Advances in pediatric colorectal surgical techniques
Section snippets
Fecal incontinence
Fecal incontinence is a devastating problem that affects several children who have undergone complex colorectal operations (eg, repair of high ARMs), and others with primary conditions or injuries involving the spinal cord. Successful management of fecal incontinence hinges upon differentiating between true incontinence and that associated with severe constipation (encopresis or pseudoincontinence). This distinction is crucial as patients with pseudoincontinence often have the capacity for
Early experience with the ACE procedure
The first ACE procedure was described by Malone et al2 nearly 3 decades ago. The original description involved amputating and reversing the appendix, and then reimplanting it into a submucosal tunnel within the cecum to create a nonrefluxing conduit.2 Later modifications included in situ (nonreversed) implantation of the appendix and fenestration of the appendiceal mesentery to prevent the antireflux mechanism from compromising the appendiceal blood supply.3, 4 Still others proposed a less
Technical considerations in the prevention of stomal stenosis
The relatively high rate of stenosis in earlier reports led to the development of novel tissue-flap techniques in an effort to reduce the incidence of this complication. These have included the Y-appendicoplasty,6 the Y–V umbilicoplasty,7, 8 the V-quadrilateral-Z (VQZ) flap,9 and the umbilical tubular skin flap,7 among others. The rates of stenosis using these techniques have been reportedly < 10%, but meaningful comparison between these techniques is made difficult because of the marked
Cecoplication, leakage, and the emergence of laparoscopy
The need to create an antireflux valve to prevent stomal leakage remains controversial and has not been examined in a prospective manner. In the 2 largest reported experiences of ACE procedures where cecoplication was routinely performed, leak rates were observed in 3% and 7% of patients, with a median follow-up of at least 2.5 years.5, 12 Several centers have since reported their experience using ACE procedures without cecoplication, and this has largely been driven by the introduction of
ACE procedures in patients with a missing appendix
In the case where the appendix is missing, the 2 main options for constructing an ACE conduit include the tubularized cecal flap4, 19 and the Monti procedure.11 The cecal flap involves the creation of a neoappendix from a tubularized piece of cecum along its medial wall. The neoappendix is then imbricated into the cecum to create an antireflux valve. The cecum is mobilized medially so the neoappendix can be brought up to the abdominal wall where it is attached as a catheterizable stoma to the
Idiopathic constipation
Constipation is a common problem in the pediatric population, which can often be managed through dietary modifications and medical therapy. In the small subset of patients where symptoms are particularly severe, such as those who develop overflow incontinence (encopresis), management may require excessively high doses of laxatives to empty the colon and prevent soiling.1 Such high doses of laxatives can be associated with severe cramping and abdominal bloating, rendering the quality of life
Transanal resection
The use of a transanal approach in the operative management of intractable constipation was first described by McCready and Beart26 nearly 3 decades ago. Since that time, several case reports and small case-series have described the use of transanal techniques in both the adult and pediatric populations.30, 31 The main advantages of this approach include the ability to completely excise the rectum in patients with severe rectal dilation and hypomotility, and the need for only a single coloanal
Vertical reduction rectoplasty
The vertical reduction rectoplasty is a novel technique that involves partial excision of the dilated rectum with the goal of reducing rectal capacity without the need for complete resection.33, 34 The technique was developed with the premise that reducing rectal capacity and compliance would restore perception of rectal fullness, improve rectal sensory function, and improve the ability to evacuate. The vertical reduction rectoplasty was developed to accomplish these goals while avoiding the
Other considerations in the operative treatment of fecal incontinence
The armamentarium of operative strategies available to treat refractory constipation continues to grow for the pediatric surgeon. However, along with the continued evolution of surgical technique, further investigation is needed to determine which patients are most likely to benefit from a resective procedure. In this regard, there currently exists little consensus in the published data regarding the indications for operative management, particularly with the utility of manometry, contrast
Anorectal malformations
Over the past few decades, the posterior sagittal anorectoplasty (PSARP) has emerged as the preferred approach for repairing ARMs for most pediatric surgeons.37 The procedure is performed in the prone position and a midsagittal incision is used to divide the subcutaneous tissues, parasagittal fibers, muscle complex, and levator muscle equally along the midline. By staying in this plane, the technique provides excellent exposure while avoiding injury to the lateral aspect of the sphincter
Laparoscopy
Over a decade ago, Willital40 first described the use of laparoscopy in the repair of ARMs. Georgeson et al41 subsequently popularized the technique in the way of the laparoscopically assisted anorectal pull-through (LAARP) procedure, a technique that offered an approach for repairing ARMs without the need for an extensive perineal dissection. As with many new surgical techniques, the “indications” for the LAARP expanded quickly across the entire spectrum of ARMs, even including cloacal
Anterior sagittal anorectoplasty and other “sphincter-saving” techniques
