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Fecal Incontinence and Severe Constipation

Program Director:
Fonkalsrud, Eric W. M.D.

Contact Phone Number
(310) 825-6712

Description of Clinical Program
The following discussion regarding the management of fecal incontinence and/or severe constipation is based on the experience from many reports in the medical literature, and from our own clinical experience with more than 40 children and 5 adults during the past 5 years at the UCLA Medical Center. Many physicians have remarkably little experience with the surgical management of these disorders.

What is chronic fecal incontinence?

Chronic fecal incontinence is involuntary fecal leakage with soiling which may occur while awake or during sleep. The leakage occurs even in the absence of diarrhea. Many patients will also have constipation. Incontinence occurs when the anorectal sphincter does not function normally, and/or when the colon does not contract normally to expel fecal contents.

What medical conditions are associated with fecal incontinence?

Children who have undergone corrective surgery for anorectal malformations (imperforate anus) or Hirschsprung’s disease often experience constipation and fecal incontinence even though the operation was performed properly. Patients with neurologic disorders of the pelvis, such as spina bifida, often experience constipation and incontinence. Persons with neurologic impairment of any type are also often constipated with incontinence. Persons with radiation to the intestine, or a variety of other conditions may also experience constipation and incontinence.

How can fecal incontinence and constipation be treated?

Many persons with constipation with or without fecal incontinence will benefit from stool softeners, modification of the diet to increase bulk, mineral oil, laxatives, rectal suppositories, and/or enemas. For those persons who continue to experience soiling or severe constipation despite these measures, or who find them too uncomfortable, a minor surgical procedure has recently been developed which has been successful in over 95 percent of patients.

What is the new operation for treating fecal incontinence?

Enemas given through the rectum are often uncomfortable, and unpleasant for the caregiver as well as the patient, despite causing fecal elimination in the majority of patients. In 1992 the technique of injecting enema solutions directly into the cecum (first portion of the colon) was first developed and was found to be more successful in causing fecal elimination than rectal enemas, while being much less painful and cumbersome. The initial operations sutured the appendix to the abdominal wall such that a catheter could be inserted through the appendix and into the cecum, when desired to flush in the enema solution. This procedure is called the Malone antegrade continence enema, or ACE technique.

Although highly successful in correcting fecal incontinence and chronic constipation, many patients found it difficult or painful to insert the catheter, or that fecal material occasionally leaked, or that inflammation developed around the appendix opening on the skin. It has also been found advisable to save the appendix for drainage of the bladder when necessary for patients with neurologic disorders. During the past 4 years, we have found that placing a small intravenous catheter into the cecum and then bringing it out through the skin a few inches away, provides a very simple and safe method of performing the ACE procedure. The catheter is soft silicone (the same as is used for long term intravenous fluid administration) and extends from the stem less than 2 inches. Patients are able to participate in almost all types of vigorous sports.

How long does the operation take?

The operation rarely takes more than 1 hour. Most patients will be discharged home within 2 days.

What type complications may occur?

Infection around the catheter occurs in less than 10 percent. An occasional catheter has been inadvertently dislodged weeks or months later in which case it is often possible to insert a guide wire, remove the catheter, and insert a new catheter over the guide wire. More severe complications, such as peritonitis, or bleeding are extremely uncommon.

How long does a patient need the catheter?

The catheter flushes are given once, or twice each day after a meal, using the volume of solution necessary to produce an evacuation within a few minutes. Within a few weeks the volume of the flush solution is gradually reduced, and eventually discontinued in many patients within several months when emptying may occur without stimulation. Some patients with severe neurologic disorders may benefit from having the catheters for a few years. Removal of the catheter is a small procedure similar to removing a central venous catheter and rarely takes more than 10 minutes.

How should we decide whether to have the catheter placed?

Discuss the options thoroughly with your family, physicians who are very familiar with the problem, and patients who have undergone placement of the catheter in the past.

Where can we obtain more information regarding placement of the antegrade continence enema catheter?

Fonkalsrud, Eric W. M.D.
Eric W. Fonkalsrud, M.D.
UCLA Medical Center
Department of Surgery
Los Angeles, CA 90095
Phone: (310) 825-6712
Fax: (310) 794-9462
Email: efonkalsrud@mednet.ucla.edu

Fonkalsrud EW, Dunn JCY, Kawaguchi AI: Simplified technique for antegrade continence enemas for fecal retention and incontinence. J Amer College Surg 187:457-460, 1998

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