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PubMed1987

Acute colonic pseudo-obstruction (Ogilvie's syndrome). Presentation of 14 of our own cases and analysis of 1027 cases reported in the literature.

In addition to the presentation of 14 of our own patients, this study analyzes 1027 cases with acute colonic pseudo-obstruction reported in the literature from 1948 to 1987. Principal associated diseases are cardiopulmonary insufficiencies, postoperative conditions, and systemic disorders. The syndrome is related to a disturbance of colonic autonomic innervation resulting in gross dilatation of the cecum and the right hemicolon. Therapeutic measures include conservative management, colonoscopic decompression, and surgical procedures. The latter have been associated with high morbidity and mortality. Our data support a nonoperative approach to this condition, including conservative measures and colonoscopic decompression as the initial therapy of choice with few complications and high efficacy.

Aged↗
PubMed1993

Phospholipase-resistant phosphatidylcholine reduces intra-abdominal adhesions induced by bacterial peritonitis.

The majority of intra-abdominal adhesions develop postoperatively or following peritonitis. We have previously shown that L-phosphatidylcholine reduces postoperative peritoneal adhesions in rats. In the present study, we examined whether adhesion formation after bacterial peritonitis is also reduced by L-phosphatidylcholine or by DL-alpha-phosphatidylcholine, which is degraded only 50% by phospholipase A2. Peritonitis was induced in the rat by caecal ligation and double puncture; cecotomy was performed 12, 15, or 18 h later. Adhesions were assessed blindly by a scoring system 7 days after cecotomy. When cecotomy was scheduled for 18 h after caecal ligation and puncture, the 7-day mortality was 90% (n = 20). When cecotomy was performed at 12 h, no mortality was seen; however, the adhesion score was low (2.3 +/- 0.7). When cecotomy was performed 15 h after caecal ligation and puncture, the mortality was 25% and the adhesion score was 4.3 +/- 0.9. This figure was reduced significantly by intraperitoneal instillation of L-phosphatidylcholine or DL-alpha-phosphatidylcholine for 3 subsequent days. However, the mortality increased by L-phosphatidylcholine (P < 0.01), whereas mortality after DL-alpha-phosphatidylcholine remained at 30%. We conclude that administration of both L-phosphatidylcholine and DL-alpha-phosphatidylcholine decrease adhesion formation after bacterial peritonitis.

Animals↗
PubMed2004

MACE or caecostomy button for idiopathic constipation in children: a comparison of complications and outcomes.

The Malone antegrade enema (MACE) and the caecostomy button (CB) are two methods of achieving colonic lavage in constipated children with faecal soiling. We reviewed our experience with the MACE and CB, aiming to compare results, complications, and outcomes. Between June 1998 and August 2002, 37 children (15 boys) underwent MACE and 12 children (9 boys) underwent CB for idiopathic constipation that had failed conventional treatment. Rectal biopsy was ganglionic in all cases. Mean age at surgery was 9.9 years for the MACE patients and 9.8 years for the CB patients. All children are under continuous review, and mean follow-up is 18 months. Statistical analysis of proportions used Fisher's exact test. Soiling stopped completely in 30 children with MACE and in 9 with CB. Occasional soiling is still present in two children with a CB and in one with MACE. One child with a CB had resumed regular bowel activity, and the CB was removed. MACE failed in 5 (14%) patients because of ineffective colonic lavage, and in one patient (3%) the appendix was replaced by a CB because of perforation of the appendicostomy. CB failed in one patient (8%) because of faecal leak around the button; the child was subsequently converted to MACE (P = >0.5). Complications requiring operative intervention were seen in 9 (24%) of the 37 patients who underwent MACE and none of the 12 patients who underwent CB (P = 0.09). The main complication requiring surgical intervention was stoma stenosis (11%). Complications not requiring operative intervention were seen in 7 (19%) patients after MACE and 11 (92%) of the 12 patients who underwent CB (P < 0.001). The MACE and CB procedures are reliable and effective with high success rates. The MACE has a higher incidence of complications requiring operative intervention. Conversely, complications not requiring operative intervention are more frequent with CB. CB is a safe and effective alternative to MACE in children with faecal soiling.

