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Pediatric Imaging |
1 From the Department of Diagnostic Imaging, Centre for Image Guided Therapy (P.G.C., E.S., B.L.C., M.J.T., R.R., J.G.A., S.M., H.F.R.), and Department of General Surgery (S.H.E.), Hospital for Sick Children, 555 University Ave, Toronto, Ontario, Canada M5G 1X8. From the 2001 RSNA scientific assembly. Received May 16, 2002; revision requested July 15; revision received August 26; accepted October 4. Address correspondence to P.G.C. (e-mail: peter.chait@sickkids.ca).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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MATERIALS AND METHODS: Since 1994, 163 tube cecostomies for fecal incontinence were performed in patients aged 2–23 years and who weighed 8–72 kg (mean, 32.2 kg). Underlying conditions included spina bifida (n = 106), imperforate anus (n = 53), Klippel-Feil deformity (n = 1), cerebral palsy (n = 1), Hirschsprung disease (n = 1), and paraplegia (n = 1). Ventriculoperitoneal shunts were present in 85 (52%) of the 163 patients. The authors have followed up 124 (76%) of the 163 cecostomy patients. Information regarding enema technique, satisfaction with the procedure, postprocedure problems, and long-term outcome of the procedure was obtained by interviewing either the patients or the parents.
RESULTS: Tube placement was successful in all patients. One hundred ten (89%) of the 124 patients experienced a substantial decrease in the frequency of soiling accidents. The vast majority of patients expressed satisfaction with the procedure; 117 (94%) of the 124 patients rated the cecostomy procedure as better than the bowel control procedure used before. Late complications of the procedure included granulation tissue and accidentally dislodged tubes. Four patients elected to have their tubes removed for aesthetic and tube management reasons. There was no mortality related to the procedure, although one patient died of pneumonia 5 years later.
CONCLUSION: The percutaneous cecostomy procedure is a safe and effective method for treating fecal incontinence.
© RSNA, 2003
Index terms: Anus, abnormalities, 757.1435 • Catheters and catheterization, in infants and children • Colon, interventional procedures, 752.1269
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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MATERIALS AND METHODS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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In every case, the indication for the percutaneous cecostomy was fecal incontinence. All patients had one of the following underlying diagnoses: spina bifida or meningomyelocele (n = 106), imperforate anus (includes patients with VATER syndrome [vertebral and vascular anomalies, anal atresia, tracheoesophageal fistula, esophageal atresia, renal anomalies and radial dysplasia]), sacral agenesis and cloacal anomalies (n = 53), or another cause of fecal incontinence such as paraplegia (n = 1), cerebral palsy (n = 1), Hirschsprung disease (n = 1), or Klippel-Feil deformity (n = 1). Regardless of the underlying disease, the anal sphincter mechanism was lax in all patients. This was the main indication for performing the procedure. In addition, 85 (52%) of the 163 patients had a ventriculoperitoneal shunt in place at the time of the cecostomy tube procedure. All patients with ventriculoperitoneal shunts had spina bifida.
Preparation for Percutaneous Cecostomy
Some patients underwent a barium enema study before admission to detect the position of the cecum. A barium enema study is recommended when the history or imaging performed before the procedure indicates variant or complex anatomy.
We reduced the admission time before the procedure from a 1-day to a same-day admission by changing from the nasogastric administration of 25 mL/kg polyethylene glycol electrolytes (PegLyte solution; Pharmascience, Montreal, Quebec, Canada) to oral administration of 45 mL sodium phosphate solution (Phospho-Soda oral laxative; Fleet, Lynchburg, Va), which the patient ingested the night before admission. The patients consumed a fluid diet for 2 days before the percutaneous cecostomy procedure. Radiography of the abdomen was performed just prior to the procedure to assess bowel cleansing, and a repeat dose of the Phospho-Soda was given, if necessary.
Procedure
The procedures were performed by three of the authors (P.G.C., B.L.C., M.J.T.). The procedures were performed with the use of conscious sedation in 138 patients, general anesthesia in 16 patients, or local anesthetic in nine patients.
The procedure was performed on a C-arm fluoroscopic table with tilting capabilities (CAS 8000V; Toshiba Medical Systems, Tochigi, Japan). Limited abdominal and pelvic ultrasonography (US) was performed before the procedure to identify fluid collections and the position of major organs, including the gallbladder, liver, and urinary bladder. Glucagon hydrochloride (Glucagon for Injection; Eli Lilly, Scarborough, Ontario, Canada) was administered intravenously at a dose of 0.5–1.0 mg to inhibit colonic peristalsis.
Ampicillin was added to our prophylactic antibiotic regimen before and after the procedure. The antibiotic regimen now includes three intravenously administered antibiotics: 2.5 mg/kg gentamicin (Gentamicin Injection USP; Sabex, Boucherville, Quebec, Canada) every 8 hours, 10 mg/kg metronidazole (Metronidazole Injection; Abbott, St Laurent, Quebec, Canada) every 8 hours, and 20 mg/kg ampicillin (Ampicillin Sodium for Injection USP; Novofarm, Toronto, Ontario, Canada) every 6 hours.
