Therapeutic cecostomy tubes in infants with imperforate anus and caudal agenesis

Background/Purpose: Caudal agenesis is indicative of a poor prognosis for achieving normal bowel function in children with high imperforate anus (HIA). Complications with impaction, soiling, megarectosigmoid, and adverse responses to rectal enemas are inevitable and associated with long-term psychosocial dysfunction. In an attempt to avoid these outcomes, the authors began a prospective evaluation in these high-risk patients of skin level cecostomy tubes placed in infancy. Methods: Between October 1997 and March 200]1, 8 infants with variants of caudal agenesis underwent presumptive therapeutic placement of a cecostomy tube in conjunction with colostomy closure (n = 7) and anal transposition (n = 1). Mean age at time of cecostomy placement was 16 months. Efficacy of daily irrigations with individually modified electrolyte solutions has been evaluated over the subsequent 1 to 41 months with a mean follow-up of 22 months. Results: Effective daily colonic evacuation was achieved in 7 infants. Transient episodes of incomplete emptying often associated with soiling were resolved with adjustments in solution contents and volume. No patient has required admission for impaction, and only 1 patient has required rectal enemas. There have been no major complications, and minor problems with cramping, granulation tissue, and site discomfort quickly resolved. One patient with anal anastamotic stricture consistently has not responded to antegrade irrigation and continues to require intermittent rectal enemas and anal dilation. Attempts to wean the irrigations occur as the infants grow older and are able to participate in toilet training; however, in this preschool population, tapering of the frequency has been tolerated only transiently. Conclusions: Antegrade enemas via a cecostomy device are highly effective for bowel management in infants with HIA and caudal agenesis. They can be placed with minimal morbidity at the time of initial reconstruction or colostomy closure. Consideration of this procedure in all infants with HIA may be indicated.