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The Percutaneous Cecostomy Tube in the Management of Fecal Incontinence in Children
CLINICAL STUDY
The Percutaneous Cecostomy Tube in the Management of Fecal Incontinence in Children Waqas Ullah Khan, BSc, BEd, MSc, Janakan Satkunasingham, MD, Rahim Moineddin, PhD, Irfan Jamal, BSc, Samia Afzal, PhD, Peter Chait, MB, FRCPC, Dimitri Parra, MD, Joao G. Amaral, MD, Michael J. Temple, MD, and Bairbre L. Connolly, MB, FRCPC
ABSTRACT Purpose: To retrospectively evaluate experience with percutaneous cecostomies and their long-term outcomes. Materials and Methods: Between June 1994 and March 2009, 290 patients (mean age, 10.1 y) with fecal incontinence underwent percutaneous cecostomy tube placement and subsequent tube management. Technical success, procedural complications, and long-term follow-up until March 2012 were evaluated. Results: A cecostomy was successfully placed in 284 patients (98%), and 257 of 280 patients (92%) underwent a successful exchange to a low-profile tube. A total of 1,431 routine exchanges to low-profile tubes were reviewed in 258 patients (mean, 1.6 ⫾ 1.3 routine tube changes per 1,000 days). Eighty-five patients (29%) experienced one or more early problems after cecostomy, and 10 (3%) had major complications. In the total 463,507 tube-days, 938 late problems were noted: 917 (98%) minor and 22 (2%) major. Forty patients had the cecostomy catheter removed and 141 “graduated” to an adult health care facility. Conclusions: The percutaneous cecostomy procedure provides a safe management option for fecal incontinence in the pediatric population.
ABBREVIATIONS BMI = body mass index, RAS = retention anchor sutures, VP = ventriculoperitoneal
From the Faculty of Health Sciences (W.U.K.), School of Medicine, Trinity College, Dublin, Ireland; Research Institute (W.U.K.) and Department of Diagnostic Imaging (P.C., D.P., J.G.A., M.J.T., B.L.C.), Hospital for Sick Children; Departments of Family and Community Medicine (R.M.), Arts and Science (I.J.), and Immunology (S.A.), University of Toronto; Campbell Family Institute for Breast Cancer Research (S.A.), University Health Network, Toronto; and Department of Diagnostic Radiology (J.S.), Kingston General Hospital, Kingston, Ontario; Diagnostic Imaging (P.C.), Scarborough Centenary Hospital, Scarborough, Toronto, Ontario, Canada. Received July 3, 2014; final revision received October 12, 2014; accepted October 17, 2014. Address correspondence to B.L.C., Hospital for Sick Children, 555 University Ave., Room 8263, Toronto, ON, Canada M5G 1X8; E-mail: [email protected] From the SIR 2009 Annual Meeting. P.C. is a patent holder and receives royalties on the Chait Trapdoor device (Cook, Bloomington, Indiana). J.S. was funded by the SIR Foundation Medical Student/Resident Research Grant program. None of the other authors have identified a conflict of interest. & SIR, 2015 J Vasc Interv Radiol 2015; 26:189–195 http://dx.doi.org/10.1016/j.jvir.2014.10.015
Bowel and bladder control is generally learned between 2 and 4 years of age. Medical conditions can impede this developmental milestone, including neuromuscular disorders, spina bifida, and imperforate anus (1). If left untreated, fecal incontinence can be medically, socially, developmentally, and emotionally disabling (2). Multiple therapies have been used to manage defecation disorders, including dietary modifications, laxatives, suppositories, enemas, manual disimpaction, biofeedback, and electrostimulation (2–5). Despite these efforts, many patients do not achieve fecal continence (5). Intermittent fecal disimpaction and retrograde enemas are effective in partial emptying of the colon, but require a caregiver to administer. This inhibits independence and compliance as the child grows older (6). A surgically constructed appendicostomy is a method to deliver antegrade enemas and colonic washouts, but is associated with stomal stenosis and leakage, resulting in noncompliance (5,6). In 1996, Shandling et al (2) described management of overflow incontinence by a catheter inserted
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percutaneously into the cecum under fluoroscopic guidance (2). The cecostomy tube allows for delivery of antegrade enemas to evacuate the entire colon at regular controlled intervals, thereby avoiding uncontrolled fecal soiling. It also avoids the pain associated with catheterization of appendicostomies, and favorable clinical outcomes have been reported in children with this approach (1–4,7–11). The purpose of the present study is to report our experience with the image-guided percutaneous cecostomy procedure and the long-term safety and outcomes of this intervention, with a focus on the lessons learned over the years.
MATERIALS AND METHODS This is a retrospective single center case series review. All 290 patients who underwent a cecostomy procedure between June 1994 and March 2009 were reviewed until March 2012 (average follow-up, 11 y; range, 3–18 y). Patients who had a Malone antegrade continence enema were excluded, and institutional research ethics board approval was obtained.
Data Collection Data were obtained from the hospital’s picture archiving and communication systems, interventional radiology database (Esh-IGT, Toronto, Ontario, Canada), and electronic patient charts. These records provided inpatient and outpatient clinic details, emails, and telephone documentation between patient families and the interventional radiology clinic nurse. Table 1 . Patient Demographics (N ¼ 290) Characteristic Mean age (y) ⫾ SD
Value 10.1 ⫾ 4.4
Sex Male Female
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Patient demographics (sex, age, underlying diagnosis, weight and height at primary cecostomy insertion, and tube exchanges) were obtained (Table 1). Each patient’s course was divided into early and late. The early period extended from the periprocedural phase until the initial pigtail catheter was changed to a longer-term low-profile tube, approximately 8 weeks after insertion. Periprocedural data included type of bowel preparation, antibiotics, insertion technique, and technical difficulties during the initial and first low-profile tube placement. The late period included follow-up and tube maintenance until March 2012 or tube removal. Early and late problems included difficulties with tube changes, tube dwell times, and bowel irrigation problems. Late outcomes included patient status at final review: continence achieved, tube removed, “graduation” to an adult facility, or death.
Device The initial device was an 8-F Mac-Loc pigtail catheter (Cook, Bloomington, Indiana). When the tract had matured (6–8 wk), it was replaced with a Chait Trapdoor cecostomy (Cook, Bloomington, Indiana), a lowprofile purpose-designed device (8 F). There were three tube lengths available for different tract lengths: 0–6 cm (short), 3–9 cm (medium), and 6–14 cm (long) (11) (Fig).