Technique
The cecum was distended with air by using a 22-F silicone Foley catheter (Rusch-Pilling, Kamunting, Malaysia) that was inserted through the rectum. The balloon at the tip of the catheter was inflated to keep it in position, since the anal opening was lax. To obtain access, a single puncture was made by using fluoroscopic guidance with a Majestic 18-gauge, 7-cm, one-wall needle with a Seldinger shield (Merit Medical, South Jordan, Utah). Once access to the cecum was obtained, 5 mL of contrast material (iohexol injection 65%, Omnipaque; Nycomed Imaging, Oslo, Norway) was injected through a T-connector to confirm its intraluminal position. The needle was preloaded with two pediatric retention sutures (Enterostomy Suture Anchor Set; Cook, Bloomington, Ind) that were deployed into the cecum with a 0.035-inch Amplatz guide wire (Cook) (Figs 1, 2). The needle was then removed, and two retention suture threads were clamped with mosquito forceps (hemostatic forceps; KMedic, Nothvole, NJ). The tract was dilated with an 8-F Coons dilator (Cook). This technique evolved from the initial procedure, during which a 19-gauge BSDN needle (Cook) and one retention suture were used (6).
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A week after the insertion of the cecostomy tube, antegrade enemas began. The retention sutures were cut 10 days after the percutaneous cecostomy procedure. Our antegrade enema routine underwent some changes. Patients could now customize their irrigation procedure to their individual needs rather than follow a set standard. They were guided in this process by a dedicated cecostomy nurse in our interventional department. Most patients (88 of 124, 71%) used a combination of sodium phosphate enema (Merck-Frost, Mississauga, Ontario, Canada) at a dose of 2 mL/kg up to a total dose of 130 mL, followed by saline solution at a dose of 200–400 mL, which had been prepared by the patient (10 mL salt/1 L water). Patients who experienced cramping or adverse effects could use other methods such as glycerine (0.5–1.0 mL/kg) or bisacodyl (Dulcolax Microenema; Boehringer Ingelheim, Ridgefield, Conn), followed by saline. Patients also worked out an individualized irrigation routine and usually performed an antegrade enema every 1–3 days. If excessive soiling was encountered between wash-throughs, peristaltic stimulants such as sennosides (Senokot preparation; Purdue Frederick, Stamford, Conn), laxatives such as lactulose (Lactulax; Rougier, Mirabel, Quebec, Canada), or mineral oil were taken orally to soften the stool for a more complete colonic evacuation and cleansing.
Long-term Care
After 6 weeks, the Dawson Mueller Mac-Loc catheter was exchanged for a low-profile Chait Trapdoor cecostomy catheter (Cook). This exchange was performed over a wire with fluoroscopic guidance. No sedation or antibiotic coverage was necessary, and the procedure was performed on an outpatient basis. Our initial routine involved replacing the Chait Trapdoor catheters only when problems arose; however, we now suggest yearly changes of this catheter. For this procedure, we found it easier to cut the old catheter below the "trapdoor" and advance the new catheter over a wire. This displaced the distal part of the old catheter, including the distal pigtail coils, into the cecum, where they were then passed easily through the rectum (Fig 4).
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Other catheters used by a small number of patients include the Mic-Key catheter (Ballard Medical Products, Draper, Utah), the Dawson-Mueller Mac-Loc catheter, and the Bard Button (C.R. Bard, Murray Hill, NJ)
The long-term care of the cecostomy patients was performed by a team comprising a pediatric interventional radiologist, a general surgeon, a pediatrician, and a cecostomy nurse.
Outcome
Information was collected regarding different aspects of the procedure, including the duration the cecostomy tube had been in situ or the reason for its removal, the type of catheter used, the goal or the reason for undergoing the procedure and if that goal was met, any problems or complications regarding the cecostomy procedure, the frequency of irrigation, the effect of the procedure on the frequency of soiling accidents, the satisfaction with the procedure, and whether the patient would recommend the procedure to others. This information was obtained by interviewing either the patients or their parents as appropriate to the age of the patient and his or her understanding. Interviews were conducted either in person or by telephone. The questions asked were identical in all interviews and were read from a questionnaire that was prepared by the authors. Abstract questions such as the patient’s level of satisfaction with the procedure were graded by the interviewee on a qualitative scale between "very unsatisfied" and "very satisfied." All interviews were performed by a single author (E.S.).
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RESULTS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Among the patients who underwent a cecostomy, there was one death, which was unrelated to the cecostomy procedure (the patient died of pneumonia 5 years after the cecostomy procedure).
The cecostomy tube was successfully placed in all patients. In the patient with Hirschsprung disease, the tube was removed after 90 days because of vomiting. Four other patients elected to have their catheters removed due to catheter maintenance (poor patient compliance) (n = 2) or aesthetic considerations (n = 2).
