Long-term follow-up of patients after antegrade continence enema procedure

Abstract

Background: Antegrade continence enema (ACE) has become an important therapeutic modality in the treatment of intractable constipation and fecal incontinence. There are little data available on the long-term performance of the ACE procedure in children.

Methods: A retrospective review of patients who underwent the ACE procedure was conducted. Irrigation characteristics and complications were noted. Outcome was assessed for individual encounters based on frequency of bowel movements, incontinence, pain, and predictability.

Results: One hundred seventeen patients underwent an ACE. One hundred five patients had at least 6 months of follow-up, and were included in the analysis. Diagnoses included myelodysplasia (39%), functional intractable constipation (26%), anorectal malformations (21%), nonrelaxing internal anal sphincter (7%), cerebral palsy (3%), and other diagnoses (4%). The average follow-up was 68 months (range 7-178 months). At the last follow-up, 69% of patients had successful bowel management. Of the 31% of patients who did not have successful bowel management, 20% were using the ACE despite suboptimal results, 10% required surgical removal, and 2% were not using the ACE because of behavioral opposition to it. Patients were started on normal saline, but were switched to GoLYTELY (PEG-3350 and electrolyte solution) if there was an inadequate response (61% at final encounter). Additives were needed in 34% of patients. The average irrigation dose was 23 ± 0.7 mL/kg. The average toilet sitting time was 51.7 ± 3.5 minutes, with infusions running for 12.1 ± 1.2 minutes. Stomal complications occurred in 63% (infection, leakage, and stenosis) of patients, 33% required surgical revision and 6% eventually required diverting ostomies.

Conclusions: Long-term use of the ACE gives successful results in 69% of patients, whereas 63% had a stoma-related complication and 33% required surgical revision of the stoma.

Figure 1

ACE assessment scheme. Each domain is assessed from left to right. For example, a patient with pain cannot be better than “poor.” A patient who is unpredictable cannot be better than “fair.” If the patients had stoma closure because of lack of response, then they were considered in the “poor” category. ACE = antegrade continence enema.

Figure 2

Percentage of successful management before and after the antegrade continence enema. There was significant improvement in the overall population, the functional intractable constipation, myelodysplasia, nonrelaxing IAS, and anorectal malformations group. IAS = internal anal sphincter.

Figure 3

Kaplan-Meier curve for relapse-free probability. The mean time for the first relapse was 88.4 ± 4.9 months.