Technique Periprocedure Care. Bowel preparation regimens were employed to cleanse the bowel. An abdominal radiograph the morning of the procedure was used to assess residual fecal load. A previous contrast enema study was uncommonly employed to determine cecal position. Intravenous sedation or general anesthesia was used, and antibiotic prophylaxis was given intravenously. Abdominal and pelvic ultrasonography identified organ positions and any fluid collections (eg, ventriculoperitoneal [VP] shunt fluid). Intravenous glucagon 0.5–1.0 mg
170 (59) 120 (41)
Diagnosis Spina bifida with VP shunt Spina bifida without VP shunt
138 (48) 27 (9)
Imperforate anus
64 (22)
Vater syndrome Other
19 (7) 42 (14)
Weight o 3% 3%–25%
60 (21) 65 (22)
25%–75%
78 (27)
75%–97% 4 97%
70 (24) 15 (5)
NA
2 (1)
Values in parentheses are percentages. NA = not available, SD ¼ standard deviation, VP ¼ ventriculoperitoneal.
Figure. Permanent cecostomy tube. Trapdoor tube shown in different lengths called short, medium, or long according to the length of the straight component as highlighted by the arrows. Each tube comes with a unique adapter and connecting tube for use during irrigations. The low-profile tube lies flat against the skin, and the spring design provides its retention mechanism. (Available in color online at www.jvir.org.)
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(Eli Lilly, Scarborough, Ontario, Canada) was administered for bowel paralysis. The colon was distended by using an insufflator (E-Z-EM, Anjou, Quebec, Canada) through a rectal Foley catheter. The air column was followed with fluoroscopy until it reached the cecum. The cecum was punctured under fluoroscopic guidance with a Merit 18-gauge needle (Cook) preloaded with two pediatric retention anchor sutures (RASs; Cook). Intraluminal position was confirmed with contrast medium. A 0.035inch Amplatz guide wire (Cook) was used to deploy the two RASs. The tract was dilated to 8 F, and an 8-F pigtail catheter was placed. The position was confirmed by using fluoroscopy, contrast medium, and air. The tube was vented to decompress the cecum, and the thread
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of the RAS was secured. Some patients who underwent an open surgical procedure (eg, bladder augmentation) had their cecostomy tubes placed in the operating room by interventional radiologic means via a modified technique. Postprocedure analgesia included morphine (0.05 mg/ kg) or acetaminophen as needed (15 mg/kg). After bowel sounds returned, oral fluids were increased to diet as tolerated. The tube was kept vented and flushed twice daily with saline solution 5 mL, and the patient was discharged within 3–4 days after the procedure if afebrile, without pain, and tolerating food. Teaching regarding irrigations, tube care, and contact numbers were provided before discharge. Antegrade enemas were commenced 10 days after insertion.
Table 2 . Evolution of Cecostomy Tube Procedure over a Duration of 18 Years Practice Bowel preparation
Initial Approach (i) 25 mL/kg PEG electrolytes (PegLyte) via NG tube; (ii) oral 45 mL sodium phosphate
Current Approach
Changing to Phospho-Soda solution reduced
packet; 4 12 y, 1 packet
admission time before
solution oral laxative Prophylactic antibiotic preprocedure
Triples 5 d: ampicillin (20 mg/kg every 6 h), gentamicin (2.5 mg/ kg every 8 h), metronidazole (10 mg/kg every 8 h)
Needle puncture
18-gauge BSDN (Cook Medical, Bloomington, Indiana)
Immediate postinsertion Timing tube changes
Rationale for Change
Pico-Salix twice daily: r 6 y, 0.25 packet; 6–12 y, 0.5
procedure from 1 d to same-day admittance Cefoxitin only (30 mg/kg) IV
5-d course longer than in-
single dose or triple antibiotic if complicated
hospital stay; deemed unnecessary for
insertion
uncomplicated insertion
18-gauge Merit needle preloaded with 2 RASs
Sharper needle required for cecal puncture
Tube capped off postprocedure
Tube vented for first 10 d
Gaseous cecal distension– pneumoperitoneum
Replace Trapdoor catheter only
Replace Trapdoor catheter
Reduces pain/difficulty of
preloaded with 2 RASs
“as needed” when an issue developed
every 12–15 mo
changing catheters hardened with fecal residue
Technique of tube changes
Cut tube, place wire in old tube, advance new tube over wire, and push both into cecum
Removed old Trapdoor over Glidewire and advanced new one (exchange)
Issues: (i) non-Glidewire unraveling; (ii) tubes retained in cecum; (iii) tubes retained, not passed beyond surgical strictures
Adult care
Initially followed in pediatric hospital
Long-term catheter
Variety of balloons and prototypes
Transitioned to adult facilities at age 18 y Development of low-profile Trapdoor
Trapdoor catheters
Short (1998)
Long (1999), medium (2005)
available Glucagon
pediatric hospital in event of a complication Buttons stood proud of skin and caused difficulties with belts/trousers Variety of lengths based on distance from skin to cecum
Given 0.5–1 mg IV dose, repeat if needed
Irrigation solution
Difficulty to care for adults in
Phosphate-containing irrigation solutions
Same but checked blood sugar at 1 and 4 h later Saline solution alone or with mineral oil or glycerin
IV ¼ intravenous, NG ¼ nasogastric, PEG ¼ polyethylene glycol, RAS ¼ retention anchor suture.
Incidence of rebound hypoglycemia following glucagon Concern with phosphate toxicity
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Two weeks after the procedure, the patient attended the interventional radiology clinic when the RAS threads were cut, and any questions about their tube, irrigations, or site were addressed. Patients customized the enema routine to personal needs, with guidance from the interventional radiology clinic nurse. Evolution of practice regimens is noted in Table 2. The pigtail catheter was exchanged without sedation or antibiotics to a low-profile tube after 6–8 weeks as an outpatient procedure.
Late Period. Low-profile cecostomy tubes were exchanged by removal of the old tube and insertion of the new one over a Glidewire. Previously, this was performed by cutting the old catheter below the Trapdoor device, inserting a short straight wire into the cut tube, and pushing the old and new tube in series over the wire into the cecum (Table 2). The tube choice (short, medium, long) depended on thickness of the patient’s abdominal wall.
Outcome Measures Technical success was defined as placement of the pigtail catheter into the bowel in a position that functioned for colonic irrigation (eg, cecum or ascending colon). Technical failure was the inability to place the catheter into the bowel such that it was functional for colonic irrigation. Complications were divided into early (ie, periprocedure until placement of the low-profile device) and late (ie, following placement of permanent low-profile device). Complications were assigned according to the Society for Interventional Radiology classification system as minor (class A, no therapy; and class B, nominal therapy, overnight observation) or major (class C, therapy, hospitalization o 48 h; class D, major therapy, increased level of care, hospitalization 4 48 h; class E, permanent adverse sequelae; and class F, death) (12).
Statistical Analysis Data were analyzed by using SAS for Windows statistical software package (version 3.1; SAS Institute, Cary, North Carolina). Summary statistics were used to describe the patient cohort: χ2, Fisher exact test, and logistic regression were used for inferences (eg, between and within group associations). For linear regression analysis, log-transformation for nonnormal data was performed. A P value of .05 or lower was considered statistically significant.