The most widely used long-term catheter for the cecostomy procedure in this study population was the Chait Trapdoor catheter, which was used in 111 (90%) of the 124 patients. The Mic-Key catheter and Dawson-Mueller Mac-Loc catheter were each used in six (4%) of the 124 patients. Finally, the Bard Button was used in one patient. The cecostomy catheters were in situ for an average of 3.1 years (range, 2–73 months). The two main reasons expressed by patients or parents for undergoing a cecostomy procedure were to decrease the number of soiling accidents and to increase both the patient’s independence in performing the bowel control procedure and the patient’s overall independence. Ninety-eight (79%) of the 124 patients reported they achieved their main goal after undergoing the cecostomy procedure.
Seventy-four (60%) of the 124 patients experienced some cecostomy tube related problems at some point during the follow-up period; however, most were minor and did not necessitate medical intervention. In eight (6%) of the 124 patients, a cecostomy tube infection occurred, which required oral antibiotic treatment. Cecostomy tube failure occurred in 12 (10%) of the 124 patients. These included the uncoiling of the tube inside the body in two (2%) of the patients and tube breakage in 10 (8%) of the patients. In 18 (14%) of the 124 patients, reinsertion of the cecostomy tube was required, mostly as a result of accidental removal of the tube. A number of patients experienced minor difficulties related to the cecostomy tube, including slight clogging of the cecostomy tube and partial dislodgment of the tube. These problems were easily corrected at home and did not require medical intervention.
The development of granulation tissue accompanied with redness at the cecostomy site appeared at one time or another in 75 (60%) of the 124 patients and was not accompanied with any pain or discomfort at the tube site. The granulation tissue was periodically accompanied with a discharge, which was usually colorless or slightly yellow and odorless. This was treated by means of cauterization with silver nitrate. Antegrade enemas were administered according to the needs of the patient (range, every 1–7 days; mean, every 2.4 days). The vast majority of patients (110 of 124, 89%) reported a decrease in the frequency of soiling accidents after the procedure compared with the frequency before the procedure. A third of the patients now experience fewer than one soiling accident per 6 months.
The vast majority of patients (116 of 124, 94%) expressed satisfaction with the procedure. According to our results, 117 (94%) of the 124 patients rated the cecostomy procedure as better than the irrigation or bowel control procedure that they used before, and they were satisfied with its effectiveness. One hundred twenty (97%) of the 124 patients said that they would recommend the cecostomy procedure to others in their situation.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Before the Procedure
The replacement of the polyethylene glycol electrolyte solution with a smaller and more palatable oral dose of sodium phosphate solution was an improvement, since the latter did not require the insertion of a nasogastric tube and could easily be taken at home. Therefore, a same-day admission became sufficient rather than a previous night admission (6).
The addition of ampicillin to the antibiotic regimen of metronidazole and gentamicin before and after the procedure increased the spectrum of antibacterial coverage, which is now similar to that used for major bowel surgery.
Procedure
We now recommend that a more complete abdominal and pelvic US examination be performed before the procedure, especially for patients with an in situ ventriculoperitoneal shunt. This is done to identify the major organs and to detect any anatomic anomalies or any collections of abdominal fluid. Although the presence of a collection of abdominal fluid is not a contraindication for a percutaneous cecostomy procedure, its location should be noted and avoided, especially if it is to be associated with a ventriculoperitoneal shunt.
Technique
The cecostomy tube procedure can now be performed as a single puncture technique. This represents a substantial change from our original approach. Use of a single puncture technique decreases the number of steps, thus simplifying the procedure.
The 19-gauge BSDN needle was replaced with the Majestic 18-gauge, 7-cm one-wall needle with a Seldinger shield. The Majestic needle is equipped with a clear hub that makes it easier to see the retention sutures as they are loaded into the needle. In our experience, the Majestic needle provides a better sensitivity as the puncture is made. To decrease the risk of leakage further, we decreased the size of the dilator from a 10-F to an 8-F Coons dilator and the size of the initial catheter from a 10-F to an 8.5-F Dawson Mueller Mac-Loc catheter. The Dawson Mueller Mac-Loc catheter has a further advantage in that it is not made of latex; therefore, it can be used in some of our patients with latex allergies. Latex allergy is a concern, especially in patients with spina bifida (9).
Short- and Long-term Care
We now recommend that the Chait Trapdoor catheter be replaced every 12–15 months to reduce the risk of catheter breakdown and to make catheter replacement a simple outpatient elective procedure. The new replacement technique involved advancing the catheter into the cecum as opposed to removing it. This is an improvement on the older method of catheter exchanges, since we found that the catheter became hardened and stiff with fecal residue and could be painful when removed.
Substantial changes have taken place in the preparation for the percutaneous cecostomy procedure, the procedural technique, the catheter itself, and the follow-up and support services for these patients. The long-term follow-up shows that this is a safe and effective procedure for the control of fecal incontinence, with minimal complications and good patient acceptance.
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ACKNOWLEDGMENTS |
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FOOTNOTES |
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