Laparoscopic Approach to Enteral Access for Chronic Constipation

Constipation is a common problem and represents up to 25 % of pediatric gastroenterology clinical practice. A subset of these children will develop chronic intractable constipation (CIC), which is refractory to medical therapy with the exception of frequent enemas to accomplish fecal evacuation. For patients who demonstrate compliance with these regimens, enteral access for administration of antegrade continence enemas (ACE) can provide greater independence and increased quality of life. Malone popularized an appendicostomy with a continence valve mechanism initially, which was later modified to be performed laparoscopically. Variations of this procedure have been developed to establish enteral access for patients with a surgically absent appendix, establishing a neo-appendix from colonic or ileal segments. Further methods utilize surgical endoscopy and hybrid endoscopic/laparoscopic techniques to place commercially available cecostomy tubes. In general, procedures are well tolerated and recovery is rapid. However, in many cases, establishing enteral access imposes a lifelong commitment to ACE administration; thus careful patient selection and patient education are necessary to maximize odds of success.