RESULTS The technical success rate was 98%, as four of 290 insertions failed on the initial attempt. However, all were successful at a subsequent procedure.
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Early: Procedural Outcomes A single puncture was used in 265 of 290 insertions (91.4%), two punctures were used in 17 (5.8%), and more than two were used in two (0.7%). A combined open surgical procedure was employed in four patients (1.4%), and laparoscopy was employed in two (0.7%). In 259 patients (89%), the placement was uneventful. Technical difficulties encountered in 31 patients (11%) and included initial failure as described earlier (n ¼ 4), RAS thread break (n ¼ 4), peritoneal tube placement recognized and rectified immediately (n ¼ 5), small bowel needle puncture (n ¼ 2), extracecal tube placement (n ¼ 6: ascending colon, n ¼ 2; transverse colon, n ¼ 2; sigmoid colon, n ¼ 1; terminal ileum, n ¼ 1), minor spill at cecostomy tube site (n ¼ 1), more than one tube used (n ¼ 4), challenging anatomy (n ¼ 6), and loss of initial access (n ¼ 3). Tubes placed in the ascending and transverse colon (n ¼ 2) functioned adequately, whereas sigmoid and ileal tubes (n ¼ 2) recognized at 2 and 3 months, respectively, required replacement. This yields a technical success rate of 98% (284 of 290). Exchange to a low-profile device occurred in 280 of 290 patients. Six were lost to follow-up, two had early tube removals (colectomy for Hirschsprung disease, n ¼ 1; diagnosis of Munchausen syndrome by proxy, n ¼ 1), and there were two early deaths (r 6 wk). Exchange to a lowprofile tube placement occurred at less than 6 weeks (n ¼ 71), 6–10 weeks (n ¼ 115), 10–26 weeks (n ¼ 45), 26–52 weeks (n ¼ 18), or more than 52 weeks (n ¼ 27), and details were missing for four subjects. The exchange was uneventful in 257 of 280 patients (92%), whereas 23 (8%) experienced difficulties such as a need for sedation (n ¼ 12), problematic granulation tissue at the cecostomy site (n ¼ 4), tube dislodgment or migration (n ¼ 4), tube breakage (n ¼ 1), severe site pain (n ¼ 1), and steering the tube through the distal ileal stoma into the cecum (n ¼ 1). On Fisher exact test, no significant association was identified between patients with an uneventful primary insertion, difficult insertion, difficult subsequent tube insertions, and the variables of age, diagnosis, weight, height, body mass index (BMI), method of insertion, and tube exchange (P 4 .05). Those patients weighing less than the third centile were more likely to have difficulty during their low-profile tube insertion (Fisher exact test, P ¼ .004).
Late: Follow-up and Maintenance A total of 1,431 low-profile tube changes were performed in 258 of 280 patients (range, 1–18 per patient), with a mean of 1.6 ⫾ 1.3 (standard deviation) changes per 1,000 days. No significant associations between the number of routine changes and patient diagnosis, age, weight, height, BMI, method of insertion, or early complications were observed (P 4 .05, χ2 analysis). The majority of exchanges (1,244 of 1,431) were
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Table 3 . Minor Early and Late Complications Incidence
Complication Fever Peritonitis/peritoneal spill Gastrointestinal issues Continuing accidents/soils Cramping/pain Irrigation difficulty Vomiting, nausea, ileus Constipation
Early
Late
(n ¼ 139) 31
(n ¼ 1,092) 11
1
0
0
36
0
16
0 26
31 13
DISCUSSION
0
22
The most successful methods to manage fecal incontinence are those that completely evacuate the colon and regulate bowel movements, which avoid socially and psychologically embarrassing episodes of incontinence. The percutaneous cecostomy is effectively used in the management of the majority of patients and overcomes many problems experienced with a surgically performed appendicostomy (2–6,13–16). Since 1994, evolution in terms of techniques, devices, and medical management (Table 2) demonstrate the learning curve inevitable with a new procedure (2–4,15). The present study reports our experience with cecostomy tubes in a large pediatric cohort over a long follow-up. Patients whose weight was lower than the third centile (n = 60; 21%) were more likely to experience problems during their cecostomy catheter insertion. Two thirds of these patients had spina bifida, which is frequently associated with scoliosis and a protuberant abdomen. Cecal puncture in these patients is often difficult as a result of cecal position, mobility, and anatomic distortion, which necessitates a long oblique tract (8,17). Although cecostomies have been shown to be effective and safe to use in patients with VP shunts, there is an inherent risk of shunt infection (15,18). These infections can result from enteric content leakage as a result of a poorly sealed tract. This, in turn, can be avoided by providing a more secure cecal fixation. Alternative etiology includes proximity to the VP shunt tubing, which can be avoided by maximizing the distance from the VP shunt (18). A high number of complications were documented by thorough chart review. Although 30% of patients experienced early problems and 84% experienced late problems, this may represent an overcall, as all symptoms reported by the patient or caregiver(s) were included. Most early (139 of 149; 93%) and late (1,092 of 1,114; 98%) problems were minor tube, site, irrigation regimen, or bowel management problems that did not require medical intervention (2,3,5,6,15,16). Retraction of coils into the tract from growth, weight gain, or accidental pull make exchanges difficult. Upsizing the length as the child grows is important to avoid this problem. The use of different lengths of tubes has alleviated the problem of too-short devices (eg, coils in the tract creating a spiral) or too-long devices (eg, tube
Site issues Abscess
0
6
Bleeding
0
26
4 14
76 45
Granulation tissue Local inflammation/infection Leakage/discharge Pain at site Tract issues
10
116
27
100
Fistula
0
8
Tract loss Tube issues
0
2
Blocked tube
0
31
Broken/cracked tube Coils in tract
0 0
74 47
Stuck/retained old tube
0
14
Complete/partial dislodgment Tube removed
8 0
234 12
18
172
Other
(Table 3). The majority (n ¼ 1,092; 98%) were minor, with a complication rate of 1.9 per 1,000 tube-days. Twenty-two major complications (2%) occurred in 16 patients (Table 4). A major complication rate of 0.03 per 1,000 tube-days was observed. Fisher exact test showed no significant association between patients with and without late complications and the variables of age, diagnosis, weight, height, BMI, and method of insertion (P 4 .05).
uneventful, but a variety of patient, site, or tube problems were recorded in 187 cases (13%; Table 3). Forty patients had their cecostomy catheter removed because they achieved continence (n ¼ 12) or stopped using it (n ¼ 5), because of personal preference (n ¼ 5) or tract loss and decline of new insertion (n ¼ 1), and for unclear reasons (n ¼ 17). When reviewed, 141 patients graduated to an adult health care facility at a mean age of 20.8 years ⫾ 4.2.