Adolescent↗
PubMed1998

The Malone antegrade colonic enema procedure: outcome and lessons of 6 years' experience.

The successful management of faecal incontinence can dramatically improve the quality of life of affected children. The introduction of the non-refluxing, catheterisable appendico-caecostomy provides the opportunity to treat previously resistant patients. Over a 6-year period, 29 children had a Malone antegrade continent stoma for enema administration (MACE). Incontinence was related to spina bifida in 12 children, ano-rectal anomaly in 12, Hirschprung's disease in 2, followed excision of a pelvic tumour in 2, and was secondary to intractable chronic constipation in 1. The conduit was fashioned from the appendix (20), a caecal tube (8), or a gastric tube (1). Surgical complications were stomal stenosis (11), wound infection (1), anastomotic leak (1), MACE stoma prolapse (1), and a pressure sore (1). Colonic irrigation was achieved with washouts of saline (24), saline plus phosphate (4), and saline plus Picolax (1). Twenty-three patients have complete control of bowel function, but 4 still soil. Two remain incontinent, 1 of whom is still being instructed. One child subsequently had a colostomy, but still uses the MACE stoma. Successful bowel management requires motivation, dedication, commitment, and the input of a clinical nurse specialist. The MACE is a relatively straightforward operative procedure that provides an effective washout technique that is acceptable to both parents and children.

Adolescent↗
PubMed1999

Comparison of results of laparoscopic and open antegrade continence enema procedures.

Several modifications of the Malone antegrade continence enema (ACE) procedure have now been reported. In this study we have compared the results of our experience with the laparoscopic appendicostomy (LACE procedure) with the published results of previously described open ACE procedures. Children who had the LACE procedure at our institutions were reviewed. Intra- and postoperative problems were identified by review of hospital case notes and from a questionnaire completed by the children's caregivers. These results were compared with the reported results of the original Malone procedure, the Peña modification, and the open appendicostomy as described by Wilcox. Since 1994, 30 children have had LACE procedures performed at our institutions. Two have required conversion to an open procedure because of difficulty locating the appendix. The stoma is being used for regular antegrade colonic washouts in 29 of the 30, compared with 19 of 31 in Malone's series and 16 of 20 in Peña's. Improvement in soiling has been achieved in 27 (90%) of our patients, 15 of whom are completely clean, a rate similar to that of the other types of procedure (61%-78%). Stenosis of the stoma has occurred in 8 children (27%), compared with rates of 10%-33% in other series. Stomal leakage has been troublesome for 2 (6.7%), compared with leak rates between 5.6% and 15% in other series. The LACE procedure is technically the simplest. The laparoscopic approach to the ACE procedure appears to be a simpler and safe alternative to previously described methods. It causes minimal morbidity, has a high long-term viability rate, and resulted in improved control of soiling in 90% of the children with faecal incontinence in whom it has been employed.

Adolescent↗
PubMed2003

Colonoscopy: why are general surgeons being excluded?

