O2091: Malone Appendicostomy in Patients with Functional Constipation and Behavioral or Neurodiverse Disorders

Background: Treatment of functional constipation in pediatric patients with behavioral disorders or neurodiversity can be very challenging. Such patients can have difficulty taking laxatives, tolerating suppositories or daily rectal enemas, and achieving success with toilet training. In this subgroup of patients with medically refractory constipation, antegrade flushes via a Malone appendicostomy may be good option for them to achieve regular bowel movements and social continence.

Methods: We retrospectively reviewed all patients (from January 2020 to March 2022) who were referred to a single institution and had failed medical management with laxatives and rectal enemas for functional constipation and underwent an appendicostomy to provide antegrade mechanical emptying.

Results: Of 42 patients (median age 9.9 years) who were referred for medically refractory functional constipation and underwent a Malone or Neo-Malone appendicostomy, 30 (71%) had underlying neurodiversity or a behavioral disorder, including an anxiety disorder in 18 patients (60%), autism spectrum disorder in 11 (37%), attention deficit hyperactivity disorder in 9 (30%) and Trisomy 21 in 2 patients. Twenty-six of 42 (62%) patients were given an indwelling device to administer flushes, and 16 (38%) elected to perform intermittent catheterizations. Twenty-two of 30 patients (73%) have no stooling accidents post-appendicostomy and 5/30 (17%) reported some accidents but less than prior to the appendicostomy. Three of the 30 patients (10%) failed antegrade flushes, and then underwent colonic evaluation and colon resection for dysmotility and are subsequently clean. There was no significant difference compared to the 12 patients who underwent Malone appendicostomy who had no underlying neurodiversity or behavioral disorder.

Conclusion: Children with medically refractory constipation in this series had a high rate of behavioral disorders or neurodiversity. Such patients often have difficulty tolerating medical therapy or achieving toilet training. Antegrade flushes via Malone appendicostomy are a well-tolerated and effective treatment option for these patients.