Complications Early. Early problems after insertion were experienced in 85 patients (29%), 40 of whom had multiple problems (n ¼ 149), including 10 major complications (3%). The most common early minor complications (n ¼ 139) are summarized in Table 3. The major complications (n ¼ 10 patients) are detailed in Table 4. There was no significant association between patients with or without an early complication and the variables of diagnosis, age, weight, height, BMI, method of insertion, and difficulty at insertion (P 4 .05, Fisher exact test). Late. During the follow-up (total 463,507 tube-days in 234 of 279 patients [84%]), 1,114 problems occurred
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Table 4 . Major Early and Late Complications Experienced by Patients SIR Grade/Timing
Complication
Early
Incidence 10
C
Prolonged ileus, prolonged hospital stay Peritonitis, only IV antibiotics required
4 1
Tube dislodged, unable to reinsert, required new insertion (GA)
1
D
Peritonitis, pelvic abscess required drainage (GA) Peritonitis, VP shunt infected, VP shunt revision required (GA)
1 1
Peritonitis, VP shunt infected, VP shunt revision and abscess drainage required
1
F Late C
D
Peritonitis, quadriplegia, no abdominal signs/symptoms, death on day 1 despite IV antibiotics
1 22
Prolonged parastomal fistula, closed spontaneously
3
Stuck spiral Tube in tract, too painful to remove, required GA for exchange Early method exchange, retained old cecostomy tube in cecum, GA for colonoscopy to remove
2 1
Site abscess, required incision and drainage
1
Site infection, hospital admission and IV antibiotics 4 48 h required Anaphylaxis to tape
1 1
Severe excessive granulation, required excision under GA
1
Loss tract, unable to reinsert tube, entire new primary cecostomy insertion required Early method exchange, cut cecostomy tube stuck at sigmoid stricture, unable to pass; GA,
2 1
sigmoidoscopy to remove Difficult exchange, peritoneal spill, admission, IV antibiotics Seizure, from phosphate absorption, required ICU admission
1 2
Parastomal fecal fistula, cecostomy tube removed and new one inserted
1
Parastomal fecal fistula, failed attempt at Biodesign Fistula Plug, new primary cecostomy performed
1
Infection, hospital admission, 4 48 h antibiotics
1
Stuck coils in tract, unable to uncoil and remove, GA to exchange Severe dysmotility with severe abdominal pain, required hospital admission 7 d
1 1
Prolonged severe site discharge, old cecostomy tube removed, new cecostomy inserted
1
GA ¼ general anesthesia, ICU ¼ intensive care unit, IV ¼ intravenous, SIR ¼ Society of Interventional Radiology, VP ¼ ventriculoperitoneal.
protruding from the skin; Table 2). Mechanical failures such as catheter breakage, blockage, accidental dislodgment, or leakage were usually successfully exchanged through the preexisting tract without difficulty. Tubes were exchanged every 12–15 months, as hardening and encrustation of the tube occurred if it was left in situ too long. Tract problems of granulation tissue, inflammation, leakage, and bleeding were common, but site abscess was uncommon (19). Leakage around the tube can be reduced by slowing the flush of the enema solution (20). A parastomal cutaneous fecal fistula must be excluded. This may require removal of the tube to close the fistula or surgical excision of the fistula and tract. Vomiting, pain, and cramping can occur with phosphate-based enemas. Phosphate absorption occurred in three cases, two of which resulted in phosphate toxicity causing nausea, vomiting, and seizures that required intensive care unit admission. Although phosphate solutions have been reported to be safe and effective for colonic washouts in the pediatric community, toxicity is a concern especially in patients with renal impairment (21). We have now omitted all phosphate-based
purgatives from patient enema regimens. Irrigation regimens (eg volume, frequency, and additives) are tailored to the individual, with advice from a dietitian and cecostomy nurse. These myriad tube, tract, and irrigation regimen problems highlight the need for a multidisciplinary team approach for cecostomy management. Patient perspective of incontinence management was reviewed in a subset of these patients (n ¼ 124) in a previous publication (15). Dedicated experienced personnel or an encopresis team are invaluable in managing these issues. This patient population is too complex to be managed successfully by interventional radiologic means alone, and finding adult care programs for these aging patients is a major challenge. There are several limitations to the present study, which include its retrospective nature and possible overstatement of complications. Inevitable changes in operators, equipment, and clinical practice have been summarized in Table 2. Some data may be missing, especially from the early years, and this report did not include a quality-of-life or fecal incontinence score, as this has been previously addressed (15).
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In conclusion, the percutaneous cecostomy procedure has undergone extensive changes over the years. Our findings suggest it is a safe method for the management of fecal incontinence in children. However, this complex group of patients with myriad maintenance problems requires ongoing multidisciplinary supportive care.
REFERENCES 1. Bishop PR, Nowicki MJ. Defecation disorders in the neurologically impaired child. Pediatr Ann 1999; 28:322–329. 2. Shandling B, Chait PG, Richards HF. Percutaneous cecostomy: a new technique in the management of fecal incontinence. J Pediatr Surg 1996; 31:534–537. 3. Chait PG, Shandling B, Richards HM, Connolly BL. Fecal incontinence in children: treatment with percutaneous cecostomy tube placement–a prospective study. Radiology 1997; 203:621–624. 4. Chait PG, Shandling B, Richards HF. The cecostomy button. J Pediatr Surg 1997; 32:849–851. 5. Donkol RH, Al-Nammi A. Percutaneous cecostomy in the management of organic fecal incontinence in children. World J Radiol 2010; 2:463–467. 6. Malone PS, Ransley PG, Kiely EM. Preliminary report: the antegrade continence enema. Lancet 1990; 336:1217–1218. 7. Hoy NY, Metcalfe P, Kiddoo DA. Outcomes following fecal continence procedures in patients with neurogenic bowel dysfunction. J Urol 2013; 189:2293–2297. 8. Yamout SZ, Glick PL, Lee YH, et al. Initial experience with laparoscopic Chait Trapdoor cecostomy catheter placement for the management of fecal incontinence in children: outcomes and lessons learned. Pediatr Surg Int 2009; 25:1081–1085. 9. van den Berg MM, Hogan M, Caniano DA, Di Lorenzo C, Benninga MA, Mousa HM. Colonic manometry as predictor of cecostomy success in children with defecation disorders. J Pediatr Surg 2006; 41:730–736.
