The Malone ACE Procedure for Fecal Incontinence

Dr Walsh, Dr Koyle, Dr Waxman

Disclosures

Infect Urol. 2000;13(4) 

In This Article

Discussion

Pediatric urologists frequently become involved in the care of patients with urinary incontinence and, especially in the spinal defects/myelomeningocele population, with fecal incontinence. When standard techniques of diet manipulation, drugs and laxatives, or high rectal washout (as described by Shandling and Gilmour[9]) fail, there has been little recourse for this select group. In 1990, Malone and colleagues[1] first described the technique for and rationale behind the antegrade continence enema procedure. Initially, this antegrade enema technique was used for fecal incontinence based on the Mitrofanoff principle of reimplanting a dismembered appendix in the cecum. Further experience with this initial dismembered technique and the orthotopic appendicocecostomy was reported in 1993 by Squire and associates[10] and by Koyle and colleagues,[5] who expanded the indication for the antegrade continence enema to patients with severe constipation. The short- and long-term success appeared to be excellent in the majority of patients, although the procedure was not universally successful or free of complications.

As Malone and coworkers[1] suggested, physicians need to individualize the approach to each patient. Success depends on experimentation by the patient and family to determine the ultimate frequency and volume of enema administration. Various solutions can be used for the enema. Tap water, saline solution, and/or soapy water have been used successfully without metabolic sequelae. The use of tap water eliminates the potential for hyperphosphatemia associated with phosphate enemas. Monitoring of renal function and electrolyte levels every 3 months ensures no long-term problems from free water absorption or loss of electrolytes.[3,5]

Complications are not infrequent, especially as they relate to stress; revision surgery is often necessary. Stomal stenosis may occur secondary to poor vascularization of the appendix, which may be potentiated by less frequent catheterization of the antegrade continence enema stoma than an appendicovesicostomy stoma. Early recognition and initiation of a daily dilation routine may prevent this complication. The in situ technique we have presented hopefully will minimize risks of vascular compromise. Placement of a gastrostomy button through the MACE channel may be useful in isolated cases of recurrent stenoses; in stomal, fecal, or gaseous leaks; in painful catheterizations; or when compliance issues are encountered. Other problems related to stomal creation include stomal prolapse, granulation tissue formation, and wound infection. The latter should lead to a neurologic consultation for the patient with a ventriculoperitoneal shunt; rapid action may be necessary.

The MACE procedure is an important adjunct in the care of children and adolescents with problems of fecal elimination in whom standard medical therapies have failed. In addition to the spina bifida population, we have used the MACE procedure in patients who have continued to have fecal problems after rectal pull-throughs for an imperforate anus and in older children with cerebral palsy and Down syndrome where there has been intractable constipation. This procedure is often combined with an additional urologic procedure, adds little time to the hospital stay, and does not increase morbidity.

It appears that the application of this procedure can be extended to the adult population as well. Patients with intractable constipation may be candidates for the antegrade continence enema procedure. Adults must be highly motivated to care for themselves. Many can escape the need for caregivers or family members who are currently involved in their care. Laparoscopic-assisted techniques would be especially suited to patients who present with isolated bowel dysfunction.[11] Also, one might surmise that techniques of percutaneous access to the cecum performed under local anesthesia and which allow the MACE principle to be employed would be helpful to the growing number of adults who require custodial care and have associated bowel management issues. Patients must understand, however, that several revisions may be necessary before success is achieved.

Patient selection, preparation, and education cannot be overemphasized because of the complexity of the underlying abnormalities and subsequent surgeries that might be required for those patients with fecal elimination problems. To give children or adults with fecal or urinary incontinence independence with increased self-esteem and confidence by making them clean and dry must be the aim of all urologists who embark on the care of patients with those complex problems.

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