A systematic review on bowel management and the success rate of the various treatment modalities in spina bifida patients

Velde SV, Biervliet SV, Bruyne RD, Winckel MV. (2013). A systematic review on bowel management and the success rate of the various treatment modalities in spina bifida patients.

Spinal Cord. 2013 Oct 15. doi: 10.1038/sc.2013.123. [Epub ahead of print]

Abstract

Study design:Systematic review.Objectives:To determine the different treatment modalities aimed at achieving fecal continence in spina bifida (SB) patients and their effectiveness.Setting:International literature.Method:Electronic databases were searched ('Pubmed', 'Web of science', 'CINAHL' and 'Cochrane') identifying studies published since the mid-eighties and screened for relevance according to the Centre for Reviews and Dissemination procedure guidelines. A total of 37 studies were selected for inclusion.Results:Studies on toilet sitting, biofeedback, anal plug, retrograde colon enemas (RCE) and antegrade colon enemas were found. Fecal continence was achieved in 67% of SB patients using conservative methods (n=509). In patients using RCE (n=190) an 80% continence rate was reached. Patients following surgical treatment (n=469) reached an 81% continence rate, however, 23% needed redo surgery because of complications. Better fecal continence was associated with an improved quality of life, which was negatively influenced by the amount of time spent on bowel management.Conclusion:Evidence favors an individually tailored stepwise approach with surgery as a final step in case of failure of conservative measures. Continued specialized support throughout life remains important to maintain continence. Cross-over and comparative trials are needed in order to optimize treatment.Spinal Cord advance online publication, 15 October 2013; doi:10.1038/sc.2013.123.

 

PMID:24126852

Achieving Fecal Continence in Patients With Spina Bifida: A Descriptive Cohort Study

Velde SV, Biervliet SV, Renterghem KV, Laecke EV, Hoebeke P, Winckel MV. Achieving Fecal Continence in Patients With Spina Bifida: A Descriptive Cohort Study. Journal of Urology. 2007 Oct 16; [Epub ahead of print]

PURPOSE: Fecal incontinence is a major problem in patients with myelomeningocele. We evaluate the results of a stratified approach aimed at obtaining fecal pseudo-continence in patients with myelomeningocele.

MATERIALS AND METHODS: We conducted a cross-sectional descriptive study of last file data in 80 patients 5 to 18 years old with myelomeningocele followed at our center. Beginning at birth patients with myelomeningocele were seen at least annually by the pediatric gastoenterologist, a member of the multidisciplinary "spina team." Constipation was treated with diet and osmotic laxatives. Starting at age 5 years, treatment was targeted at achieving pseudo-continence. A toilet training scheme was started, associated with induced defecation by digital stimulation. Retrograde tap water enemas were used in patients with unsatisfactory results. If retrograde enemas were unsuccessful, an antegrade continence enema procedure was proposed. For children unable to sit on a toilet regular manual evacuation of stools was advised.

RESULTS: Eight of the 80 patients were fecal continent. Pseudo-continence was achieved in 50 of the 72 incontinent patients (69%), including 5 of 5 following only a strict toilet scheme, 21 of 24 (87.5%) performing retrograde enemas, 16 of 20 (80%) performing orthograde enemas through an antegrade continence device and 8 of 10 performing regular manual evacuation of stools. In 4 of the 20 patients (20%) performing orthograde enemas complications led to closure of the antegrade continence device. Treatment failed and was stopped in 17 patients. Success of treatment was not related to level of spinal lesion or degree of mobility.

CONCLUSIONS: Fecal pseudo-continence was achieved in 58 of 80 patients (72.5%) with myelomeningocele.