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10. Kaye RD, Towbin RB. Imaging and intervention in the gastrointestinal tract in children. Gastroenterol Clin North Am 2002; 31:897–923. 11. Allen AW, Varma MK, Meyermann MW. The Chait Trapdoor cecostomy catheter: an alternative access device to pigtail catheters for chronic cholecystostomy drains. J Vasc Interv Radiol 2008; 19:137–140. 12. Sacks D, McClenny TE, Cardella JF, Lewis CA. Society of Interventional Radiology clinical practice guidelines. J Vasc Interv Radiol 2003; 14: S199–S202. 13. Curry JI, Osborne A, Malone PS. The MACE procedure: experience in the United Kingdom. J Pediatr Surg 1999; 34:338–340. 14. Driver CP, Barrow C, Fishwick J, Gough DC, Bianchi A, Dickson AP. The Malone antegrade colonic enema procedure: outcome and lessons of 6 years’ experience. Pediatr Surg Int 1998; 13: 370–372. 15. Chait PG, Shlomovitz E, Connolly BL, et al. Percutaneous cecostomy: updates in technique and patient care. Radiology 2003; 227:246–250. 16. Sierre S, Lipsich J, Questa H, Bailez M, Solana J. Percutaneous cecostomy for management of fecal incontinence in pediatric patients. J Vasc Interv Radiol 2007; 18:982–985. 17. Holbrook C, Tsang T. Laparoscopic insertion of antegrade continence enema catheter: a technique enabling early postoperative usage. Surg Laparosc Endosc Percutan Tech 2012; 22:e58–e60. 18. Yamout SZ, Huo BJ, Li V, Escobar MA, Caty MG. Risk of ventriculoperitoneal shunt infections after laparoscopic placement of Chait Trapdoor cecostomy catheters in children. J Laparoendosc Adv Surg Tech A 2009; 19:571–573. 19. Webb HW, Barraza MA, Stevens PS, Crump JM, Erhard M. Bowel dysfunction in spina bifida–an American experience with the ACE procedure. Eur J Pediatr Surg 1998; 8(Suppl 1):37–38. 20. Becmeur F, Demarche M, Lacreuse I, et al. Cecostomy button for antegrade enemas: survey of 29 patients. J Pediatr Surg 2008; 43: 1853–1857. 21. Sabri M, Di Lorenzo C, Henderson W, Thompson W, Barksdale E Jr, Khan S. Colon cleansing with oral sodium phosphate in adolescents: dose, efficacy, acceptability, and safety. Am J Gastroenterol 2008; 103: 1533–1539.
The Percutaneous Cecostomy Tube in the Management of Fecal Incontinence in Children Waqas Ullah Khan, BSc, BEd, MSc, Janakan Satkunasingham, MD, Rahim Moineddin, PhD, Irfan Jamal, BSc, Samia Afzal, PhD, Peter Chait, MB, FRCPC, Dimitri Parra, MD, Joao G. Amaral, MD, Michael J. Temple, MD, and Bairbre L. Connolly, MB, FRCPC
ABSTRACT Purpose: To retrospectively evaluate experience with percutaneous cecostomies and their long-term outcomes. Materials and Methods: Between June 1994 and March 2009, 290 patients (mean age, 10.1 y) with fecal incontinence underwent percutaneous cecostomy tube placement and subsequent tube management. Technical success, procedural complications, and long-term follow-up until March 2012 were evaluated. Results: A cecostomy was successfully placed in 284 patients (98%), and 257 of 280 patients (92%) underwent a successful exchange to a low-profile tube. A total of 1,431 routine exchanges to low-profile tubes were reviewed in 258 patients (mean, 1.6 ⫾ 1.3 routine tube changes per 1,000 days). Eighty-five patients (29%) experienced one or more early problems after cecostomy, and 10 (3%) had major complications. In the total 463,507 tube-days, 938 late problems were noted: 917 (98%) minor and 22 (2%) major. Forty patients had the cecostomy catheter removed and 141 “graduated” to an adult health care facility. Conclusions: The percutaneous cecostomy procedure provides a safe management option for fecal incontinence in the pediatric population.
ABBREVIATIONS BMI = body mass index, RAS = retention anchor sutures, VP = ventriculoperitoneal
From the Faculty of Health Sciences (W.U.K.), School of Medicine, Trinity College, Dublin, Ireland; Research Institute (W.U.K.) and Department of Diagnostic Imaging (P.C., D.P., J.G.A., M.J.T., B.L.C.), Hospital for Sick Children; Departments of Family and Community Medicine (R.M.), Arts and Science (I.J.), and Immunology (S.A.), University of Toronto; Campbell Family Institute for Breast Cancer Research (S.A.), University Health Network, Toronto; and Department of Diagnostic Radiology (J.S.), Kingston General Hospital, Kingston, Ontario; Diagnostic Imaging (P.C.), Scarborough Centenary Hospital, Scarborough, Toronto, Ontario, Canada. Received July 3, 2014; final revision received October 12, 2014; accepted October 17, 2014. Address correspondence to B.L.C., Hospital for Sick Children, 555 University Ave., Room 8263, Toronto, ON, Canada M5G 1X8; E-mail: [email protected] From the SIR 2009 Annual Meeting. P.C. is a patent holder and receives royalties on the Chait Trapdoor device (Cook, Bloomington, Indiana). J.S. was funded by the SIR Foundation Medical Student/Resident Research Grant program. None of the other authors have identified a conflict of interest. & SIR, 2015 J Vasc Interv Radiol 2015; 26:189–195 http://dx.doi.org/10.1016/j.jvir.2014.10.015
Bowel and bladder control is generally learned between 2 and 4 years of age. Medical conditions can impede this developmental milestone, including neuromuscular disorders, spina bifida, and imperforate anus (1). If left untreated, fecal incontinence can be medically, socially, developmentally, and emotionally disabling (2). Multiple therapies have been used to manage defecation disorders, including dietary modifications, laxatives, suppositories, enemas, manual disimpaction, biofeedback, and electrostimulation (2–5). Despite these efforts, many patients do not achieve fecal continence (5). Intermittent fecal disimpaction and retrograde enemas are effective in partial emptying of the colon, but require a caregiver to administer. This inhibits independence and compliance as the child grows older (6). A surgically constructed appendicostomy is a method to deliver antegrade enemas and colonic washouts, but is associated with stomal stenosis and leakage, resulting in noncompliance (5,6). In 1996, Shandling et al (2) described management of overflow incontinence by a catheter inserted
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percutaneously into the cecum under fluoroscopic guidance (2). The cecostomy tube allows for delivery of antegrade enemas to evacuate the entire colon at regular controlled intervals, thereby avoiding uncontrolled fecal soiling. It also avoids the pain associated with catheterization of appendicostomies, and favorable clinical outcomes have been reported in children with this approach (1–4,7–11). The purpose of the present study is to report our experience with the image-guided percutaneous cecostomy procedure and the long-term safety and outcomes of this intervention, with a focus on the lessons learned over the years.
MATERIALS AND METHODS This is a retrospective single center case series review. All 290 patients who underwent a cecostomy procedure between June 1994 and March 2009 were reviewed until March 2012 (average follow-up, 11 y; range, 3–18 y). Patients who had a Malone antegrade continence enema were excluded, and institutional research ethics board approval was obtained.
