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Objective To present the results of simultaneous creation of both Mitrofanoff stoma and Malone antegrade continence stoma (MACE) using simple division of the appendix and a cecal extension method. Materials and Methods Between June 2011 and November 2016, simultaneous Mitrofanoff and MACE was performed in 16 children (12 children—simple division of the appendix, 4 children—appendicovesicostomy and cecal extension of the appendix). Extension of the appendix was achieved by tubularization of the excised cecal flap next to the short appendicular stump. The new extended channel was then wrapped by cecal wall. Results Follow-up was 40 months (10-74 months). Currently, in all children, both stomas are easily catheterizable. Obstruction of MACE occurred in 5 children (4 with split appendix, 1 with extended appendix); Mitrofanoff stomal stenosis occurred in 1 child. Endoscopic revision and prolonged catheterization of stenotic stomas were effective in all cases. Wound infection and dehiscence was noted in 2 children (both with split appendix). Drainage and intravenous antibiotics were effective. All Mitrofanoffs are continent. In 4 children there is incident minor leakage of the MACE (3 with split appendix and in 1 with extended appendix). Conclusion The split appendix procedure is feasible. Cecal extension of the appendix seems to be a good option when the appendix is too short for a simple split procedure.

Objective To review peri-procedural outcomes from a large, multi-institutional series of pediatric urology patients treated with laparaendoscopic single-site surgery (LESS) for major extirpative and reconstructive procedures. Materials and Methods Consecutive LESS cases between January 2011 and May 2014 from three free-standing pediatric referral centers were reviewed. Data include age, sex, operative time, blood loss, length of stay, and complications according to the modified Clavien-Dindo classification. Hasson technique was used for peritoneal entry, GelPOINT advanced access platform was inserted, and standard 5mm laparoscopic instruments were used. Results Fifty-nine patients (median age 5 years, 4 months-17 years) met inclusion criteria: 29 nephrectomies, 9 nephroureterectomies, 3 bilateral nephrectomies, 5 heminephrectomies, 5 renal cyst decortications, 3 bilateral gonadectomies, 2 Malone antegrade continence enema, 2 calyceal diverticulectomy, and 1 ovarian detorsion with cystectomy. Median operative times for each case type were comparable to published experiences with traditional laparoscopy. Overall mean and median length of stay was 36.2 hours and 1 day, respectively. There were two complications: port site hernia requiring surgical repair (Clavien IIIb) and a superficial port site infection that resolved with antibiotics (Clavien II). Cosmetic outcomes were subjectively well received by patients and their parents. Operative time was significantly shorter between the first half of the experience and the second half (102 vs 70 minutes, P Conclusion LESS approach can be broadly applied across many major extirpative and reconstructive procedures within pediatric urology. Our series advances our field's utilization of this technique and its safety.

This study is a case report of home-based colonic dialysis (CD) for treating end-stage renal disease in a 20-year-old woman. She had a history of Malone antegrade continence enema (MACE) for treating neuropathic bowel at the age of 11 years. The patient refused any type of renal replacement therapy. However, she agreed to CD through the MACE stoma by changing the colonic irrigation solution to the peritoneal dialysis solution. The patient was discharged with a plasma creatinine (Cr) level of 1.7 mg/dL and blood urea nitrogen (BUN) level of 8 mg/dL. She has continued CD on a regular basis at home. The patient's serum Cr and BUN has remained in the steady low state during 24 months of follow-up (mean Cr level = 2.8 mg/dL and mean BUN level = 10.7 mg/dL).

Continent catheterizable channels have revolutionized reconstructive surgery to achieve both urinary and fecal continence. The Mitrofanoff and Malone antegrade continent catheterizable channels offer improved quality of life relative to permanent incontinent stomas. A frequently employed surgical option for creating a Mitrofanoff when an existing appendicocecostomy exists involves harvesting a separate piece of intestine. If however the Malone has preceded the creation of a Mitrofanoff, we describe a surgical technique that may avoid the need for a bowel harvest and resultant anastomosis. We report our series of patients utilizing a novel alternative strategy in the select clinical circumstance of an existing appendicocecostomy to expand the armamentarium of the urologic reconstructive surgeon.

