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132. Kongress der Deutschen Gesellschaft für Chirurgie

Deutsche Gesellschaft für Chirurgie

28.04. - 01.05.2015, München

Bowel management: What is the best method to keep children clean

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  • Viktoria Pfeifle - Universitätskinderspital beider Basel, Kinderchirurgie, Basel, Schweiz

Deutsche Gesellschaft für Chirurgie. 132. Kongress der Deutschen Gesellschaft für Chirurgie. München, 28.04.-01.05.2015. Düsseldorf: German Medical Science GMS Publishing House; 2015. Doc15dgch610

doi: 10.3205/15dgch610, urn:nbn:de:0183-15dgch6108

Published: April 24, 2015

© 2015 Pfeifle.
This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 License. See license information at http://creativecommons.org/licenses/by/4.0/.


Outline

Text

Introduction: Fecal incontinence is an often underestimated problem and has social and psychological impact to patients and also their parents. The main causes for fecal incontinence due to an organic reason in childhood are congenital anorectal malformations, Hirschsprung disease or spina bifida. The term bowel management is usually used for the treatment of fecal incontinence and refers to an individualized program with the aim to keep the patient artificially clean in the underwear. The main principle of bowel management is the administration of fluid to wash out the colon, so that the child can stay clean in the underwear in between two treatments without soiling. This can be done either by transanal irrigation or an antegrade continence enema which requires surgery.

Material and methods: A literature search was performed using the combination “bowel management” AND “children”, as well as “antegrade continence enema” AND “children”. Data, e.g. patient characteristics, type of Bowel Management, complications and outcomes, were extracted and collected in a datasheet using Excel.

Results: Literature search produced a total of 163 articles. After applying the exclusion criteria to the abstract review and a further exclusion after full text analysis due to inadequate data or bias, a total of 48 articles were accepted as suitable and therefore included. 12 studies were found using retrograde enema, whereas 34 studies used an antegrade way of enema administration, where a surgical approach was needed. 3 studies compared the outcome of antegrade to retrograde enema.

Data of 2630 individuals with a mean age of 10.7 years was collected. The underlying diseases were in most cases spina bifida (n=1030) and anorectal malformations (n= 1098), but also idiopathic constipation (n=193), Hirschsprung disease (n=59) and others like tumor or trauma (n=84).

When using a bowel management where the amount of fluid was determined by radiography, the success rate was 93% in children with hypomotility of the bowel and 88% in children with hypermotility and the tendency to diarrhea. When using a method to determine the volume of enema by ultrasound the success rate was 98.5% in cases with hypomotility and 59% in cases with hypermotility. In studies where the volume of enema was only estimated the overall success rate was 70.3%.

Only few complications were reported.

In studies that presented data of an antegrade continence enema, the overall success rate was 77.4%. None used an individualized determined amount of enema.

The most common complications were due to the stoma site. Rarely seen were more severe complications. Overall 163 patients had to undergo second surgery.

Conclusion: There is no evidence why an antegrade enema should work better than the retrograde administration of fluid and still, in many cases the indication for surgery for an antegrade enema was set when conservative bowel management with rectal irrigation failed. As long as there is no clear evidence that the way of administration matters, it is of great importance to show prior to surgery that bowel management works. Because of the need for major surgery and the significant complication rates, all conservative measures must be tried first. If the child’s quality of life can be improved, e.g. it feels more independent because it can administer the enema itself through its stoma or button a surgical approach for performing bowel management is justified. Furthermore, it might be a good option for those children that are already traumatised due to previous surgery or manipulation of the anal region.