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Introduction: The antegrade continence enema (ACE) has been shown to be a safe and effective method for managing fecal incontinence in the pediatric population. The purpose of this study was to examine our experience with the ACE procedure using the appendix as a catheterizable conduit in children with anorectal malformations (ARMs)., Methods: We reviewed the charts of all patients who underwent an ACE procedure using the appendix as a catheterizable conduit between January 1992 and January 2010. Preoperative diagnosis (ARM type), operative details, functional outcomes, and postoperative complications were assessed. Technical modifications over time included selective cecoplication, implementation of the umbilical V-V appendicoplasty technique, and laparoscopy for cecal mobilization., Results: Mean age was 9.9 ± 0.6 years, and 67% were male. The most common preoperative diagnosis was rectourethral fistula in boys (39%) and persistent cloaca in girls (61%). Forty-five complications occurred in 41 patients with an overall incidence of 25.6% (stricture, 18%; leakage, 6%; prolapse, 4%; intestinal obstruction, 0.6%). The incidence of stomal leakage was lower in patients when a cecoplication was performed (2.9% [4/138] vs 29.4% [5/17]; P < .01), and the incidence of stricture was lower in patients when the umbilical anastomosis was created using the V-V appendicoplasty technique (11% [11/100] vs 30% [18/60]; P < .01). Successful management of incontinence was reported by 96% of all patients., Conclusions: The ACE procedure using the umbilical V-V appendicoplasty provides an effective and cosmetically superior means for bowel management in children with ARMs. The rate of late complications is not insignificant however, and preventative strategies should focus on careful operative technique and ensuring compliance with catheterization protocols well past the initial postoperative period., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Purpose: The Malone appendicostomy, for antegrade enemas, has improved the quality of life for many children with fecal incontinence. In patients whose appendix has been removed, a neo-appendix can be created. We describe our approach and experience with this procedure as an option for surgeons managing children with fecal incontinence., Methods: The procedure involves creating a transverse flap of cecum that receives its blood supply by a transverse mesenteric branch. This flap is then tubularized around a feeding tube. The surrounding colon is plicated around the neo-appendix to prevent leakage of stool. The tip of the flap is then anastomosed to the deepest portion of the umbilicus. We reviewed our experience with this procedure, including results and complications. IRB approval was obtained., Results: Eighty patients required a neo-appendicostomy. Sixty-six patients (82%) had an anorectal malformation, four had spina bifida, and ten had other diagnoses. The reasons for not having an appendix available included: "incidental" appendectomy (34, 42.5%), use of the appendix for a Mitrofanoff procedure (20, 25%), and Ladd's procedure (5, 6%). In fifteen patients (19%) we could find no appendix and assume that it was removed previously. Following neoappendicostomy, nine patients (11%) developed a stricture, and seven patients had leakage (9%). In 2004, we modified the appendiceal-umbilical anastomosis and among these patients, only one patient (3%) developed a stricture, compared with eight patients (18%) without the modification. All seven patients with leakage were within the first forty cases. No patient in the last forty cases had a leakage., Conclusions: In patients with the potential for fecal incontinence, the appendix should be preserved. In patients without an appendix, the neo-appendicostomy is a valuable tool for fecally incontinent patients. We have found that the V-V anastomosis had a reduced rate of stricture, and the rate of leakage seems to be related to surgical experience., (Copyright © 2011 Elsevier Inc. All rights reserved.)