Summary Introduction Faecal incontinence due to constipation associated with myelomeningocele (MMC) is a frustrating problem. It could have a bad impact on patients and their families' quality of life. Conservative measures could be a starting point. In case of failure, Malone antegrade continence enema (MACE) is commonly considered. However, it is associated with higher complications. Peristeen transanal irrigation (TAI) depends on the injection of water into the colon through a rectal catheter with an inflatable balloon to promote a controlled evacuation of large quantities of faecal contents. Transanal irrigation could be an alternative in these patients to avoid surgery. Objective The objective of this study was to evaluate the long-term effectiveness and satisfaction of TAI management (Peristeen®, Coloplast, Denmark) in children with MMC who failed to respond to conservative measures for stool incontinence. Study design All patients with MMC who did not respond to conservative measures for stool incontinence and were using TAI with the last follow-up 6 months before the end date were included. Data were collected retrospectively from January 2008 till January 2016. The data collected included the age of starting Peristeen, duration of using the Peristeen, acceptance and compliance of the patient's family with the TAI. Success was defined as stool continence. Results A total of 109 patients (55 males and 54 females) diagnosed as having MMC were started on TAI Peristeen. With a mean follow-up of 48 months (24–108), 101 patients (90.4%) achieved complete stool continence and 8 patients were considered failures. Discussion The study results are comparable with those of previously reported publications. The main limitation of Peristeen TAI is that it cannot be performed by the patient himself/herself. This may present a problem with later independence. Conclusion Transanal irrigation with Peristeen® system is a safe and good alternative option for stool incontinence when other conservative measures fail. Download : Download high-res image (192KB) Download : Download full-size image Fig. Results TAI (Peristeen®).

Background/Purpose The Malone antegrade continence enema (MACE) channel is an effective means to manage patients with neurogenic bowel; however, complications may occur that may require surgical revision. Specific reports of the outcomes of these interventions are limited. We describe our clinical results following revision of MACE. Methods We retrospectively identified patients undergoing MACE revision for at our institution between 1997 and 2009. Type of MACE (in situ appendicocecostomy (AC=247), ileocecostomy (IC=25), cecal flap (CF=10)) performed was recorded, time from creation to revision, site of revision, and need for repeat surgical revision were recorded. Results Of a total of 282 patients that underwent creation of MACE during the study period, 49 patients (17%) required surgical revision. Of these 49 patients, 42 had undergone AC, four had IC and three had CF. Mean time from MACE creation to revision was 19months. Sixty-eight revision procedures were performed in the 49 patients. Skin level or endoscopic procedures accounted for 52/67 (78%) procedures. Sixteen patients (33%) required more than one revision and three patients (6%) required more than two procedures. Conclusions Skin level revisions accounted for over three-fourths of MACE revisions. In our series, two thirds of patients requiring revision required only a single procedure, but one third required more than one revision.

Objective The primary aim of this study was to determine if there is a change in the quality of life in pediatric patients with unremitting functional constipation and/or encopresis after undergoing a MACE procedure. Methods Patients, ages 5 to 18years with unremitting constipation and a normal evaluation, including anorectal manometry and colonic manometry, who opted to undergo a MACE procedure were contacted to participate in the study. Patients with congenital anorectal malformations as well as spinal cord disorders were excluded from the study. The patient's parent/guardian completed the PedsQL TM Generic Core Scales QOL survey prior to the operation, 6months, and 12months after the procedure. Results A total of 15 consecutive patients meeting protocol criteria were recruited within a period of 20months. The mean age at the MACE procedure was 9.8years (range 7.0–11.1). 5 patients were female. The mean QOL score pre-MACE was 64.1. At 6months post-MACE the mean overall QOL score was 90.2, and it was 92.0 at 12months. All 15 patients at the 6month follow up had significant improvement in their QOL (p=1.9×10 −7 ) and all subcategories of QOL were significantly improved as well. Conclusions A MACE procedure is of benefit to otherwise normal pediatric patients who have unremitting functional constipation with failure of medical treatment. Our patients had a significant improvement in all QOL categories and overall QOL.