PMID: 17945290

Severe constipation: an under-appreciated cause of VP shunt malfunction: a case-based update

Martinez-Lage JF, Martos-Tello JM, Ros-de-San Pedro J, Almagro MJ. Severe constipation: an under-appreciated cause of VP shunt malfunction: a case-based update. Child's Nervous System. 2007 Oct 10;

BACKGROUND: Increased intra-abdominal pressure has been reported to result in raised intracranial pressure in a variety of conditions such as obesity and pregnancy, and it also constitutes an infrequent cause of ventriculoperitoneal (VP) shunt malfunction. Patients with neurological deficits, as those with myelomeningocele or cerebral palsy, are prone to developing a neurogenic bowel and to suffer chronic constipation. Although previously recognized, VP shunt failure attributed to constipation has only recently been described. We briefly review the etiopathogenesis, diagnosis and management of severe constipation leading to VP shunt malfunction. Our aim is to draw the attention of pediatric neurosurgeons towards severe constipation as a possible cause of VP shunt failure thus avoiding unnecessary surgical valve revisions, to which children with hydrocephalus are often submitted to.

ILLUSTRATIVE CASES: We report two children that developed transient VP shunt failure because of intense constipation that caused exacerbation of previously shunted hydrocephalus. One of the patients constitutes the first description of this complication associated with an anteriorly placed anus and the other with intestinal paresis after ileostomy. Conservative treatment aimed at alleviating the increased intra-abdominal pressure resulted in complete resolution of the children's manifestations of VP shunt failure, without having to resort to surgical revision of the VP shunt.

PMID: 17926043

Transient ventriculoperitoneal shunt malfunction after chronic constipation: case report and review of literature.

Muzumdar D, Ventureyra EC. Transient ventriculoperitoneal shunt malfunction after chronic constipation: case report and review of literature. Child's Nervous System. 2007 Apr;23(4):455-8. Epub 2006 Aug 29.

BACKGROUND: Significant constipation in patients with shunt-dependent hydrocephalus may often be enough to bring a subclinical shunt malfunction to clinical attention or even to be the cause of temporary distal peritoneal shunt malfunction. The treatment of the constipation may address the symptomatic shunt dysfunction so as to avoid operative intervention. The pathogenesis of distal shunt malfunction and its management in such a situation are discussed, and the relevant literature is briefly reviewed.

CASE REPORT: A 16-year-old young boy had shunt-dependent hydrocephalus secondary to prematurity and intraventricular hemorrhage at birth. He was chronic flaccid paraplegic and had a neurogenic bladder and bowel involvement. He presented with acute dull aching intermittent headaches, nausea, and constipation of short duration. There was no underlying shunt infection. CT brain showed dilated lateral ventricles. Shunt survey revealed a convoluted course and kink in the distal peritoneal catheter. After administration of a bowel enema, the headaches and nausea resolved over the next few hours, and the posttreatment CT showed significant decrease in ventricular size.

CONCLUSION: Chronic constipation is an important predisposing factor for distal malfunction in shunt-dependent hydrocephalus and should be ascertained in evaluation of a ventriculoperitoneal shunt malfunction. Appropriate treatment of significant constipation can relieve shunt malfunction and reestablish cerebrospinal fluid circulation. A shunt exploration can be avoided in such a situation. A close neurological monitoring of the patient is essential during the course of treatment. An interdisciplinary approach between concerned medical specialties and enhanced awareness is mandatory to ensure appropriate bowel management.

PMID: 17009006

Constipation as a reversible cause of ventriculoperitoneal shunt failure. Report of two cases.

Powers CJ, George T, Fuchs HE. Constipation as a reversible cause of ventriculoperitoneal shunt failure. Report of two cases. Journal of Neurosurgery. 2006 Sep;105(3 Suppl):227-30.

Ventriculoperitoneal (VP) shunt failure is a common problem encountered by pediatric neurosurgeons. The majority of such failures are due to obstruction of the device. Conditions in which intraabdominal pressure is chronically elevated, such as pregnancy, have been associated with shunt failure. Chronic constipation may also result in abnormally elevated intraabdominal pressure and may be an underrecognized cause of distal VP shunt failure. The authors describe the cases of two children who presented with clinical and imaging evidence of VP shunt failure and who were also severely constipated. Treatment of their constipation resulted in both clinical and imaging-documented resolution of their shunt failure.

PMID: 16970237