Journal of Pediatric Gastroenterology & Nutrition:
Beckers, Goedele M.A.*; de Meij, Tim G.J.†
*Section of Pediatric Urology, Department of Urology
†Department of Pediatric Gastroenterology, VU University Medical Center, Amsterdam, The Netherlands.
Address correspondence and reprint requests to Goedele M.A. Beckers, Section of Pediatric Urology, Department of Urology, VU University Medical Center, de Boelelaan 1117, Room 4F029, 1081 HV Amsterdam, The Netherlands (e-mail: firstname.lastname@example.org).
Received 3 August, 2011
Accepted 9 August, 2011
The authors report no conflicts of interest.
We describe an endoscopic caecostomy with a Chait Trapdoor catheter in a patient with spina bifida who developed leakage of fluid and subsequent peritonitis due to insufficient anchoring of the caecum to the abdominal wall.
Colon cleansing by administration of antegrade enemas can be useful in severely constipated patients with spina bifida not responding sufficiently to retrograde bowel management. We present a 6-year-old boy with a history of spina bifida (L5-S1 level), hydrocephalus treated with a ventriculoperitoneal drain, tethered cord and concomitant chronic neurological bladder disorder, and severe faecal incontinence with constipation. The bladder disorder was treated with intermittent catheterisation; the constipation was treated with high doses of oral laxatives and retrograde colonic cleansing. Faecal incontinence worsened and the frequency of bowel movements decreased despite intensifying the retrograde bowel irrigation. Therefore, we decided to perform a caecostomy with an endoscopically placed Chait Trapdoor catheter to start antegrade bowel cleansing. After preparing the colon with Colopeg, a colonoscopy was performed under general anaesthesia, and after the caecum was reached, 1 set of paediatric anchors was placed under view as described (1). Antibiotic prophylaxis was given before starting the procedure (cefazolin 50 mg/kg and metronidazole 20 mg/kg). We proceeded by dilating the tract with an 8-F Coons dilator (Cook Medical, Bloomington, IN) and tried to insert a small Chait catheter stretched on its stiffener. During this procedure, the treat of the anchors broke at skin level and we were unable to advance the Chait catheter into the caecum. We replaced the paediatric anchors and dilatated the tract with a 10-F Coons dilator (Cook), and the small Chait catheter, stretched on a stiffener, was advanced in the caecum. The anchors broke again while advancing the catheter through the caecal wall; however, the catheter showed nice curls after removing the stiffener and the guide wire, and as the caecum seemed to be pulled well against the abdominal wall, it was decided not to replace the anchors for the third time. Antibiotics were continued intravenously for 24 hours. Six hours later, the catheter was rinsed with 100 mL of tap water and enteral feeding was restarted. On the first postoperative day, our patient developed abdominal cramps shortly after instilling the catheter with 100 mL of tap water, without any concomitant symptoms. Abdominal examination revealed no tenderness or pain at percussion, only some creptitation of the right abdominal wall, considered as a physiologic sign after the procedure. The next day, the boy started vomiting clear fluid. Abdominal examination revealed no abnormalities, besides the crepitating of the right abdominal wall. No further examinations were performed. Several hours later, the patient developed a crepitating mass in the right hemiscrotum and complained of interscapular pain. At this time, the abdomen was distended but not painful on palpation. Neurological examination was normal; the parents reported normal reactions. A plain x-ray showed extensive free intraabdominal air (Fig. 1). Under suspicion of bowel perforation or dislocation of the catheter, a laparotomy was performed. A large amount of pus was evacuated from the abdomen. There was no intraabdominal leakage of stool. We observed the catheter inserted through the caecal wall in the colon, but this had “fallen down” so that 1 curl of the catheter was pulled out of the caecum into the abdominal cavity. The catheter was reinserted and the caecum was fixed to the abdominal wall with absorbable sutures. Because of the large amount of intraabdominal pus, the ventriculoperitoneal drain was exteriorised. Antibiotics were restarted (cefazolin 50 mg · kg−1 · day−1 and metronidazole 20 mg · kg−1 · day−1). After 3 days, Klebsiella and extended-spectrum β-lactamase–positive Escherichia coli were cultured from the removed part of the ventriculo-peritoneal drain (VPD), so antibiotics were changed to meropenem for 3 days. The child recovered uneventfully. It turned out that he did not need the VPD anymore. Catheter rinsing was restarted with 10 mL of tap water twice per day, starting the day after surgery; after 5 days, the water amounts were augmented with 25 mL per rinse. Retrograde enemas could be stopped at the eighth postoperative day; the faecal incontinence stopped completely with 1 antegrade enema daily.
For effective bowel management in patients with spina bifida, most of the time, enemas are needed to resolve the problem of faecal incontinence (2). Caecostomy tubes have been shown to be a good alternative to retrograde bowel cleansing, with good patient and caretaker satisfaction (3). Catheter placement can be performed under fluoroscopic guidance, by laparoscopic guidance, or by colonoscopy (1,3,4). Large series document only a few major complications such as infections of ventriculoperitoneal shunts, which are greatly prevalent in children with spina bifida requiring antegrade bowel cleansing (1,5). To our knowledge, no complications are reported due to breakdown of the anchors during or shortly after the procedure. Leakage of fluid into the abdominal wall is mentioned by Chait et al (1) and is reported as a cause of early infection of a VPD in 1 child (5), but in reviewing the few cases described in the literature, the risk seems to be low.
Care must be taken regarding complications of abdominal surgery in patients with spina bifida. Because their abdominal sensation is changed due to their neurological abnormalities, peritonitis does not always cause abdominal tenderness. Doctors should be aware of this, especially when a VPD drains intraabdominally. Luckily, our patient did not develop meningitis and recovered well after laparotomy.
We are convinced that anchoring the caecum against the abdominal wall is crucial in this procedure. Because the paediatric insertion set for the Chait Trapdoor catheter is proposed with anchors with 5/0 threads attached to them, it is safer to use the adult anchors set, which are attached to thicker threads so that the risk of early breakdown is smaller. Furthermore, careful postoperative observation for clinical signs of ongoing intraabdominal leakage is of utmost importance because peritonitis can be masked by abdominal insensitivity in patients with spina bifida. Instillation of contrast media through the Chait catheter probably would have shown us the leakage earlier. In our opinion, it is safe to perform the endoscopic caecostomy procedure, provided that the caecum is anchored securely against the abdominal wall.
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