This study compared long-term outcomes of left- vs right-sided antegrade continence enema (ACE) procedures.We retrospectively analyzed medical records and performed a follow-up telephone survey of patients who underwent the ACE procedure at Severance Children's Hospital between 1999 and 2011.A total of 49 patients underwent 51 ACE procedures. The procedures were left-sided ACE in 25 patients (group 1) and right-sided in 26 patients (group 2), including 2 patients who underwent left-sided procedures a few years earlier. Fecal soiling was more common in group 1 than in group 2 (8/25 [32.0%] vs 1/26 [3.9%], respectively; P = .0109). Seven patients (28.0%) in group 1 had abdominal pain unrelieved by ACEs. Stomal reflux of fecal material was more frequent in group 1 than in group 2 (13/25 [52.0%] vs 0/26 [0%], respectively; P.0001). Nonuse or infrequent use of ACE was more common in group 1 than in group 2 (11/25 [44.0%] vs 0/26 [0%], respectively; P.0001). Patient satisfaction was higher in group 2 (P = .0015).In our experience using the sigmoid colon for left-sided ACE, right-sided ACE was superior to left-sided ACE in achieving fecal continence, resolving intractable constipation, and providing patient satisfaction.

Purpose There is little objective data demonstrating improved quality of life after a Malone antegrade continence enema (ACE) despite the dramatic subjective improvements seen by physicians and caretakers. Methods We utilized the FICQOL survey, a reliable and valid instrument for measuring the impact of fecal incontinence and constipation on quality of life (FICQOL) of caregivers and children with spina bifida. Between 2002 and 2009, 23 families were evaluated prospectively before and after an ACE procedure. Items on the survey were compared with Wilcoxon rank sum or signed rank test. Results After an ACE Malone the mean number of bowel movements (BM) per day decreased along with a decrease in number of accidents per week from 3.9 to 0.3. There was no change in the time committed to bowel care. The percentage of patients taking oral laxatives decreased from 44% to 6%. Both parent and child were less often prevented from leaving the house and the caretakers’ bother, anxiety and depression due to bowel care decreased. Although factors regarding the child’s social issues and parent’s employment improved, the changes were not statistically significant. Conclusions Among patients with spina bifida and fecal incontinence who underwent the ACE procedure at our institution, a significant improvement in fecal incontinence and QOL scores was observed using a validated instrument, FICQOL. Without changing the amount of time necessary for bowel care, the ACE procedure decreases the families’ worries and anxieties and allows them to leave home with the confidence that their child will not have leakage of stool.

Summary Introduction The Malone antegrade continence enema (MACE) procedure is effective in management of fecal incontinence and intractable constipation. Stomal incontinence and stenosis are the most common issues reported, and a recent large study of imbricated MACE procedures reports a surgical revision rate of 17%. The laparoscopic approach is now widely used and precludes imbrication. To date, few studies have reported revision rates in these patients who have undergone non-imbricated MACE creation. Objective Our goal was to report the long-term outcomes of our non-imbricated patients focusing on complication rates and need for revision. Study design Records of patients younger than 18 years of age who underwent non-imbricated MACE between January 2000 and March 2016 at our institution were reviewed. Patients with less than 2 years of follow-up or non-compliance with MACE usage were excluded from analysis. Patient age, ambulatory status, surgical technique, stomal site, and complications including stomal leakage, stomal stenosis, and need for revision were evaluated. Stomal leakage was classified based on our previously reported system. Results A total of 81 patients met inclusion criteria. Mean age at time of surgery was 8.4 years. Mean and median follow-up were 6.7 and 6.7 years, respectively. Overall revision rate, for stenosis or incontinence, was 16% with a mean time to any revision of 2.1 years (range 28 days to 7.8 years). Four patients required revision for stomal incontinence while others improved spontaneously without intervention. At the last follow-up, stomal leakage was grade 0 in 93.8% of patients, grade 2 in 2.4%, and grade 3a in 3.7% ( summary Table ). Stomal stenosis was noted in 11 patients, eight of whom required revision. Discussion Our study is limited by its retrospective nature with some component of recall bias. A single surgeon experience is also not representative of others' experiences. However, our results indicate that incontinence improves spontaneously in a majority of patients without need for revision in this non-imbricated cohort. Conclusions Our series shows a similar long-term revision rate in line with that reported in the literature. While imbrication is still recommended during open surgery when the anatomy is suitable, equitable success without imbrication supports the laparoscopic approach and a more liberal approach during open surgery if the anatomy does not permit imbrication. Table . Stomal continence. Grade 0 Grade 1 Grade 2 Grade 3a Grade 3b Initial classification 55.6% 18.5% 6.2% 14.8% 4.9% Final classification 93.8% – 2.4% 3.7% –