Data Collection Data were obtained from the hospital’s picture archiving and communication systems, interventional radiology database (Esh-IGT, Toronto, Ontario, Canada), and electronic patient charts. These records provided inpatient and outpatient clinic details, emails, and telephone documentation between patient families and the interventional radiology clinic nurse. Table 1 . Patient Demographics (N ¼ 290) Characteristic Mean age (y) ⫾ SD
Value 10.1 ⫾ 4.4
Sex Male Female
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Patient demographics (sex, age, underlying diagnosis, weight and height at primary cecostomy insertion, and tube exchanges) were obtained (Table 1). Each patient’s course was divided into early and late. The early period extended from the periprocedural phase until the initial pigtail catheter was changed to a longer-term low-profile tube, approximately 8 weeks after insertion. Periprocedural data included type of bowel preparation, antibiotics, insertion technique, and technical difficulties during the initial and first low-profile tube placement. The late period included follow-up and tube maintenance until March 2012 or tube removal. Early and late problems included difficulties with tube changes, tube dwell times, and bowel irrigation problems. Late outcomes included patient status at final review: continence achieved, tube removed, “graduation” to an adult facility, or death.
Device The initial device was an 8-F Mac-Loc pigtail catheter (Cook, Bloomington, Indiana). When the tract had matured (6–8 wk), it was replaced with a Chait Trapdoor cecostomy (Cook, Bloomington, Indiana), a lowprofile purpose-designed device (8 F). There were three tube lengths available for different tract lengths: 0–6 cm (short), 3–9 cm (medium), and 6–14 cm (long) (11) (Fig).
Technique Periprocedure Care. Bowel preparation regimens were employed to cleanse the bowel. An abdominal radiograph the morning of the procedure was used to assess residual fecal load. A previous contrast enema study was uncommonly employed to determine cecal position. Intravenous sedation or general anesthesia was used, and antibiotic prophylaxis was given intravenously. Abdominal and pelvic ultrasonography identified organ positions and any fluid collections (eg, ventriculoperitoneal [VP] shunt fluid). Intravenous glucagon 0.5–1.0 mg
170 (59) 120 (41)
Diagnosis Spina bifida with VP shunt Spina bifida without VP shunt
138 (48) 27 (9)
Imperforate anus
64 (22)
Vater syndrome Other
19 (7) 42 (14)
Weight o 3% 3%–25%
60 (21) 65 (22)
25%–75%
78 (27)
75%–97% 4 97%
70 (24) 15 (5)
NA
2 (1)
Values in parentheses are percentages. NA = not available, SD ¼ standard deviation, VP ¼ ventriculoperitoneal.
Figure. Permanent cecostomy tube. Trapdoor tube shown in different lengths called short, medium, or long according to the length of the straight component as highlighted by the arrows. Each tube comes with a unique adapter and connecting tube for use during irrigations. The low-profile tube lies flat against the skin, and the spring design provides its retention mechanism. (Available in color online at www.jvir.org.)
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(Eli Lilly, Scarborough, Ontario, Canada) was administered for bowel paralysis. The colon was distended by using an insufflator (E-Z-EM, Anjou, Quebec, Canada) through a rectal Foley catheter. The air column was followed with fluoroscopy until it reached the cecum. The cecum was punctured under fluoroscopic guidance with a Merit 18-gauge needle (Cook) preloaded with two pediatric retention anchor sutures (RASs; Cook). Intraluminal position was confirmed with contrast medium. A 0.035inch Amplatz guide wire (Cook) was used to deploy the two RASs. The tract was dilated to 8 F, and an 8-F pigtail catheter was placed. The position was confirmed by using fluoroscopy, contrast medium, and air. The tube was vented to decompress the cecum, and the thread
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of the RAS was secured. Some patients who underwent an open surgical procedure (eg, bladder augmentation) had their cecostomy tubes placed in the operating room by interventional radiologic means via a modified technique. Postprocedure analgesia included morphine (0.05 mg/ kg) or acetaminophen as needed (15 mg/kg). After bowel sounds returned, oral fluids were increased to diet as tolerated. The tube was kept vented and flushed twice daily with saline solution 5 mL, and the patient was discharged within 3–4 days after the procedure if afebrile, without pain, and tolerating food. Teaching regarding irrigations, tube care, and contact numbers were provided before discharge. Antegrade enemas were commenced 10 days after insertion.
Table 2 . Evolution of Cecostomy Tube Procedure over a Duration of 18 Years Practice Bowel preparation
Initial Approach (i) 25 mL/kg PEG electrolytes (PegLyte) via NG tube; (ii) oral 45 mL sodium phosphate
Current Approach
Changing to Phospho-Soda solution reduced
packet; 4 12 y, 1 packet
admission time before
solution oral laxative Prophylactic antibiotic preprocedure
Triples 5 d: ampicillin (20 mg/kg every 6 h), gentamicin (2.5 mg/ kg every 8 h), metronidazole (10 mg/kg every 8 h)
Needle puncture
18-gauge BSDN (Cook Medical, Bloomington, Indiana)
Immediate postinsertion Timing tube changes
Rationale for Change
Pico-Salix twice daily: r 6 y, 0.25 packet; 6–12 y, 0.5
procedure from 1 d to same-day admittance Cefoxitin only (30 mg/kg) IV
5-d course longer than in-
single dose or triple antibiotic if complicated
hospital stay; deemed unnecessary for
insertion
uncomplicated insertion
18-gauge Merit needle preloaded with 2 RASs
Sharper needle required for cecal puncture
Tube capped off postprocedure
Tube vented for first 10 d
Gaseous cecal distension– pneumoperitoneum
Replace Trapdoor catheter only
Replace Trapdoor catheter
Reduces pain/difficulty of
preloaded with 2 RASs
“as needed” when an issue developed
every 12–15 mo
changing catheters hardened with fecal residue
Technique of tube changes
Cut tube, place wire in old tube, advance new tube over wire, and push both into cecum
Removed old Trapdoor over Glidewire and advanced new one (exchange)
Issues: (i) non-Glidewire unraveling; (ii) tubes retained in cecum; (iii) tubes retained, not passed beyond surgical strictures
Adult care
Initially followed in pediatric hospital
Long-term catheter
Variety of balloons and prototypes
Transitioned to adult facilities at age 18 y Development of low-profile Trapdoor
Trapdoor catheters
Short (1998)
Long (1999), medium (2005)
available Glucagon
pediatric hospital in event of a complication Buttons stood proud of skin and caused difficulties with belts/trousers Variety of lengths based on distance from skin to cecum
Given 0.5–1 mg IV dose, repeat if needed
Irrigation solution
Difficulty to care for adults in
Phosphate-containing irrigation solutions
Same but checked blood sugar at 1 and 4 h later Saline solution alone or with mineral oil or glycerin
IV ¼ intravenous, NG ¼ nasogastric, PEG ¼ polyethylene glycol, RAS ¼ retention anchor suture.
