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A Retrospective Review of Surgical Outcomes in Patients that

Underwent a Malone or Neo-Malone Appendicostomy

Tiffany Edmonds, BSN, RN, CPNNurse Care CoordinatorJennifer Hall, RNResearcher

Disclosure

No Disclosures

Objectives

1. Identify the criteria for surgical creation of a Malone appendicostomy

2. Describe pre- and post-operative management in caring for a patient with a Malone

3. Know the surgical outcomes for patients considering a Malone procedure

4. Review the data of Malone procedures performed at Children’s Hospital Colorado within the last two years

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• International Center for Colorectal and Urogenital Care (ICCUC)

• Patients have history of:•Anorectal Malformation•Hirschsprung’s Disease•Spina Bifida •Sacral Agenesis•Chronic Idiopathic Constipation•Fecal Incontinence due to other anomalies

Background

• The patient has no potential for bowel control• Will need enema for life • Bowel Management Week

• Week long process of trial and error• Contrast enema to begin• Daily abdominal radiographs• Daily patient/parent reports• Daily enema adjustments• Starts with rectal enemas• Offer Malone procedure after successfully completing program

True Fecal Incontinence

• Antegrade continent enema (ACE)• Option offered only after proven successful with rectal

enemas• Allows independence in the administration• Appropriate for patients needing long term enema

management

Why a Malone?

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Malone

Malone

Neo-Malone

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Neo-Malone

Neo-Malone

Neo-Malone

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Neo-Malone

Neo-Malone

Malone

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Malone

Malone procedures• 47 Total Appendicostomies• (39 Malones, 8 Neo-Malones)

• Ave Age: 10Y, 4Mon (Max Age: 23Y, 6Mon; Min Ave: 2Y, 11Mon)

• Diagnoses Included:• (25) Anorectal Malformations• (14) Spinal Malformations• (4) Fecal Incontinence d/t developmental delay• (3) Hirschsprung’s Disease• (1) Idiopathic Constipation

Pre- operative• Malone

• If appendix is present: no bowel preparation • If unsure on status of appendix, can check abdominal ultrasound • Admit postoperatively

• Neo-Malone• If appendix is not present: bowel preparation needed

• Admit day prior to surgery• Golytely

• Nasogastric tube• 25 ml/kg/h for 4 hours (repeat until stool is clear yellow)• Clear liquids • NPO 2 hours prior to the procedure

• IV fluids

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Post- operative• Malone

• Start clear liquids the next day• Antibiotics for 24h• Keep catheter in place for one month• May start giving the enema through the catheter 24 hours after the first

normal meal• Neo-Malone

• Start clear liquids when no abdominal distension• Antibiotics for 24-48h• Keep catheter in place for a month• Small volume enemas 2x/day (rectal vs. catheter)

Case Study

• 8 year old male, adopted from China• History of anorectal malformation (repaired in China), right renal

hydronephrosis, recurrent UTI, chronic constipation, and fecal incontinence

• Initially came through bowel management week on rectal enemas

Contrast enema

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Rectal enemas

• Admitted for 2 days of disimpaction

• 500 ml saline + 40 ml glycerin + 27 ml castile soap

• Patient lost to follow up for 6 months

6 Months Later

• X-ray showed constipation• Repeated bowel management

week• 500 ml saline + 50 ml glycerin

+ 27 ml castile + 1 pediatric fleet + 10 ml bisacodyl

Surgery

• Sigmoid resection offered in conjunction with a Malone procedure

• Patient will be incontinent and need enemas for life due to underlying anorectal malformation

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Post- operative

• Catheter coiled in the colon• Started on 3 squares of

Senna• Follow up in clinic

2 Week Follow Up

• Malone catheter remained coiled in the colon

• X-ray clean of stool• Continue laxatives

3 Week Follow up X-ray

• Fecal impaction• Malone catheter no longer

coiled• Begin small volume enemas

two times a day• 300 ml saline + 50 ml glycerin

+ 27 ml castile soap

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4 Week Follow Up

• No fecal impaction• Removed Malone catheter

and taught parents how to access the Malone

• Begin large volume enema once a day

• 500 ml saline + 60 ml glycerin +36 ml castile soap

Follow Up X-ray

• Clean rectum and left colon• Patient tolerating enemas• No fecal accidents• Parents and patient extremely

satisfied with decision for Malone

• Close follow up with frequent x-rays

Data Summary

30 Day Post-Op Period

4 (8.5%) Complications:• (2) Wound Infections• (1) Mucosal Prolapse• (1) Seroma

Ave Time Post-Op = 7 Days

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Data Summary

Long-term Follow-up

7 (21%) Reoperations• (3) Strictures (one also with leakage)• (2) Mucosal Prolapse (one also with leakage)• (1) Atresia• (1) Difficult Catheterization

Ace Stopper• 6 months post-operatively

Summary

Ave Time Post-Op = 8.4 Months*Note: 50% of reoperations occur in the first 3 Months

• Implement use of the ACE stopper to prevent stricture/atresia

• Provide appropriate counseling to families considering a Malone procedure

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ReferencesPeña, A., & Bischoff, A. (2015). Surgical Treatment of Colorectal Problems in Children. Switzerland: Springer.Chatoorgoon, K., Peña, A., & Lawal, T. (2011). Neoappendicostomy in the management of pediatric fecal incontinence. Journal of Pediatric Surgery, 46, 1243-1249.Rangel, S.J., Lawal, T.A., & Bischoff, A. (2011). The appendix as a conduit for antegrade continence enemas in patients with anorectal malformations: Lessons learned from 163 cases treated over 18 years. Journal of Pediatric Surgery, 46, 1236-1242.

Thank You!Questions?