To determine the long-term outcomes from the Malone antegrade continence enema (ACE) procedure in adult neurogenic patients.A retrospective review of adult patients who underwent the ACE procedure for neurogenic bowel was done. Patients were studied if they had follow-up of greater than 4 years. We compared pre-ACE and post-ACE toileting times, bowel continence status, and complications, and elicited patient subjective satisfaction with their quality of life.Six patients were available for study. Mean age was 35 years with a mean follow-up of 4.5 years. Urinary diversion was done in 5 patients. Pre-ACE toileting time was 190 +/- 45 minutes versus post-ACE toileting time of 28 +/- 20 minutes (P0.001). Four of six patients pre-ACE were incontinent of stool per rectum compared with 1 of these 4 patients post-ACE (P = 0.03). Five patients were continent of stool per ACE stoma. Four patients (67%) had complications. Three of five patients (60%) who underwent synchronous urinary diversion required postoperative re-exploration. Five patients (83%) were satisfied with their outcome and rated their quality of life higher after the ACE procedure compared with pre-ACE.The ACE procedure is effective in the long-term management of adult neurogenic bowel. The complication and re-exploration rates are high. Patients must be properly selected to determine appropriate motivation.

Summary Introduction The Malone antegrade continence enema (MACE) procedure remains an effective tool in providing independence to patients with refractory constipation. Appendiceal, ileal and colonic segments are all used depending upon the patient's individual anatomy and surgeon's preference. Unfortunately, MACE stomal stenosis (SS) remains a frustrating complication. It was hypothesized that SS is associated with the type of efferent limb used for MACE construction. Objective To perform a retrospective risk analysis of the pre-operative factors that correlated with postoperative stomal stenosis. Materials and methods The study reviewed 39 consecutive patients treated with MACE by a single surgeon at the present institution. Collected data included: the type of channel construction, stoma site, pre-operative body mass index (BMI) z -score, pre-operative diagnosis, and development of SS. Stomal stenosis was defined as a documented inability to catheterize, requirement of a Chait tube, or a subsequent stomal revision. An odds ratio (OR) analysis was performed to evaluate the association with the development of SS. Results Stomal stenosis developed in 19 patients (49%) with an average follow-up of 4.7 years. The majority of patients had a diagnosis of myelomeningocele (90%), and there was no significant difference in gender distribution (54% males, 46% females). The distribution types of MACE efferent limbs consisted of appendicocecostomy in 20 (51%), cecal-wall flap in 16 (41%) and ileocecostomy in three patients (8%). Neither type of efferent limb, nor stomal location were significant predictors of postoperative SS. Pre-operative obesity (BMI ≥95%), however, demonstrated a significant risk of SS compared to non-obese patients (OR 4.44, 95% CI 1.08–18.4, P = 0.04). Discussion This was a single-institution study of a relatively small number of patients. However, examining consecutive patients with a common surgeon can minimize technique variability. Also, the rates of stenosis in this cohort were higher than most. This may have been due to a more broad definition (unable to catheterize). These findings complement recent literature showing an increased complication rate for the obese pediatric patient. Conclusion Stomal stenosis remains a frustrating complication following creation of the MACE stoma. In the present series, neither a cecal wall flap, nor the stomal site location contributed to SS. Obesity was the only identified statistically significant risk factor that led to SS. Summary Table . Stomal stenosis risk analysis. Stomal composition Patent MACE Stenosed MACE Stomal location Patent Stenosed Appendix 11 9 RLQ 12 11 Cecal flap 8 8 Umbilical 8 8 Ileocecostomy 1 2 Odds ratio 1.09 Odds ratio a 1.22 P -value 0.89 P -value 0.77 Confidence interval 0.30–3.91 Confidence interval 0.32–4.57 Pre-operative weight Patent Stenosed Pre-operative weight Patent Stenosed Normal 16 9 Normal 13 8 Obese 4 10 Overweight 7 11 Odds ratio 4.44 Odds ratio 2.55 P -value 0.04 P -value 0.16 Confidence interval 1.08–18.36 Confidence interval 0.70–9.31 MACE, Malone antegrade continence enema; RLQ, right lower quadrant. a Comparing the standard (appendiceal) MACE to the cecal flap.

