Management of Intractable Constipation With Antegrade Enemas in Neurologically Intact Children *Nader N. Youssef, *Edward Barksdale, Jr., *Janet M. Griffiths, †Alejandro F. Flores, and *Carlo Di Lorenzo *Divisions of Pediatric Gastroenterology and Surgery, University of Pittsburgh School of Medicine and Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania; and †Floating Hospital for Children, Boston, Massachusetts, U.S.A. ABSTRACT Objectives: To assess the benefit of antegrade enemas in chil- dren with severe constipation who were referred to a tertiary care center. Methods: From 1997 to 1999, 12 children (9 male, aged 8.7 ± 4.4 years) underwent cecostomy placement. All children were neurologically normal and had been extensively examined to rule out organic causes of constipation. Follow-up included a questionnaire to interview caregivers 13.1 ± 8.5 months after cecostomy placement. Results: For all children, antegrade enemas led to improvement in the number of bowel movements / week (7.1 versus 1.4, P < 0.005), number of soiling accidents / week (1.0 versus 4.7, P < 0.01), abdominal pain score (0.9 versus 2.9, P < 0.005), emo- tional health score (3.6 versus 1.9, P < 0.005), overall health score (3.6 versus 1.7, P < 0.005), number of medications used for constipation (0.8 versus 4.0, P < 0.005), number of missed school days / month (1.5 versus 7.5, P < 0.02), and number of physician office visits / year (9.2 versus 24.0, P < 0.05). Irri- gation solutions used for the antegrade enemas included poly- ethylene glycol (67%), saline and glycerin solution (25%), and phosphate enema (8%), administered everyday in seven chil- dren and every other day in five children. Adverse events in- cluded skin breakdown and granulation tissue in one patient, leakage of irrigation solution in one patient, and dislodging of the tube in two patients. Five patients discontinued the use of antegrade enemas within a mean of 14.6 ± 9.1 months after beginning treatment. Conclusion: Antegrade enemas through a cecostomy are a safe and satisfactory option for children who are neurologically in- tact and who have severe constipation that does not respond to medical treatment. JPGN 34:402–405, 2002. Key Words: Constipation—Cecostomy—Children—Antegrade—Enema. © 2002 Lippincott Williams & Wilkins, Inc. Constipation is one of the conditions most commonly referred to pediatric gastroenterologists, accounting for up to 25% of all visits (1). The aim of treating childhood constipation is to make defecation as easy and painless as possible. Long-term follow-up studies of children with constipation who are younger than 5 years have shown 50% recovered within 1 year and 65% to 70% recovered within 2 years (2). Those who do not improve require laxatives to have daily bowel movements or they may continue to soil for years. Children with neuromuscular handicaps, such as cere- bral palsy and spinal dysraphism, often have persistent defecation problems, including recurrent fecal impaction and overflow soiling. To manage fecal incontinence and constipation in this subset of constipated children, vari- ous techniques have been tried, which recently include the use of antegrade enemas through a cecostomy (3,4). In 1990, Malone et al. (5) described forming a conti- nent appendicocecostomy through which the cecum could be intermittently catheterized for administration of an antegrade continence enema. A catheterizable stoma was placed in the right iliac fossa or at the level of the umbilicus. A tubularized enteric conduit from the ileum or cecum was created in patients without an appendix (6). Using the antegrade continence enema, the large bowel could be cleaned out at regular intervals, avoiding accumulation of stools and subsequent soiling (7). To avoid the complications of stoma stenosis and prolapse associated with appendicocecostomy, newer techniques for antegrade enema administration have been developed (8). A surgeon can perform the cecostomy, or an inter- ventional radiologist or a gastroenterologist can perform the procedure using local anesthesia, similar to placing a percutaneous gastrostomy (9,10). In this study, we report the use of antegrade enemas through cecostomy catheters in a group of children who Received August 9, 2001; accepted January 10, 2002. Address correspondence and reprint requests to Dr. Nader N. Youssef, Children’s Hospital of Pittsburgh, Department of Pediatrics, Division of Gastroenterology, 3705 Fifth Avenue at DeSoto Street, Pittsburgh, PA, U.S.A. (e-mail: youssen@chplink.chp.edu). Journal of Pediatric Gastroenterology and Nutrition 34:402–405 © April 2002 Lippincott Williams & Wilkins, Inc., Philadelphia 402