Section Head Pediatric Urology Penn State university college of medicine
Introduction: Antegrade Continent Enema (ACE) and catheterizable bladder channel (Mitrofanoff) procedures are routinely performed in pediatric urology patients with a neurogenic bladder. Stomal stenosis is a common surgical complication of these procedures, occurring in 15-20% of stomas. Our frustration with this complication inspired us to modify our suturing technique to decrease the incidence of stomal stenosis.
Methods: Our historical techniques for stoma creation were initially simply suturing full thickness bowel to full thickness skin using 4-0 chromic suture. Subsequently, we tried suturing full thickness bowel to full thickness skin using 4-0 Vicryl suture with the knots buried. Our current, modified technique for stoma creation reported here consists of full thickness bowel sutured only to the dermal layer of the skin with 5-0 PDS suture knots buried. Demographics and rates of stomal stenosis were compared between patients who underwent the creation of an ACE or Mitrofanoff channel using the historical techniques (prior to April 2018) versus the current technique (from April 2018 to June 2020). Statistics were performed using Fisher’s exact test, with p-values <0.05 considered significant.
Results: The historical cohort is comprised of 74 patients (97 stomas) while 18 patients (22 stomas) underwent the current stomal creation technique. There were no significant differences in demographics between the 2 cohorts. The historical cohort included 69 ACE procedures (62 appendix, 5 small bowel, and 2 colon) and 28 Mitrofanoff procedures (3 appendix, 19 small bowel, and 6 colon). Among the current technique patients, there were 17 ACE procedures (15 appendix, 1 small bowel, and 1 colon) and 5 Mitrofanoff procedures (1 appendix, 3 small bowel, and 1 colon). Stenosis occurred in 19 of 97 stomas (19.6%) after undergoing either an ACE or Mitrofanoff procedure using the historical techniques (13 occurring in ACE cases and 6 occurring in Mitrofanoff cases). There were no cases of stomal stenosis in the current technique group (p = 0.022).
Conclusions: Our novel suturing technique for stomal creation significantly reduced the incidence of stomal stenosis. The current, modified technique is straightforward and flexible as it can be applied to any stoma placed in any position. None of the patients in the current technique cohort have manifest any of the early findings we saw in the historical stomas that ultimately stenosed. However, further follow-up will be necessary to assess the long-term reliability of this approach.