BACKGROUND: The role of surgeons as endoscopists has been extensively debated in the literature, with conflicting studies published regarding the safety and efficacy of surgeons performing colonoscopies. A multitude of medical federations and societies have set various standards for granting endoscopy privileges, many with a bias against general surgeons [1, 3]. We reviewed the colonoscopy experience at our institution to evaluate differences between gastroenterologists (GI) and general (GS) and colorectal surgeons (CRS) in procedure times and complication and cecal intubation rates. METHODS: Between January 2000 and July 2002, 5237 colonoscopies were performed at our institution. The data for procedure times, completion, and complication rates were collected in a prospective database. Complications were defined as perforation, bleeding, and postpolypectomy syndrome. Incomplete colonoscopies due to colitis, poor bowel preparation, or tumor obstruction were excluded. Chi-squared test was used to compare complication and cecal intubation rates between the three groups. Median procedure times were compared using the Kruskall-Wallis and Dunn's pairwise tests. A significant p-value was defined as <0.05. RESULTS: No differences in the complication rate was noted between the three groups: GI (0.12%), CRS (0.15%), and GS (0.11%) ( p = 0.99). There was a trend toward a lower incomplete colonoscopy rate in the GS group compared to CRS and GI: 0.32% vs 0.84% and 0.36%, respectively ( p = 0.07). The median colonoscopy times for GS (29 min), however, were shorter than for GI (34 min, p < 0.001) or CRS (31 min, p < 0.001). CONCLUSION: General surgeons perform colonoscopies expeditiously, with as low a morbidity rate and as high a completion rate as their gastroenterology or colorectal surgery colleagues. As the results of this study confirm, general surgeons should not be excluded from endoscopy suites.

Cecostomy↗
PubMed1998

Increased tumor establishment and growth after open vs laparoscopic bowel resection in mice.

BACKGROUND: Surgery can suppress immune function and facilitate tumor growth. Several studies have demonstrated better preservation of immune function following laparoscopic procedures. Our laboratory has also shown that tumors are more easily established and grow larger after sham laparotomy than after pneumoperitoneum in mice. The purpose of this study was to determine if the previously reported differences in tumor establishment and growth would persist in the setting of an intraabdominal manipulation. METHODS: Syngeneic mice received intradermal injections of tumor cells and underwent either an open or laparoscopic cecal resection. In study 1, the incidence of tumor development was observed after a low dose inoculum; whereas in study 2, tumor mass was compared on postoperative day 12 after a high-dose inoculum. RESULTS: In study 1, tumors were established in 5% of control mice, 30% of laparoscopy mice, and 83% of open surgery mice (p < 0.01 for all comparisons). In study 2, open surgery group tumors were 1.5 times as large as laparoscopy group tumors (p < 0.01), which were 1.5 times as large as control group tumors (p < 0.02). CONCLUSION: We conclude that tumors are more easily established and grow larger after open laparoscopic bowel resection in mice.

Animals↗
PubMed2005

Antegrade continence enema in the treatment of obstructed defaecation with or without faecal incontinence.

BACKGROUND: Obstructed defaecation and faecal incontinence are complex functional disorders that pose management challenges. In recent times, the antegrade continence enema (ACE) has been tried both as a primary procedure and as a final resort to avoid a colostomy in patients with a variety of functional problems. The purpose of this study was to evaluate the role of the ACE procedure as a treatment option for adult patients suffering from obstructed defaecation with or without faecal incontinence, some of whom also had slow transit constipation. METHODS: Twenty female patients underwent ACE as an appendicostomy (65%) or caecostomy (35%). The median age was 44 years (range, 20-65 years). The indications were obstructed defaecation with faecal incontinence (65%) and obstructed defaecation alone (35%). Fifteen of these patients were followed for 3-51 months (median, 6 months). Cleveland continence score, bowel score and quality of life score were recorded pre- and postoperatively along with post-procedure complications. RESULTS: Thirteen (65%) patients were satisfied with the outcome and recorded improvement in their scores while two (10%) remained the same and one (5%) was worse. This latter woman and another patient stopped using their ACE, whilst follow-up data was unavailable for three patients. Minor wound infections were noted in nine patients (45%), of whom one needed drainage of an abscess; the rest settled with antibiotics and dressings. Bowel and Cleveland continence scores improved postoperatively (p<0.001 and p=0.001, respectively) but SF36 scores did not. To date, no patient has had a colostomy following an ACE procedure. CONCLUSIONS: Colostomies can be avoided in patients with obstructed defaecation. There is, however, a need to minimise wound infections which seem to be the most troublesome complication.

