What are the benefits of a colostomy in patients with spina bifida?

Benefits of Colostomy in Patients with Spina Bifida

Colostomy offers definitive therapy for fecal incontinence in spina bifida patients who have failed or are not suitable for standard conservative or surgical treatments, providing significant improvements in quality of life, particularly in social functioning and psychological well-being. 1

Primary Benefits of Colostomy

• Colostomy provides definitive management of fecal incontinence, which has an even greater impact on quality of life than urinary incontinence due to the more noticeable odor 1
• Despite concerns about poor quality of life, patients with colostomy formation report higher social function scores and improved coping, embarrassment, lifestyle, and depression scores compared to patients with fecal incontinence 1
• 84% of patients who had a colostomy for fecal incontinence would choose to have the procedure again, indicating high satisfaction rates 1
• Colostomy can significantly shorten and simplify bowel management routines, improving overall quality of life and independence for patients 2

Bowel Dysfunction in Spina Bifida

• Bowel dysfunction, including constipation and fecal incontinence, significantly impacts health, activities of daily living, and quality of life in people with spina bifida 3
• Secondary complications from bowel dysfunction may include urologic dysfunction, skin integrity issues, shunt malfunction, and reduced social and employment opportunities 3
• Approximately 19.7% of spina bifida patients in the National Spina Bifida Patient Registry underwent procedures for neurogenic bowel management, with 17.3% receiving ACE/cecostomy and 2.8% receiving ileostomy/colostomy 4

Treatment Algorithm for Bowel Management

1. First-line approaches:

   • Dietary modifications, laxatives, suppositories, and/or manual evacuation (successful in approximately 50% of cases) 1
   • Retrograde enemas (75% success rate for achieving continence when medical treatment fails) 1

2. Second-line approaches:

   • Antegrade Continence Enema (MACE) procedure - provides improved social confidence, hygiene, and independence with 77% achieving complete or near-complete fecal continence 1
   • Consider MACE when patient is already undergoing lower urinary tract reconstruction 1

3. Third-line approach:

   • Colostomy when other approaches have failed or are unsuitable 1

Considerations for Colostomy

• Mortality risk: Approximately 2% mortality rate associated with colostomy procedure 1
• Potential complications: Bleeding, cardiopulmonary events related to anesthesia, parastomal hernia, skin rashes, leakage, and ballooning 1
• Patient selection factors: Procedures for neurogenic bowel are more likely in patients who are older, white, non-ambulatory, with higher-level lesions, myelomeningocele lesions, private health insurance, and female gender 4

Comparative Benefits of Different Approaches

• Transanal irrigation (TAI): Shows promise in children with spina bifida with good safety profile and few adverse effects, but requires further investigation 5
• Antegrade Continence Enema (MACE): Effective but still labor and time-intensive, requiring 20-60 minutes for instillation and washout 1
• Colostomy: Most definitive solution that eliminates the need for time-consuming bowel routines and provides better social functioning 1, 2

Importance of Comprehensive Management

• A systematic, step-by-step individualized approach to bowel management can lead to continence and a more functional lifestyle 6
• Consistency among providers and caregivers is critical to evaluating and managing continence in spina bifida 6
• With improved attention to factors that promote independence early in childhood, emerging adults with spina bifida may be less dependent on others for care 1

While colostomy is not the first-line treatment for bowel management in spina bifida patients, it provides a definitive solution for those who have failed conservative and less invasive surgical approaches, offering significant improvements in quality of life, social functioning, and independence.