In 1992, Okada et al52 described a less invasive perineal approach for repair of ARMs known as the anterior sagittal anorectoplasty (ASARP). The ASARP has largely been used for the repair of rectoperineal and rectovestibular fistulas, as well as a potential reoperative approach to previously repaired ARMs. Similar to the PSARP, the incision is oriented along the sagittal plane but is limited to the anterior portion of the muscle complex, leaving the posterior perineum intact. A circular
Total mobilization of the urogenital sinus
Repair of the cloacal anomaly remains the most challenging among all ARMs. The operative techniques used for the repair are extensively described elsewhere, and we will only briefly review them here. In this regard, early operative techniques attempted to completely separate all 3 structures proximal to the common channel, which often presented a technically challenging endeavor. Complications were frequent, and the development of vesicovaginal and urethrovaginal fistulas were not uncommon.57
Hirschsprung disease
The surgical options for Hirschsprung disease (HD) have evolved considerably over the last decade. Before this, operative management predominately involved a leveling colostomy, followed by an interval segmental resection of aganglionic bowel, and then ultimately closure of the diverting stoma. A multitude of techniques have been described for the definitive procedure, with the most popular being various modifications of the Swenson, Soave, and Duhamel procedures. Functional outcomes appear to
Transanal resection
Over the past decade, the transanal endorectal pull-through (TERPT) has emerged as the most popular procedure for the treatment of HD. The advantages of this approach include avoiding the morbidity associated with a transabdominal incision, and the obvious cosmetic benefit with using an entirely transanal technique. In performing the TERPT, the dissection begins between 0.5-1 cm above the dentate line. Initiating the dissection too close to the dentate line can damage the anal canal and
Laparoscopy
The use of laparoscopy to facilitate a pull-through procedure for HD was first reported by Smith et al80 in 1994. Following the initial description, a multitude of case reports and case-series have described further modifications and technical refinements. The potential advantages of the laparoscopic-assisted techniques over conventional procedures include less morbidity, shorter hospital stays, and superior cosmetic results. As a result, many surgeons have developed a laparoscopic approach
One-stage procedure
Historically, operative management for HD involved a 2- or 3-stage procedure. Beginning in the mid-1990s, one-stage primary pull-through procedures were reported with excellent early results. With the subsequent evolution of minimally invasive techniques (laparoscopic and transanal), and the associated promise of reduced morbidity and shorter recovery times, the enthusiasm for single-stage procedures grew tremendously. Although early reports suggested a higher rate of postoperative
Conclusion
Over the past decade, we have witnessed considerable evolution in the surgical management of pediatric colorectal diseases. This has largely been driven by a more thorough understanding of the anatomical basis and pathophysiology underlying these conditions and by the continued advances in minimally invasive technology. Parallel with this evolution, we have also witnessed significant improvements in the care of our surgical patients, including reduced operative morbidity, improved functional
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Pediatric fecal incontinence
Appendiceal cecoplication: a modification of the Malone antegrade colonic enema procedure
Tech Urol
Continent urinary diversion
Laparoscopy in the management of fecal incontinence and constipation
Superiority of the VQZ over the tubularized skin flap and the umbilicus for continent abdominal stoma in children
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A high easy-to-treat complication rate is the price for a continent stoma
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Laparoscopic antegrade continent enema through VQ stoma skin flaps using two ports: long-term follow-up
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Cited by (22)
A comparison of Malone appendicostomy and cecostomy for antegrade access as adjuncts to a bowel management program for patients with functional constipation or fecal incontinence
2019, Journal of Pediatric SurgeryCitation Excerpt :The most common complication experienced by patients who underwent Malone was stenosis. The rate of reported stenosis after appendicostomy varies widely in the literature and may approach 20% [16–18]. Our stenosis rate of 13% is slightly lower than this.
First results of a European multi-center registry of patients with anorectal malformations
2013, Journal of Pediatric SurgeryDuhamel pull-through assisted by transrectal port: A hybrid natural orifice transluminal endoscopic surgery approach
2012, Journal of Pediatric SurgeryCitation Excerpt :Transanal endorectal pull-through (TERPT) has emerged as one of the most popular procedures for the treatment of HD. Although there are advantages to this approach, one potential problem in the TERPT is the overstretching of anal sphincters during the endorectal dissection and anastomosis [6]. Laparoscopic Duhamel procedure avoids anal canal stretching because the pull-trough is performed by a rectorectal approach, which might be an advantage compared with TERPT.
Surgical treatment for constipation in children and adults
2011, Best Practice and Research: Clinical GastroenterologyCitation Excerpt :Some authors have placed the button in the left colon, but impaction can occur in the proximal colon. Success rates amongst the various studies vary [13–18]. However, it is vital to remember that the Malone procedure is just another way to administer an enema in an antegrade instead of retrograde fashion and therefore, before performing it, the child has to be clean with a bowel management regimen.
Laparoscopic-assisted versus complete transanal pull-through using Swenson technique in treatment of Hirschsprung’s disease
2023, Annals of Pediatric Surgery