Incidence of rebound hypoglycemia following glucagon Concern with phosphate toxicity
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Two weeks after the procedure, the patient attended the interventional radiology clinic when the RAS threads were cut, and any questions about their tube, irrigations, or site were addressed. Patients customized the enema routine to personal needs, with guidance from the interventional radiology clinic nurse. Evolution of practice regimens is noted in Table 2. The pigtail catheter was exchanged without sedation or antibiotics to a low-profile tube after 6–8 weeks as an outpatient procedure.
Late Period. Low-profile cecostomy tubes were exchanged by removal of the old tube and insertion of the new one over a Glidewire. Previously, this was performed by cutting the old catheter below the Trapdoor device, inserting a short straight wire into the cut tube, and pushing the old and new tube in series over the wire into the cecum (Table 2). The tube choice (short, medium, long) depended on thickness of the patient’s abdominal wall.
Outcome Measures Technical success was defined as placement of the pigtail catheter into the bowel in a position that functioned for colonic irrigation (eg, cecum or ascending colon). Technical failure was the inability to place the catheter into the bowel such that it was functional for colonic irrigation. Complications were divided into early (ie, periprocedure until placement of the low-profile device) and late (ie, following placement of permanent low-profile device). Complications were assigned according to the Society for Interventional Radiology classification system as minor (class A, no therapy; and class B, nominal therapy, overnight observation) or major (class C, therapy, hospitalization o 48 h; class D, major therapy, increased level of care, hospitalization 4 48 h; class E, permanent adverse sequelae; and class F, death) (12).
Statistical Analysis Data were analyzed by using SAS for Windows statistical software package (version 3.1; SAS Institute, Cary, North Carolina). Summary statistics were used to describe the patient cohort: χ2, Fisher exact test, and logistic regression were used for inferences (eg, between and within group associations). For linear regression analysis, log-transformation for nonnormal data was performed. A P value of .05 or lower was considered statistically significant.
RESULTS The technical success rate was 98%, as four of 290 insertions failed on the initial attempt. However, all were successful at a subsequent procedure.
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Early: Procedural Outcomes A single puncture was used in 265 of 290 insertions (91.4%), two punctures were used in 17 (5.8%), and more than two were used in two (0.7%). A combined open surgical procedure was employed in four patients (1.4%), and laparoscopy was employed in two (0.7%). In 259 patients (89%), the placement was uneventful. Technical difficulties encountered in 31 patients (11%) and included initial failure as described earlier (n ¼ 4), RAS thread break (n ¼ 4), peritoneal tube placement recognized and rectified immediately (n ¼ 5), small bowel needle puncture (n ¼ 2), extracecal tube placement (n ¼ 6: ascending colon, n ¼ 2; transverse colon, n ¼ 2; sigmoid colon, n ¼ 1; terminal ileum, n ¼ 1), minor spill at cecostomy tube site (n ¼ 1), more than one tube used (n ¼ 4), challenging anatomy (n ¼ 6), and loss of initial access (n ¼ 3). Tubes placed in the ascending and transverse colon (n ¼ 2) functioned adequately, whereas sigmoid and ileal tubes (n ¼ 2) recognized at 2 and 3 months, respectively, required replacement. This yields a technical success rate of 98% (284 of 290). Exchange to a low-profile device occurred in 280 of 290 patients. Six were lost to follow-up, two had early tube removals (colectomy for Hirschsprung disease, n ¼ 1; diagnosis of Munchausen syndrome by proxy, n ¼ 1), and there were two early deaths (r 6 wk). Exchange to a lowprofile tube placement occurred at less than 6 weeks (n ¼ 71), 6–10 weeks (n ¼ 115), 10–26 weeks (n ¼ 45), 26–52 weeks (n ¼ 18), or more than 52 weeks (n ¼ 27), and details were missing for four subjects. The exchange was uneventful in 257 of 280 patients (92%), whereas 23 (8%) experienced difficulties such as a need for sedation (n ¼ 12), problematic granulation tissue at the cecostomy site (n ¼ 4), tube dislodgment or migration (n ¼ 4), tube breakage (n ¼ 1), severe site pain (n ¼ 1), and steering the tube through the distal ileal stoma into the cecum (n ¼ 1). On Fisher exact test, no significant association was identified between patients with an uneventful primary insertion, difficult insertion, difficult subsequent tube insertions, and the variables of age, diagnosis, weight, height, body mass index (BMI), method of insertion, and tube exchange (P 4 .05). Those patients weighing less than the third centile were more likely to have difficulty during their low-profile tube insertion (Fisher exact test, P ¼ .004).
Late: Follow-up and Maintenance A total of 1,431 low-profile tube changes were performed in 258 of 280 patients (range, 1–18 per patient), with a mean of 1.6 ⫾ 1.3 (standard deviation) changes per 1,000 days. No significant associations between the number of routine changes and patient diagnosis, age, weight, height, BMI, method of insertion, or early complications were observed (P 4 .05, χ2 analysis). The majority of exchanges (1,244 of 1,431) were
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Table 3 . Minor Early and Late Complications Incidence
Complication Fever Peritonitis/peritoneal spill Gastrointestinal issues Continuing accidents/soils Cramping/pain Irrigation difficulty Vomiting, nausea, ileus Constipation
Early
Late
(n ¼ 139) 31
(n ¼ 1,092) 11
1
0
0
36
0
16
0 26
31 13
DISCUSSION
0
22
The most successful methods to manage fecal incontinence are those that completely evacuate the colon and regulate bowel movements, which avoid socially and psychologically embarrassing episodes of incontinence. The percutaneous cecostomy is effectively used in the management of the majority of patients and overcomes many problems experienced with a surgically performed appendicostomy (2–6,13–16). Since 1994, evolution in terms of techniques, devices, and medical management (Table 2) demonstrate the learning curve inevitable with a new procedure (2–4,15). The present study reports our experience with cecostomy tubes in a large pediatric cohort over a long follow-up. Patients whose weight was lower than the third centile (n = 60; 21%) were more likely to experience problems during their cecostomy catheter insertion. Two thirds of these patients had spina bifida, which is frequently associated with scoliosis and a protuberant abdomen. Cecal puncture in these patients is often difficult as a result of cecal position, mobility, and anatomic distortion, which necessitates a long oblique tract (8,17). Although cecostomies have been shown to be effective and safe to use in patients with VP shunts, there is an inherent risk of shunt infection (15,18). These infections can result from enteric content leakage as a result of a poorly sealed tract. This, in turn, can be avoided by providing a more secure cecal fixation. Alternative etiology includes proximity to the VP shunt tubing, which can be avoided by maximizing the distance from the VP shunt (18). A high number of complications were documented by thorough chart review. Although 30% of patients experienced early problems and 84% experienced late problems, this may represent an overcall, as all symptoms reported by the patient or caregiver(s) were included. Most early (139 of 149; 93%) and late (1,092 of 1,114; 98%) problems were minor tube, site, irrigation regimen, or bowel management problems that did not require medical intervention (2,3,5,6,15,16). Retraction of coils into the tract from growth, weight gain, or accidental pull make exchanges difficult. Upsizing the length as the child grows is important to avoid this problem. The use of different lengths of tubes has alleviated the problem of too-short devices (eg, coils in the tract creating a spiral) or too-long devices (eg, tube
Site issues Abscess
0
6
Bleeding
0
26
4 14
76 45
Granulation tissue Local inflammation/infection Leakage/discharge Pain at site Tract issues
10
116
27
100
Fistula
0
8
Tract loss Tube issues
0
2
Blocked tube
0
31
Broken/cracked tube Coils in tract
0 0
74 47
Stuck/retained old tube
0
14
Complete/partial dislodgment Tube removed
8 0
234 12
18
172
Other
(Table 3). The majority (n ¼ 1,092; 98%) were minor, with a complication rate of 1.9 per 1,000 tube-days. Twenty-two major complications (2%) occurred in 16 patients (Table 4). A major complication rate of 0.03 per 1,000 tube-days was observed. Fisher exact test showed no significant association between patients with and without late complications and the variables of age, diagnosis, weight, height, BMI, and method of insertion (P 4 .05).
