T. O. Xu1, R. E. Hanke1, T. L. Russell1, M. Rana1, C. P. Ho1, B. K. Varda1, E. A. Teeple1, A. Badillo1, M. A. Levitt1, C. Feng1 1Children’s National Hospital, 1Divisions Of Urology And Colorectal/Pelvic Reconstruction, Washington, DC, USA
Introduction: Soiling following a Hirschsprung (HD) pull-through is not uncommon and treatment options vary without a consistent protocol. We investigated the use of antegrade continence enema (ACE) creation in HD patients who continue to soil to identify the timing and factors associated with getting the patient clean.
Methods: We performed a single institution, retrospective review of patients from 1/2020-1/2023 with HD and prior pull-through who presented with persistent soiling and were treated with antegrade enemas. Patients chosen for ACE did not tolerate or respond to laxatives or rectal enemas. The primary outcome was time to become “clean of stool” which was defined as at least one bowel movement per day, less than one stool accident per week, and no significant radiographic stool burden. Kaplan-Meier survival analysis was performed, and univariate cox proportional hazard regression was used to assess factors associated with time to continence.
Results: Thirty patients underwent ACE creation at median age of 6.5 years (IQR 5.3-9.8) with median follow-up time of 11.5 months (IQR 5.6-16.5). Most patients became clean by 4-month (13/20, 65%) and 1-year follow up (16/21, 76%). The median time to become clean was 4.3 months (95% CI: 1.7-15.0). A higher proportion of patients with a descending colon or rectosigmoid transition zone achieved continence at 4 months (92% vs 43%, p<0.03) although there was no difference at 1-year. A higher proportion of patients with hypermotility continue to soil at 1 year compared to those without hypermotility (80% vs 13%, p=0.01). There was no difference in botox usage, and no factors were significantly associated with time to cleanliness on regression analysis.
Conclusion: ACE is a useful modality for HD patients with soiling, most became clean of stool in 4 months. A higher proportion of patients that achieve continence at 4 months have descending or rectosigmoid disease and a higher proportion of patients that were still soiling at 1 year have hypermotility.
