Advances in the Management of Colostomy and Incontinence
Each year in the United States, an estimated 600 children, approximately 1 in every 4,000 babies, are born with malformations of the anus and/or rectum. The anus is the opening at the end of digestive tract where stool exits the body and the rectum is the final section of the large bowel leading to the anus. Children born with defects of the anus and rectum (anorectal malformations), can benefit from surgical and nonsurgical treatment approaches.
Most patients born with anorectal malformations receive a colostomy at birth and subsequently the malformation is repaired within the next eight months or so. A colostomy creates an artificial anus (stoma) to allow feces to pass out of the body and into a stoma bag.
After the malformation has been repaired, the quality of life of children with anorectal malformations can be further improved through bowel management. The goal of a bowel management program is to help patients with fecal incontinence (the inability to voluntarily control the bowels) keep their bowels clean 24 hours per day and prevent problems that could lead to social isolation. The rate of success is high; 95% of patients who adhere to the Bowel Management Program are able to keep their bowels completely clean.
Developing Individualized Plans
To develop an individualized bowel management plan for each patient, the child is first evaluated to determine current colonic motility—how food moves through the colon. Patients with fecal incontinence can be classified into two major groups: those that suffer with constipation and those that tend to have diarrhea. Each group is managed completely differently.
For children with constipation, the treatment emphasis is on using large enemas capable of cleaning the entire colon every day. In general, these patients do not need any special diet or medication. The slow movement of wastes through the colon guarantees that the patient will stay completely clean 24 and sometimes 48 hours in between enemas.
Children with a tendency to diarrhea receive a rather small enema because their colons are easy to clean. After the enema, these children then must follow a special constipating diet and medication to slow the motility of the colon and guarantee that they stay clean in between enemas.
The Bowel Management Program is implemented by trial and error over a period of one week with daily visits to the office of the Colorectal Center at Cincinnati Children's Hospital Medical Center. X-ray films are taken every day to see how clean the colon is maintained.
Optional Procedures Depend on Success of Management Plan
Once the bowel management program is shown to be successful, the patient can have an operation called a continent appendicostomy (Malone procedure). The operation connects the appendix (a small pouch attached to the large intestine) to the navel and creates a one-way valve mechanism. This allows a small catheter (a thin, flexible tube) to be passed through the navel so the child can receive an enema while sitting on the toilet, but the valve prevents leakage of stool at other times. About 10% of patients undergoing this procedure require a revision to make the opening a little larger to allow for the catheter, or to tighten the valve to avoid leakage of stool.
The purpose of this operation is to improve the quality of life of these patients, particularly later on when they become teenagers, by allowing them to become more independent. This operation is performed only if the bowel management program is successful. Bowel management is not successful in about 5% of patients. These patients are offered the option of a colostomy.
