Small bowel ileal conduit antegrade continence enema in adults with constipation

BACKGROUND

The antegrade continence enema (ACE) procedure is used widely in paediatrics to treat constipation and faecal incontinence,¹ using the appendix or small bowel.² In postappendicetomy adult patients, we adopt a laparoscopic assisted approach utilising the terminal ileum (TI). Adults presenting with refractory constipation form a subset of complex patients who go through a robust treatment pathway involving a pelvic floor multidisciplinary team (PF-MDT) meeting, informed consent and regular follow-up maintained on the Unit’s database.

TECHNIQUE

Laparoscopic mobilisation of the caecum and preparation of a 10cm segment of TI is performed. A GIA60 (Covidien DTS Series, Crowley Park, Watford, Herts, UK) stapler is used to transect and construct the ileal tube (Figures 1–3). The distal end of the ileal tube is fashioned into the ACE stoma using a VY skin flap at a premarked area in the right iliac fossa. A catheter is left in the ACE conduit postoperatively for 4 weeks. The ileum is reconnected in circuit with an ileo-colic end-side anastomosis (Figure 2) proximal to the ileocaecal valve and the caecum is anchored to the anterior abdominal wall to prevent torsion.

Figure 1 .

Transection of the terminal ileum

Figure 3 .

Fashioned ileal conduit using terminal ileum

Figure 2 .

Ileal conduit fashioning using a GIA60 stapler

DISCUSSION

The ileocaecal valve is retained, which reduces the reflux discharge from the stoma, and the skin flap decreases the incidence of ACE stomal stenosis. The procedure involves a reconstruction with one anastomosis, hence decreasing morbidity. In addition, the laparoscopic technique aids in assessment, mobilisation and a faster recovery.