Adult↗
PubMed2007

Malone antegrade continent enema: an alternative to resection in severe defecation disorders.

PURPOSE: This study was designed to evaluate patient self-reported outcome of the Malone antegrade continent enema at a single institution in patients suffering from severe defecatory disorders. METHODS: A total of 18 patients (15 females; median age, 31 (range, 12-63) years) underwent a Malone antegrade continent enema (August 1999 to September 2004). The Malone antegrade continent enema technique has been previously described; however, in this series emphasis was placed on method appendix tunneling. Patients' charts were reviewed and follow-up telephone interviews were conducted. Indications for Malone antegrade continent enema were chronic constipation (n = 12), intractable fecal incontinence (n = 5), or both (n = 1). The underlying pathology included neurogenic (n = 2), congenital (n = 4), postsurgery-related (n = 4), irritable bowel syndrome (n = 6), and megarectum (n = 2). The appendix (n = 17) or cecum (n = 1) was used as a conduit. RESULTS: The mean follow-up was 18.5 (range, 3-67) months. Fourteen patients (78 percent) still use the Malone antegrade continent enema routinely and report good functional outcome. Three patients (20 percent) required stoma creation as subsequent alternate treatment. A total of 10 patients experienced 12 complications: 3 perioperative (infections) and 9 postoperative Malone antegrade continent enema use/nonuse complications (4 stomal orifice strictures, 2 fecal impactions, 2 appendiceal perforations, and 1 irrigation catheter knot). No patient experienced leakage from the appendiceal stoma. During the follow-up interval, one patient underwent proctectomy for megarectum. No failures occurred in patients with congenital or neurogenic disorders. CONCLUSIONS: Malone antegrade continent enema is a reasonable option for the treatment of select patients with severe defecation disorders. Good functional patient self-reported outcome was achieved by 78 percent of patients. The social inconvenience of stoma leakage is avoided with appropriate surgical technique. Malone antegrade continent enema is one option that provides a less invasive surgical alternative than colectomy or ileostomy for severe defecation disorders.

Adolescent↗
PubMed1992

Ogilvie's syndrome.

Four cases of Ogilvie's syndrome (acute colonic pseudo-obstruction) are reported. All occurred in the early puerperium following cesarean section and cesarean hysterectomy. In three of the patients, the diameter of the distended cecum was less than 9.0 cm and so management was conservative while in the fourth patient it was more than 9.0 cm, and so surgical intervention was carried out. A cecal diameter of 9.0 cm or above is an indication for surgical intervention to prevent possible colonic perforation. Other indications for surgery include established cecal perforation and failed conservative management. It is important that an early diagnosis is made and management instituted in order to prevent complications and associated high mortality.

Adult↗
PubMed1993

The clinical application of the Malone antegrade colonic enema.

Continent, catheterizable enterostomies (Malone stomas) have been formed in 25 patients. A reversed appendicocecostomy was used for the majority, although experience has led to modifications of this procedure. Antegrade enemas are regularly administered via these stomas in the treatment of fecal incontinence and intractable constipation. There have been only two important surgical complications, and the technique has proved to be highly successful. Follow-up of the patients has shown that individual requirements can be met with variations in the administration of the enemas.

Adolescent↗
PubMed2004

Routine pouchograms are not necessary after continent urinary diversion.

OBJECTIVES: Pouchograms are routinely performed before catheter removal after continent urinary diversion at our institution. Our aim was to determine the necessity of pouchograms based on a review of our experience. METHODS: A retrospective review of patient records and radiographic studies was done for patients undergoing radical cystectomy and continent urinary diversions between 1991 and 2001. RESULTS: Seventy-two patients underwent continent urinary diversion (orthotopic, n = 59; cutaneous, n = 13) during the study period. All underwent pouchogram postoperatively (median 22 days; range 20 to 27). Six patients (8.3%) had a demonstrable radiographic leak; in 5 of the 6 patients, the urine leak was suspected on clinical grounds. Three patients (4.7%) developed urosepsis after pouchogram. CONCLUSIONS: Our findings indicate that routine pouchograms before pouch activation after continent urinary diversion may not be necessary.