Background/Purpose: Children with anorectal dysfunction can now be treated by antegrade continence enema (ACE), as described Malone et al. Those with idiopathic constipation, however, are not thought to be suitable for this treatment. Over 150 children attend the authors' department with proven slow transit constipation (mostly proven on nuclear transit/X-ray study), and the authors reviewed the outcome in the 40 of these who have had the ACE procedure. Families completed a questionnaire and attended interview with an independent assessor. Methods: Of the 40 patients, 32 patients were assessed. Follow-up ranged from 3 to 54 months (median, 18 months) and age ranged from 5 to 17 years (median age, 10 years). Three of 32 stomas were no longer in use. Frequency of soiling was reduced significantly in 20 patients, and a further 6 patients were clean ( P P Results: Stomal complications were frequent, (stenosis in 16 of 29, mucus leak in 20 of 29, fecal leak 3 of 29, catheter-related pain in 20 of 29). Slow evacuation (12 of 29) and pain with enema (17 of 20) also were common. Conclusion: Malone appendicostomy does improve the well being of patients with slow transit constipation, but the advantages are less dramatic than in children with normal motility. J Pediatr Surg 36:1227-1230. Copyright © 2001 by W.B. Saunders Company.

Objective The aim of our study was to review the management of stomal stenosis after the Malone antegrade continence enema (MACE) procedure at our center, and to describe and assess the early outcomes of 2 novel procedures used in the management of conduit stenosis: Maceoscopy and the rendez-vous . Subjects/patients and methods We retrospectively reviewed 45 consecutive MACE cases performed by 1 surgeon at St George's hospital over a 13-year period. Results Until April 2002, 5 cases presented with difficulty catheterizing their MACE. This was attributed to stenosis without further investigation, and the MACE revised surgically. Of 13 cases presenting with suspected stenosis since May 2002, 8 channels turned out to be patent when assessed and catheterized endoscopically via Maceoscopy. Two truly stenotic MACEs were revised; patency of the other 3 was reestablished by means of a new double-endoscopic procedure we have termed the rendez-vous.

Background/Purpose: The Malone antegrade continence enema (MACE) has proved invaluable in the management of children with faecal incontinence. The authors have reviewed their experience in depth to try and ascertain why some MACEs fail. Methods: The records of 31 children who had a MACE procedure between 1990 and 1995 were reviewed. Their preoperative bowel management, the operative procedure, the postoperative washout regime, and the outcome were assessed. Success was graded either as full, described as totally clean or minor rectal leakage on the night of the washout; partial, described as clean but significant stomal or rectal leakage, occasional major leaks, still wearing protection, and perceived improvement by the parents or child; or failure, described as regular soiling or constipation, no perceived improvement, and the procedure abandoned. There were 18 boys and 13 girls in the series. The mean age at survery was 8.4 years. Results: Overall success rate was 19 of 31 (61%) with a mean follow-up of 3.25 years. The diagnosis and success rates were: anorectal anomaly 11 (success, 8 of 11, 73%), neuropathic bowel, 11 (8 of 11, 73%), chronic constipation 8 (3 of 8, 38%).

Background: Fecal incontinence is common in children who have anorectal malformations, Hirschsprung's Disease, and spina bifida and can negatively impact their emotional and social development. Enemas have been used as an artificial way to keep children clean and to improve their quality of life. This method is unpleasant for many children, particularly when they reach adolescence. Malone in 1990 described an alternative method in which the appendix is used as a conduit to administer an antegrade enema. Methods: The authors describe their experience with this new procedure, modified by them, and used in 20 patients. In the original procedure, the base of the appendix is divided, inverted, and reimplanted into the cecum with an antireflux technique. The authors simplify this by plicating the cecum around the appendix to create a one-way valve mechanism but leaving the appendix in its original position. The authors also mobilize the cecum and exteriorize the appendix at the umbilicus to create an inconspicuous stoma. If the native appendix is absent a neoappendix was created from a flap of cecum. Results: Nineteen of 20 patients (95%) are now completely clean 24 hours a day. Stricture of the stoma occurred in two patients and required revision. Leakage at the appendicostomy site occurred in three patients, and two required a tighter plication. Conclusions: The technique is used to change the route of enema administration, and is only used in patients for whom bowel management with rectal enemas has been proven successful. The appendix must be preserved whenever possible in patients at risk for fecal incontinence.

