Which Surgical Approach for Catheterizable Channels in Bowel and Bladder Management Is Best?Which Surgical Approach for Catheterizable Channels in Bowel and Bladder Management Is Best? https://pediatricsnationwide.org/wp-content/themes/corpus/images/empty/thumbnail.jpg 150 150 Jessica Nye, PhD Jessica Nye, PhD https://secure.gravatar.com/avatar/?s=96&d=mm&r=g
- April 06, 2022
- Jessica Nye, PhD
Specific patient characteristics, such as appendix size, may help guide clinicians when deciding which surgical approach to use for patients in need of catheterizable channels for bladder and bowel management.
Many patients with neurologic disorders experience urinary and fecal incontinence. The appendix or the transverse ileal tube can be repurposed as a catheterizable channel to allow for independence with more effective bladder or colon emptying.
“The problem is that most of the kids that require the channel for the bladder tend to require that same channel for the colon. So how do we go about providing patients with both channels? The appendix is a nice, long structure that is kind of perfect to use as a catheterizable channel and it can be split and used to drain the bladder and flush the colon,” says Daniel DaJusta, MD, from the Section of Urology at Nationwide Children’s Hospital and clinical assistant professor of Urology at The Ohio State University College of Medicine.
There are currently no clinical guidelines to help physicians to make decisions about whether to use the transverse ileal tube (Monti technique) or intact or split appendix (Mitrofanoff technique) for the catheterizable channel. Dr. DaJusta and colleagues sought to evaluate the clinical outcomes of these surgical procedures, as real-world outcomes may help guide clinical decisions in the future.
Between 2014 and 2018, 25 pediatric patients underwent Monti, 46 intact appendix Mitrofanoff and 36 split appendix Mitrofanoff catheterization procedures at Nationwide Children’s. These patients were aged median seven years, 60.8% were girls and 56.1% had neurologic diagnoses.
The overall complication rate without need for surgical revision was 36.0% for Monti, 21.7% for intact appendix Mitrofanoff and 47.2% for split appendix Mitrofanoff. Among all patients, most complications were due to stenosis (55.6%) and most complications were at the skin level (58.3%).
Patients who underwent split appendix Mitrofanoff procedures were at increased risk for complications (adjusted hazard ratio [aHR], 2.32; 95% CI, 1.04-5.19; P =.04).
“Our complication rate for split appendix was very similar to a previous paper. It’s not that split appendix necessarily has a worse complication, but, that our intact Mitrofanoff complication rate was much lower than what’s previously been reported,” says Dr. DaJusta.
Altogether, these data indicate that intact and split appendix Mitrofanoff procedures should not be considered as equivalent. Certain characteristics, such as appendiceal blood supply, appendix length, and abdominal wall thickness may be important features to consider when making decisions about which technique to use. Although there was insufficient data to perform an analysis of patient characteristics and risk for complications, the team at Nationwide Children’s have changed their protocols to collect these data so that they can assess patient features in a future study.
“We looked at our results and decided that we need to prospectively collect additional information, especially appendix size and patient abdominal wall thickness, in order to better understand overall success of the operation, not only for split appendix Mitrofanoff but even for intact Mitrofanoff and Monti procedures. Our ultimate goal is to use the information from this paper to help us potentially bring the complication rate of split appendix down,” concludes Dr. DaJusta.
Zann A, Sebastiao Y, Ching CC, Fuchs M, Jayanthi VR, Wood RJ, Levitt MA, DaJusta D. Split appendix Mitrofanoffs have higher risk of complication than intact appendix or monti channels. Journal of Pediatric Urology. 2021;17:700.e1-700.e8.
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