臺北榮總Malone灌腸造口手術後經驗

1. 葉奕廷 王國強 蔡昕霖 劉君恕 錢大維
臺北榮總兒童外科
臺北榮總
Malone式
灌腸造口手術
之經驗

2. 兒童大便失禁
 盛行率: 0.8 – 7.8%
 慢性便秘是最常見的原因
 慢性便秘的成因：
原發性便秘
肛門直腸發育不良（無肛症）
神經性（脊柱裂）
巨結腸症
腸胃道活動不良
 大便失禁會造成生活品質不良且引起行為及情緒異常
 約1/3的病人會持續有大便失禁的狀況直到成年
Basson S, Pediatr Surg Int 2014

3. 嚴重慢性便秘的治療方式
大容積的灌腸
給予的方式
逆行性：limited by the patients ability to resist the
urge and the ability of the sphincter, thus only
clears the distal colon
順行性：從盲腸造口進行灌腸
Initially described in 1990 by Malone
More effective in evacuation of both sides of the colon

4. 灌腸造口手術有高成功率
 High success rates (78-94%) have been reported
Basson S, Pediatr Surg Int 2014; Randall J, J Pediatr Surg 2014
 However, more than 40% of patients discontinuing use of their ACE
after a median of 11 years in one study
Yardley ID, J Pediatr Surg 2009
 Reason for discontinuation:
Successful resolution of symptoms
Disuse due to non-compliance or ineffectiveness
 Predictor of poor outcome:
Underlying etiology: worse prognosis in idiopathic constipation or GI
dysmotility patients
Age at operation: younger patients (<5 y/o) may have decreased
compliance and more complications (controversial)
Basson S, Pediatr Surg Int 2014

5. 灌腸造口手術常見的併發症
在闌尾造口與皮膚相接處產生狹窄requiring surgical
revision (usually at or near the skin level) is the
most common complication
Randall J, J Pediatr Surg 2014
Other complications include: stomal granulation,
stomal leakage, stomal prolapse, local infection
and incisional hernia

6. 本院Malone式灌腸造口手術病例 (‘03-’16)
# Etiology
Age
at OP
Type of
OP
Known
Complications
F/U
period
Documented
improve
Current ACE Use
1 ARM 10 Malone nil 2 year yes n/a
2 Syringomyelia 21 Malone nil 12 years yes
No (symptoms
resolved)
3 ARM 20 Malone nil 1 year yes n/a
4 ARM 8 Malone Wound infection 12 years yes Yes
5 Spinal bifida 7 Malone Stomal stricture 1 year yes n/a
6 ARM 19 Monti Stomal stricture 7 years yes Yes
7 Spinal bifida 13 Malone Stomal stricture 11 years yes
No (rectal
irrigation)
8 Spinal bifida 12 Malone Stomal stricture 10 years yes
No (symptoms
resolved)
9 ARM 28 Monti Stomal stricture 9 years yes Yes
10
Sacral
meningocele
14 Malone nil 1 year yes No (not effective)
11 ARM 23 Malone nil 1 year yes Yes
n/a: not available for chart/telephone interview

7. Malone式灌腸造口之手術適應症
肛門直腸發育異常（無肛症）
High type, or low type s/p multiple
operations with severe to total
incontinence with constipation
神經性失禁
Severe constipation with total
incontinence
不適合手術：原發性便秘

8. 手術方式
仍有盲腸：Malone式
Non-reverse,in-situ appendicostomy
Cecal flap (seromuscular) wraping around appendix
Fashioning of stoma by V-shape skin flap or direct
anastomosis
盲腸已被切除：Monti式（以一段末端迴腸代替盲腸）
One segment of terminal ileum(about 40-60 cm from
ileocecalvalve) was used as conduit
Tapering of the conduit at anti-mesenteric side
術後5-7天開始進行灌腸
導管在術後兩個禮拜後移除

9. 手術之成果：灌腸的方式及頻率
病患 灌洗液 頻率 灌腸所需時間
2 Tap water 1/day 45 min
4 Saline + glycerin 2-3/week* 60 min
6 Tap water 1/day 50 min
7 Saline + glycerin 1/day 60 min
8 Saline + glycerin 1/day 60 min
9 Tap water 1/day 20 min
10 GB 1/day Variable
11 Saline 2/day 60 min
* The patient is completely clean if ACE is performed once daily, but
modified to 2-3/week due to lifestyle

10. 評估失禁的評分標準
St. Mark’s Hospital Incontinence Score
Item Never Rarely Sometimes Weekly Daily
Incontinence for solid 0 1 2 3 4
Incontinence for liquid 0 1 2 3 4
Incontinence for gas 0 1 2 3 4
Alteration in lifestyle 0 1 2 3 4
No Yes
Need to wear pad 0 2
Taking constipating medicine 0 2
Lack of ability to defer defecation
for 15 minutes
0 4
* Never: no episode in recent 4 weeks; rarely: 1 episode in recent 4
weeks; sometimes, > 1 episode in recent 4 weeks but not weekly
Vaizey CJ, Gut 1999

11. 術後大便失禁獲得中等程度的改善
St. Mark’s Hospital Incontinence Score
Patient Number Continence Score (0 – 24)
2 10
4 18
6 9
7 15
8 20
9 15
10
11 14
Median 15
* Worse performing items: incontinence of gas, need to wear pads,
lack of ability to defer defecation

12. 術後對於自我照顧以及生活品質的滿意度
Item #2 #4 #6 #7 #8 #9 #10 #11 Median
Confidence in
one’s ability to
manage the
irrigation
8 10 8 7 7 10 7 6 7.5
Confidence that
ACE will give
control to one’s
bowel
9 9 8 6 6 10 7 7 7.5
Confidence to go
to social event 8 9 10 8 6 10 7 6 8
Confidence to
undertake daily
activities
10 10 10 10 7 7 7 6 8.5
Confidence to
attend full-day
activities
7 10 8 10 6 8 7 6 7.5
Overall satisfaction
of life 8 10 8 8 8 6 8 6 8
Overall satisfaction
with the procedure 9 10 8 6 6 9 6 6 7

13. 停止使用灌腸造口的原因
(Patients #2, #7, #8, #10)
Patient #2 discontinued ACE 4 years after the
procedure because of resolution of symptoms
Patient #7 discontinued ACE 6 years after the
procedure because she felt that the effectiveness
decreased and shift to colonic hydrotherapy machine
at home to manage her bowel
Patient #8 discontinued ACE 2 years after the
procedure because she felt that the effectiveness
decreased. In addition, she regained continence
gradually over the next 4 years and is currently partially
continent without intervention
Patient #10 discontinued ACE 3 months after the
procedure because the time interval to rectal
emptying is highly variable (irrigant: GB only)

14. 特定病患滿意度較低的原因
(Patients #7, #8, # 11)
Patient #7: weekly incontinence for solid stool,
alteration of lifestyle and personal preference
of rectal irrigation with good result
Patient #8: weekly incontinence for solid stool
Patient #10: highly variable time interval to
rectal emptying (irrigant: GB only)
Patient #11: comorbidity of schizophrenia,
poor self-care, weak family support, totally
rely on caretaker to administer the irrigations

15. 結論
灌腸造口手術在多數病患初期可以獲致令人滿
意的結果（改善大便控制以及增進生活品質）
早期「成果不佳」可能與順從度不佳或者自我
照顧、家人支持不足有關
晚期「停止使用」可能與逐漸失去效用或者失
禁症狀自行緩解有關