Bowel control depends on a normal internal sphincter, normal external sphincter, sensation, peristalsis, a normal ano-rectal angle, psychosocial factors and the absence of scarring. Normally, stool enters the rectum and results in relaxation of the internal anal sphincter. This is independent of the central nervous system. Voluntary contraction of the external sphincter is needed to contain flatus or feces. When any component of this system fails, or is not normally developed, this may result in "fecal incontinence," or the inability to control bowel function. Treatment of fecal incontinence may include spontaneous defecation, dietary modification, laxatives, manual expression, disimpaction, bowel training, biofeedback, suppositories, electrostimulation, and large volume enemas delivered via a special rectal balloon catheter. (Bartolo 1991; Younoszai 1992; Keck, Staniunas et al. 1994; Berquist 1995; Lestar, Kiss et al. 1998).

Antegrade colonic enemas (Sheldon, Minevich et al. 1997) have been described as a surgical procedure where the appendix is used to form a cutaneous cecostomy for fluid irrigation (Malone, Antegrade Colonic Enema - MACE) (Malone, Ransley et al. 1990; Ellsworth, Webb et al. 1996; Malone, Curry et al. 1998; Wilcox and Kiely 1998). Transcolonoscopic extraperitoneal cecostomies have also been described. (Ganc, Netto et al. 1988) A percutaneous approach to the placement of a cecostomy catheter was described for colonic decompression in adults (Casola, Withers et al. 1986), and was adapted for the introduction of antegrade enemas in paediatric fecal incontinence by Chait and Shandling (Ramamurthy 1996; Shandling, Chait et al. 1996; Chait, Shandling et al. 1997; Towbin 1997). We have had experience with 128 patients to date between June 1994 and August 1999.

Placement of the cecostomy tube involves two different procedures that take place about six weeks apart. In the first, a temporary cecostomy catheter (C-tube) is inserted into the patient's colon through the skin usually in the lower right part of the abdomen. Approximately six weeks later, a more permanent tube is exchanged over the wire in a brief outpatient procedure. The C-tube insertion procedure is designed to allow a small-volume enema to be given through the tube to periodically clean out the colon. In this way, potentially embarrassing accidents are avoided, and the patient often gains freedom to pursue activities previously prevented by fear of incontinent episodes. The C-tube remains in the colon and provides a comfortable, convenient way to fully cleanse the bowel with an enema. Emptying the colon in this regular, predictable way can prevent unexpected leakage. After their C-tube insertion, some patients are able to give their own enemas for the first time. All of our patients have described almost complete resolution of their fecal incontinence with few unexpected accidents.