uneventful, but a variety of patient, site, or tube problems were recorded in 187 cases (13%; Table 3). Forty patients had their cecostomy catheter removed because they achieved continence (n ¼ 12) or stopped using it (n ¼ 5), because of personal preference (n ¼ 5) or tract loss and decline of new insertion (n ¼ 1), and for unclear reasons (n ¼ 17). When reviewed, 141 patients graduated to an adult health care facility at a mean age of 20.8 years ⫾ 4.2.
Complications Early. Early problems after insertion were experienced in 85 patients (29%), 40 of whom had multiple problems (n ¼ 149), including 10 major complications (3%). The most common early minor complications (n ¼ 139) are summarized in Table 3. The major complications (n ¼ 10 patients) are detailed in Table 4. There was no significant association between patients with or without an early complication and the variables of diagnosis, age, weight, height, BMI, method of insertion, and difficulty at insertion (P 4 .05, Fisher exact test). Late. During the follow-up (total 463,507 tube-days in 234 of 279 patients [84%]), 1,114 problems occurred
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Table 4 . Major Early and Late Complications Experienced by Patients SIR Grade/Timing
Complication
Early
Incidence 10
C
Prolonged ileus, prolonged hospital stay Peritonitis, only IV antibiotics required
4 1
Tube dislodged, unable to reinsert, required new insertion (GA)
1
D
Peritonitis, pelvic abscess required drainage (GA) Peritonitis, VP shunt infected, VP shunt revision required (GA)
1 1
Peritonitis, VP shunt infected, VP shunt revision and abscess drainage required
1
F Late C
D
Peritonitis, quadriplegia, no abdominal signs/symptoms, death on day 1 despite IV antibiotics
1 22
Prolonged parastomal fistula, closed spontaneously
3
Stuck spiral Tube in tract, too painful to remove, required GA for exchange Early method exchange, retained old cecostomy tube in cecum, GA for colonoscopy to remove
2 1
Site abscess, required incision and drainage
1
Site infection, hospital admission and IV antibiotics 4 48 h required Anaphylaxis to tape
1 1
Severe excessive granulation, required excision under GA
1
Loss tract, unable to reinsert tube, entire new primary cecostomy insertion required Early method exchange, cut cecostomy tube stuck at sigmoid stricture, unable to pass; GA,
2 1
sigmoidoscopy to remove Difficult exchange, peritoneal spill, admission, IV antibiotics Seizure, from phosphate absorption, required ICU admission
1 2
Parastomal fecal fistula, cecostomy tube removed and new one inserted
1
Parastomal fecal fistula, failed attempt at Biodesign Fistula Plug, new primary cecostomy performed
1
Infection, hospital admission, 4 48 h antibiotics
1
Stuck coils in tract, unable to uncoil and remove, GA to exchange Severe dysmotility with severe abdominal pain, required hospital admission 7 d
1 1
Prolonged severe site discharge, old cecostomy tube removed, new cecostomy inserted
1
GA ¼ general anesthesia, ICU ¼ intensive care unit, IV ¼ intravenous, SIR ¼ Society of Interventional Radiology, VP ¼ ventriculoperitoneal.
protruding from the skin; Table 2). Mechanical failures such as catheter breakage, blockage, accidental dislodgment, or leakage were usually successfully exchanged through the preexisting tract without difficulty. Tubes were exchanged every 12–15 months, as hardening and encrustation of the tube occurred if it was left in situ too long. Tract problems of granulation tissue, inflammation, leakage, and bleeding were common, but site abscess was uncommon (19). Leakage around the tube can be reduced by slowing the flush of the enema solution (20). A parastomal cutaneous fecal fistula must be excluded. This may require removal of the tube to close the fistula or surgical excision of the fistula and tract. Vomiting, pain, and cramping can occur with phosphate-based enemas. Phosphate absorption occurred in three cases, two of which resulted in phosphate toxicity causing nausea, vomiting, and seizures that required intensive care unit admission. Although phosphate solutions have been reported to be safe and effective for colonic washouts in the pediatric community, toxicity is a concern especially in patients with renal impairment (21). We have now omitted all phosphate-based
purgatives from patient enema regimens. Irrigation regimens (eg volume, frequency, and additives) are tailored to the individual, with advice from a dietitian and cecostomy nurse. These myriad tube, tract, and irrigation regimen problems highlight the need for a multidisciplinary team approach for cecostomy management. Patient perspective of incontinence management was reviewed in a subset of these patients (n ¼ 124) in a previous publication (15). Dedicated experienced personnel or an encopresis team are invaluable in managing these issues. This patient population is too complex to be managed successfully by interventional radiologic means alone, and finding adult care programs for these aging patients is a major challenge. There are several limitations to the present study, which include its retrospective nature and possible overstatement of complications. Inevitable changes in operators, equipment, and clinical practice have been summarized in Table 2. Some data may be missing, especially from the early years, and this report did not include a quality-of-life or fecal incontinence score, as this has been previously addressed (15).
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In conclusion, the percutaneous cecostomy procedure has undergone extensive changes over the years. Our findings suggest it is a safe method for the management of fecal incontinence in children. However, this complex group of patients with myriad maintenance problems requires ongoing multidisciplinary supportive care.
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