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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?