Background. Our center has previously reported the use of the Malone antegrade continence enema procedure in children. The procedure involves bringing the appendix to the surface of the abdominal wall to provide a nonrefluxing catheterizable channel that enables antegrade colonic lavage for the control of fecal incontinence. Methods. This report critically evaluates 23 patients treated for fecal incontinence with up to 6 years of follow-up. After operation, specific scoring criteria were used for assessment. Success in surgical technique, control of fecal soiling, and improvement in quality of life were evaluated. Results. More than 85% of patients achieved maximal or near-maximal scores in all three categories. Postoperative complications remain a relevant concern when this procedure is undertaken, but we have found that significant postoperative complications are few and can be minimized by meticulous follow-up. Conclusions. Overall, the Malone antegrade continence enema procedure has been shown to be safe and highly effective. There is the potential for wider application in older age groups where sphincter and pelvic floor muscles have been compromised as a result of trauma or cancer surgery.

Objectives. Patients with neurogenic voiding dysfunction often have coexisting neurogenic bowel problems. Impaired bowel evacuation is a cause of major morbidity and impaired lifestyle for these patients. The Malone antegrade continence enema (ACE) performed synchronously with a urinary continence procedure has been successful in pediatric patients. We report early experience combining the ACE with a urinary continence procedure in adult neurogenic patients. Methods. Adult patients with neurogenic voiding dysfunction and impaired bowel evacuation refractory to conservative management underwent a urinary continence procedure synchronously with an ACE. Results. Two patients have undergone the procedure. One patient chose a continent catheterizable supravesical bladder augmentation, whereas the other patient chose an ileal conduit. Both patients had a separate appendiceal stoma for their ACE. Both patients are continent of stool at their appendiceal stoma and per rectum. Both patients have stabilized their urinary tracts. Complications were minimal. Conclusions. The ACE may benefit adult patients with impaired bowel evacuation and may be combined with a urinary continence procedure. Further study of the ACE is warranted.

The previously reported Malone antegrade continence enema (MACE) was used in 21 children for intractable fecal incontinence or constipation. Twelve are completely clean, and three are much improved (71% success rate). However, only four of the 21 have not had some type of complication, either minor or major. Five of the 21 now have a colostomy, and one has abandoned the procedure.

Eight patients with bowel incontinence underwent an open Malone Antegrade Continence Enema (MACE) procedure between May 1997 to May 2000. Indications for the procedure included high anorectal malformation in 3, bowel dysmotility in 1. spinal dysraphism in 3 and presacral teratoma in 1. Age at presentation varied between 06 to 12 years. All but one patient claimed excellent results. Complications of the procedure included stomal stenosis in 1, stomal leak in 2 and inadequate emptying of effluent in 1. Patient selection was the key to success. All patients except one, were children who were literate and had access to a western toilet Whereas, for the vast majority in the Indian rural setting, the procedure may not be beneficial but for a select group of bowel incontinence children, this procedure may bring a dawn of hope.

The Malone antegrade continence enema is effective in improving fecal continence in neurogenic bowel. We were able to perform this procedure laparoscopically via a single incision in a patient with spina bifida and fecal incontinence who did not require bladder reconstruction.

PURPOSE Cecal/colonic flap (CCF) has been suggested as an alternative to the appendix or Monti reconfigured ileum (MRI) for the Malone antegrade continence enema (MACE) procedure in children. The literature regarding its efficiency is scant. We, therefore, analyzed our results of MACE, and compared these 3 alternative techniques, regarding stomal incontinence, and stenosis/obstruction. MATERIAL AND METHODS We conducted a retrospective chart search. All patients who underwent the MACE procedures at our institute were included in our study. RESULTS Seventeen patients with fecal incontinence (11 males, 6 females; mean age 12.8 years) underwent the MACE procedure between 1998 and 2008. Diagnoses included myelodysplasia (8 patients), anorectal malformations (6), sacral agenesis (2), and pelvic trauma (1). The MACE conduits were constructed using the appendix in 5 patients, MRI in 8, and CCF in 4. One patient with an appendix-MACE underwent dilation of a stenosed stoma. In two of the patients with MRI revision was necessary for obstruction/stenosis. No appendix or MRI conduits leaked. All 4 patients with CCF conduits became incontinent 6 to 24 months following surgery. One of these patients also required dilation for stomal stenosis. Attempts to cure incontinence by submucosal injection of dextronomer/hyaluronic acid at the conduit-colon junction failed in 2 patients. Two CCF conduits were successfully replaced by MRI, 1 was replaced by button cecostomy, and 1 is awaiting reconstruction. CONCLUSIONS Our initial results reveal that CCF has failed as a conduit for the MACE procedure because of 100% stomal incontinence. We, therefore, abandoned this procedure, and recommend the appendix or MRI for MACE procedures.

