Additional Bowel Management Strategies, Malone Procedure / Appendicostomy
In those cases of children who have a successful bowel management program, the parents frequently ask if this program will be needed for life. The answer is "yes" for those patients born with a poor prognosis type of defect. However, since we are dealing with a spectrum of defects, there are patients with some degree of bowel control; they are subjected to the bowel management program in order not to be exposed to occasional embarrassing accidents of uncontrolled bowel movements. However, as time goes by the child becomes more cooperative and more interested and concerned about his / her problem. It is conceivable that later in life, a child may stop using enemas and remain clean, following a specific regimen of a disciplined diet with regular meals (three meals per day and no snacks) to provoke bowel movements at a predictable time.
However there are some preliminary conditions to be followed before trying that:
- The child has to be completely clean with the bowel management followed until now. This means that parents (or the child) are able to understand if they had a proper bowel movement. In other words, the child or the parents have to be able to evaluate both the quantity and the consistency of the stool.
- The child is cooperative. The child has to be aware of his / her problem and motivated to experiment with new strategies to solve the problem.
- The main target of the bowel management is, as we said before, to improve the quality of life of our children and insert them in a social context without "accidents," especially at school
How to proceed
Every summer, the children with some potential for bowel control can try, on an experimental basis, (by trial and error) to find out how well they can control their bowel movements without the help of enemas. This is done during the summer vacations to avoid accidents at school at at time that they can stay home and try some of the strategies. Some of the fundamental points include:
- Reduced socialization: It is expected that parents and child will stay at home and socialize very little.
- Regular diet with a regular schedule: Since the child is not going to school it is easier to control his / her diet. It is very important that the child will have meals at a regular time in order to take advantage of the gastrocolic reflex.
- The child must sit on the toilet after every meal and try to pass stool.
- He / She must remain alert all day while trying to learn to discriminate the feeling of an imminent bowel movement.
- If the child belongs to the "constipated" group, it is advisable to give him / her a laxative every day in a single dose, to try to provoke an effect as controlled as possible; ideally that is a single bowel movement per day. The dose of the laxative is adjusted by trial and error. It is best to first try the less aggressive and natural types of laxative, and then, depending on the child's response, use medications with more active ingredients. The first choice, of course, must be a laxative type of diet; the next one is either a bulking forming type of product or else a stool softener. If this medication does not work, a laxative with an active ingredient is indicated. After a few days or weeks, the family and child are in a position to decide whether they want to continue with the new regimen or go back to the bowel management program. This decision is up to the family and the child and is based on the quality of life experienced with each type of method.
Most preschool and school-age children enjoy a good quality of life while undergoing the bowel management program. However, when they reach puberty, many express a high degree of dissatisfaction. They feel that their parents are intruding on their privacy by giving them enemas. It is feasible but rather difficult for them to administer the enema themselves. For this specific group of children, an operation called a continent appendicostomy or a Malone procedure has been designed.
It is important to stress that the Malone procedure is just another way to administer an enema. Before implementing the Malone procedure some preliminary conditions need to be met:
- The child has to be perfectly clean with his/her regular bowel management. It does not make sense to operate on child who is not successful with the bowel management in order to create another route to administer the enema.
- The child has to be absolutely motivated both in terms of the operation and the administration of the enemas as well as for his / her ability to evaluate the effects.
The operation consists of connecting the cecal appendix to the abdominal wall (usually at the belly button) and creating a valve mechanism that allows catheterization of the appendix but avoids leakage of stool through it. If the child has lost his/her appendix, it is possible to create a new one from the colon. This is called a continent neo-appendicostomy.
This procedure allows the child to administer an enema, inserting a small catheter into the orifce on the belly button while sitting on the toilet. The enema infusion enters the bowel pushing the stool forward. It is very easy and comfortable for any child.