Adult↗
PubMed2004

Continent right colon reservoir using a cutaneous appendicostomy.

INTRODUCTION: Although orthotopic reconstruction has become the preferred form of lower urinary tract reconstruction after cystectomy there remains a select group of patients who are not appropriate for an orthotopic neobladder substitute. A continent cutaneous reservoir provides an alternative means to store urine and protect the upper urinary tract without the need for a urostomy appliance. We report our surgical technique of a continent cutaneous right colon reservoir using a catheterizable submucosally embedded appendicostomy. TECHNICAL CONSIDERATIONS: The continent cutaneous right colon reservoir with bilateral ureteroileal coloappendicostomy incorporates the ascending and proximal transverse colon, which are detubularized and folded to form the reservoir component of the urinary diversion. The terminal ileum acts as the afferent limb, with the intact native ileocecal valve providing the antireflux mechanism. The continence catheterizable mechanism incorporates the submucosally tunneled appendix with preservation of the mesentery in a flap-valve technique. CONCLUSIONS: The continent cutaneous right colon reservoir with bilateral ureteroileal coloappendicostomy is a reasonable alternative for cutaneous urinary diversion when an intact appendix is present, with good functional results and excellent continence.

Appendix↗
PubMed2004

Use of an ureteroileocecal appendicostomy urinary reservoir in patients with recurrent pelvic malignancies treated with radiation.

OBJECTIVE: Evaluation of a modified right colon urinary reservoir in a heavily radiated patient population undergoing pelvic exenteration. METHODS: A retrospective chart review was performed on all patients with recurrent gynecologic, colorectal, and urological tumors who underwent total pelvic or anterior exenteration and urinary diversion from 3/01 to 7/03 using an ureteroileocecal appendicostomy urinary reservoir. RESULTS: Fourteen patients were identified over the study interval. The mean age of the patients was 53 years (range, 22-78 years). All patients received external beam, intracavitary, or a combination of both radiation treatment modalities to the pelvis preoperatively. Eight patients received intraoperative radiation therapy (IORT) at a mean dose of 16.25 Gy (range, 12.5-17.5 Gy). The primary sites of disease were as follows: cervix, five; prostate, three; uterus, two; colon/rectum two; and one each for vulva and bladder. Complete stomal continence was achieved in all patients after a median follow-up of 10 months (range, 2-31 months). Two patients experienced a traumatic disruption of the stomal-skin anastomosis in the early postoperative period (postoperative days 7 and 14). One late complication related to the ureterointestinal anastomosis was observed and consisted of an anastomotic stricture managed conservatively. One patient experienced an entero-pouch fistula following re-exploration for an acute postoperative hemorrhage. CONCLUSION: The early outcomes using the ureteroileocecal appendicostomy urinary reservoir in heavily radiated patients demonstrate the technical feasibility of this design as both minimal early stoma and ureterointestinal complications may occur. Longer postoperative follow-up will be required to address the late outcomes of this procedure and its ultimate use in this population.

Acidosis↗
PubMed2000

Antegrade continence enema for the treatment of neurogenic constipation and fecal incontinence after spinal cord injury.

OBJECTIVE: To describe the effects of an antegrade continence enema stoma formed in a paraplegic man with intractable constipation and fecal incontinence. DESIGN: Case report. SETTING: Spinal cord injury unit, Veterans Affairs hospital. PARTICIPANTS: Spinal cord injury (SCI) patient with T12 paraplegia. INTERVENTION: Surgical formation of antegrade continence enema stoma. MAIN OUTCOME MEASURES: Time of bowel program care, ease of fecal elimination, safety of procedure. RESULTS: Bowel care time was decreased from 2 hours to 50 minutes daily; 6 bowel medications were discontinued; fecal incontinence was eliminated; and no surgical or medical side effects noted after the procedure. CONCLUSION: The antegrade continence enema procedure is a safe and effective means of treating intractable constipation and fecal incontinence in the adult SCI patient. This option should be considered for those persons in whom medical management of bowel care has been unsuccessful.