Purpose The Malone antegrade continence enema (MACE) is a major advance in treating severe congenital bowel elimination disorders . Various colonic accesses are possible to perform bowel wash outs. Results of right (RACE) and left (LACE) colonic accesses using either appendix, Yang-Monti tube or Mickey button are compared. Material and methods It is a retrospective study of 32 MACE procedures performed in our department between May 1994 and April 2006. Results Male to female ratio was 0.77, with a median age of 13 years (range from 2 to 21 years) and a median follow up of 31 months (6 – 132 months). Indications were mainly spina bifida (19 patients). Twenty three achieved faecal continence, 6 failed (19%), 4 needed nappies for inadequate continence (2 with urinary incontinence), and 2 had a colostomy . Mean irrigation volume was 400 ml (200 - 1000 ml) 2 to 3 times a week. Two patients became clean without irrigation. Duration of bowel wash out was significantly shorter in the 15 LACE (mean 27mn; 10-45mn) compared to the 16 RACE (mean 45mn; 15-120 min). Four major complications (fistula, peritonitis, abscess and obstruction) and 8 minor complications (leakage, stenosis) occurred with 11 Monti tubes and 6 Mickey buttons. No major complications and 6 minor complications (leakage, false passage) were recorded in 14 appendix MACE. Conclusions Conclusion: The LACE procedure provides shorter duration of enemas and less abdominal discomfort whereas the appendix access has less complications than the other types of colonic access.

Introduction To report a single institution's long term results of the various MACE procedures in the treatment of chronic constipation in children with neuropathic bowel. Materials and methods A retrospective chart review of 253 MACE procedures was performed. Age at surgery, channel technique, location of stoma, number and type of revisions required and continence were documented and a database was created. Results 236 patients had at least 6 months follow-up and are included in this report. There were 172 In-situ appendicocecostomies, 23 split appendix channels, 9 appendicocecostomy with cecal extension, 22 Yang-Monti ileocecostomies and 10 colon flap colocecostomies. Mean age at surgery was 10.2 years (2-36 years), and mean follow-up was 50 months (6-115 months). 93% of the patients achieved faecal continence, with no difference between channel techniques. A total of 61 surgical revisions were performed in 56 patients (23.7%). Complications occurred more commonly with the split appendix (26%), and the caecal extension (33%) than the other techniques, but this did not reach statistical significance. There was no significant difference in stomal complications with an umbilical location (17.5%) versus lower abdominal stoma (15%). Mean time to revision for the entire cohort was 18.7 months (1-105 months). Conclusions The long term results of the MACE channel in large cohort of patients with chronic neuropathic constipation are encouraging. Almost 25% of the patients will require revisional surgery and patients/parents should be counselled accordingly. There were no differences in outcomes based on channel technique, though the apppendicocecostomy was associated with the lowest risk of re-operation.

The Malone antegrade continence enema (MACE) is a therapeutic option to treat chronic constipation and fecal incontinence in patients with neurogenic bowel. Previous reports have described the short-term success of this procedure, but no report has described the durability of the procedure during pregnancy. We present the case of a spinal cord injury patient who underwent an uncomplicated pregnancy after a MACE procedure with no stomal catheterization difficulties or leakage during or after the pregnancy.

The principles of antegrade colonic washout and the Mitrofanoff non-refluxing catheterisable channel were combined to produce a continent catheterisable colonic stoma. The intention was that antegrade washouts delivered by this route would produce complete colonic emptying and thereby prevent soiling. The procedure has been successfully carried out in five patients with intractable faecal incontinence.