5 mg if patient <10 years and 7.5 mg if >10 years) and glycerine (median dose 37.5 mL).
  • In the 7 patients without improvement, the stoma was closed after a median time of 7 months & 5 ultimately underwent colostomy.
  • Risk factors for poor outcome: younger age, shorter duration of symptoms, Hirschsprung’s disease, cerebral palsy, previous abdominal surgery, and abnormal colonic manometry (Previous studies have not shown that preop manometry helpful in predicting outcome of ACE).
  • 13% of patients were able to discontinue ACE without recurrence of symptoms
  • Major complications occurred in 12 patients.  12 patients had infections, 4 had abscess, and 3 had peritonitis.  Minor complications were commonplace including leakage in 21 and granulation tissue in 41 patients.

I think this report does provide a balanced view of cecostomy/appendicostomy placement; this will be helpful in counseling families.  While the majority of children will be able to irrigate their colon and thus minimize their intractable constipation, many will have issues with the tube site and particularly early on there is a risk of serious infections.

Related blog entries:

Clues about constipation and more than 2.5 million views

Stimulants for constipation | gutsandgrowth

It’s worth the cost | gutsandgrowth

thyroid | gutsandgrowth

Additional references:

  • Percutaneous Endoscopic Colostomy (PEC) – YouTube (LEFT-SIDED PROCEDURE)

  • -J Pediatr Surg 2010; 45: 213-9.  ACE highly effective for intractable constipation
  • -JPGN 2011;52: 574.  n=117. 69% success with antegrade enemas.
  • -JPS 2002; 37: 348-51.  sigmoid irrigation.
  • -Lancet 1990; 336: 1217. Malone’s initial description.

It’s worth the cost

Recently the cost of Sitzmarks® increased to $175 (for 12)–it’s worth the cost.  According to one study, the use of a transit study helps determine which patients will benefit from colonic manometry (JPGN 2012; 54: 258-62).  A retrospective review of 24 children showed that all five children with normal oral-anal transit (OTT) studies had normal colonic manometry.  In contrast, 9/19 (47%) with abnormal (slow OTT) had abnormal colonic manometry.

The authors define their approach to OTT which is helpful.

  • In patients with a fecal impaction, this was cleared prior to starting study
  • If patients had difficulty with capsule ingestion, markers were administered by embedding in part of a banana or mixed with applesauce
  • Stimulant laxatives withheld for 72hrs prior to study
  • AXR obtained on days 3 and 5
  • Slow OTT (abnormal) defined as >6 markers proximal to rectum on day 5

Of those with abnormal colonic manometry, two-thirds (6) were referred for surgical intervention; one patient with normal OTT had surgery.  Surgeries:  3 cecostomy, 4 subtotal colectomy.

Additional references:

  • -JPGN 2004; 38: 75. Colostomy in 10 children with intractable constipation.
  • -Arch Dis Child. 2004 Jan;89(1):13-6. Benninga MA, Voskuijl WP, Akkerhuis GW, Taminiau JA, Buller HA. Related Articles,  Colonic transit times and behaviour profiles in children with defecation disorders.
  • -J Pediatr Surg. 2004 Jan;39(1):73-7. Youssef NN, Pensabene L, Barksdale E Jr, Di Lorenzo C.  Is there a role for surgery beyond colonic aganglionosis and anorectal malformations in children with intractable constipation?
  • -Am J Gastroenterol. 2003 May;98(5):1052-7.  Pensabene L, Youssef NN, Griffiths JM, Di Lorenzo C. Related Articles, Colonic manometry in children with defecatory disorders. role in diagnosis and management.
  • -JPGN 2002 Jul;35(1):31-8. Gutierrez C, Marco A, Nogales A, Tebar R. Total and segmental colonic transit time and anorectal manometry in children with chronic idiopathic constipation.
  • -JPGN 2001 Nov;33(5):588-91.  Villarreal J, Sood M, Zangen T, Flores A, Michel R, Reddy N, Di Lorenzo C, Hyman PE.  Colonic diversion for intractable constipation in children: colonic manometry helps guide clinical decisions.
  • -http://www.sitzmarks.com/buyonline.aspx