Cecostomy↗
PubMed2006

[Treatment of severe chronic constipation through the antegrade continent enema procedure].

The antegrade continent enema procedure was first described in 1990 by Malone for the treatment of severe fecal neurogenic incontinence in children. Since then, this technique has been successfully carried out in adults, as well as in patients with refractory constipation. The procedure provides a continent and catheterizable channel, generally an appendicostomy, through which antegrade washouts are given to produce colonic emptying. We describe the case of a 23-year-old man with severe constipation and overflow fecal incontinence who underwent an appendicostomy. There were no immediate postoperative complications and saline washouts were started on the fourth day. Since then, the patient has had a bowel movement between 1 and 3 hours after each washout, has recovered continence, and no longer wears an absorbent pad.

Adult↗
PubMed2003

Adenosine A1 receptor blockade reverses experimental postoperative ileus in rat colon.

Inhibition of colonic propulsive motility is the main contributor to postoperative ileus in humans. Experimental models for investigating colonic propulsion in surgically induced postoperative ileus have not previously been available. This study was designed to assess whether adenosine A(1) receptor antagonists (R)-1-[(E)-3-(2-phenylpyrazolo[1,5-a]pyridin-3-yl) acryloyl]-piperidin-2-yl acetic acid (FK352) and 8-cyclopentyl-1, 3-dipropylxanthine (DPCPX) reverse the colonic motility disorder in newly developed rat experimental ileus models. When rats underwent anesthesia (pentobarbital) or surgical traumas (partial gastrectomy, cecectomy or gentle touching of the colon with fingers), colonic propulsive motility was evaluated by migration of intracolonically injected dye in awake unrestrained rats. Propulsive motility resulted in significant decrease after the treatment of the anesthesia or partial gastrectomy. Intravenous administration of either adenosine A(1) receptor antagonist reversed the slowed colonic propulsion in these experimental ileus models. The present study suggests that the blockade of adenosine A(1) receptors has therapeutic potential for postoperative ileus.

Anesthesia↗
PubMed1998

The Malone (antegrade colonic enema) procedure: early experience.

PURPOSE: The aim of this study was to assess the results of the Malone (antegrade colonic enema) procedure for fecal incontinence. METHODS: By a retrospective review of patients treated between 1990 and 1996 in a tertiary referral center, 36 patients were treated with a Malone procedure. Age at operation was 8.3 (range, 3 to 14) years, the mean period of follow-up was 39 (range, 9 to 72) months. The indication was fecal soiling in 35 and chronic constipation in one. The underlying diagnosis was an anorectal anomaly in the majority of patients. The appendix was used in 30 patients and a cecal flap in six, and a submucosal antireflux procedure was also performed in 10. In 35 patients, a circular stoma was created and in one a V flap was used. Antegrade colonic enemas were performed daily in 10, alternate days in 23, and in three patients the stoma was no longer used. Enemas were performed with a 10F catheter using a mixture of phosphate enema (or liquorice) and saline. RESULTS: Fecal soiling was completely controlled in 28 patients, and eight children soiled more than once a week. Complications occurred in 15 patients; the main problem was stenosis of the conduit, which occurred in 9 of 30 appendiceal stomas and three of six cecal stomas. Stomal stenosis was treated with surgical revision in eight patients. Additional complications were reflux through the stoma (n=2), pain on catheterisation (n=1), and small bowel obstruction (n=1). In one patient the Malone has been converted to a colostomy. CONCLUSIONS: The Malone procedure is a simple technique that can effectively control fecal incontinence in the majority of cases. It appeared to be better in older children. Stomal stenosis is a frequently encountered problem that may require surgical revision.

Appendix↗