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Neoappendicostomy in the management of pediatric fecal incontinence
Kaveer Chatoorgoon1, Alberto Pena, Taiwo Lawal
1Colorectal Center for Children, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.
Insights
Creating a neo-appendix (Malone appendicostomy) offers a solution for fecal incontinence in children lacking an appendix. This surgical technique, involving a cecal flap, shows reduced complication rates with experience and modifications.
Area of Science:
- Pediatric Surgery
- Gastroenterology
- Urology
Background:
- The Malone appendicostomy improves quality of life for children with fecal incontinence.
- When the appendix is unavailable, a neo-appendix can be surgically created.
Purpose of the Study:
- To describe the surgical approach and outcomes of neo-appendicostomy for managing fecal incontinence in children.
- To evaluate the efficacy and complications of this procedure as an alternative when the native appendix is absent.
Main Methods:
- A transverse flap of cecum, based on a mesenteric pedicle, was created and tubularized.
- The flap was anastomosed to the umbilicus, with surrounding colon plicated to prevent leakage.
- Surgical outcomes, including strictures and leakage, were reviewed retrospectively.
Main Results:
- Eighty patients underwent neo-appendicostomy, most with anorectal malformations or spina bifida.
- Reasons for appendix absence included prior appendectomy or use in other procedures.
- Complication rates for stricture (3% vs. 18%) and leakage (0% vs. 11%) were reduced with surgical modifications and experience.
Conclusions:
- Preserving the native appendix is recommended for potential fecal incontinence management.
- Neo-appendicostomy is a viable option for fecal incontinence when the appendix is absent.
- Surgical modifications and experience significantly decrease complication rates like stricture and leakage.
Purpose:
The Malone appendicostomy, for antegrade enemas, has improved the quality of life for many children with fecal incontinence. In patients whose appendix has been removed, a neo-appendix can be created. We describe our approach and experience with this procedure as an option for surgeons managing children with fecal incontinence.
Methods:
The procedure involves creating a transverse flap of cecum that receives its blood supply by a transverse mesenteric branch. This flap is then tubularized around a feeding tube. The surrounding colon is plicated around the neo-appendix to prevent leakage of stool. The tip of the flap is then anastomosed to the deepest portion of the umbilicus. We reviewed our experience with this procedure, including results and complications. IRB approval was obtained.
Results:
Eighty patients required a neo-appendicostomy. Sixty-six patients (82%) had an anorectal malformation, four had spina bifida, and ten had other diagnoses. The reasons for not having an appendix available included: "incidental" appendectomy (34, 42.5%), use of the appendix for a Mitrofanoff procedure (20, 25%), and Ladd's procedure (5, 6%). In fifteen patients (19%) we could find no appendix and assume that it was removed previously. Following neoappendicostomy, nine patients (11%) developed a stricture, and seven patients had leakage (9%). In 2004, we modified the appendiceal-umbilical anastomosis and among these patients, only one patient (3%) developed a stricture, compared with eight patients (18%) without the modification. All seven patients with leakage were within the first forty cases. No patient in the last forty cases had a leakage.
Conclusions:
In patients with the potential for fecal incontinence, the appendix should be preserved. In patients without an appendix, the neo-appendicostomy is a valuable tool for fecally incontinent patients. We have found that the V-V anastomosis had a reduced rate of stricture, and the rate of leakage seems to be related to surgical experience.
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