Experience of the MACE Procedure at A Regional Pediatric Surgical Unit: A 15-Year Retrospective Review
12 May 2013
22 August 2013
17 January 2014 (online)
Introduction The Malone antegrade continence enema (MACE) procedure is an established treatment option for children with constipation or fecal incontinence. This study retrospectively analyses the management and outcomes of children who underwent MACE procedures at a regional pediatric surgery unit.
Patients and Methods Children who underwent a MACE procedure in our unit between 1998 and 2012 were identified. Demographic and clinical data were obtained from contemporaneous records. Using the continence scale described by Malone, overall outcomes were categorized as full, partial, or failure (full: totally clean or minor rectal leakage on night of washout; partial: clean but significant stoma or rectal leakage, occasional major leak and/or still wearing protection but perceived by child or parent to be an improvement; failure: regular soiling or constipation persisted, no perceived improvement, procedure was abandoned). Data entry and statistical analysis were performed using Excel and SPSS (IBM Corp., Armonk, New York, United States).
Results A total of 40 children (29 male) were identified for inclusion. Underlying diagnoses were idiopathic constipation (16), anorectal anomalies (14) and Hirschprung's disease (10). The MACE procedure was performed laparoscopically in 26 cases and using an open technique in 14 cases. Mean age at the time of surgery was 8.9 years (range, 3–19 years) and mean follow-up time was 6.5 years (range, 1–10 years). Outcomes categorized as full were 62.5% for chronic idiopathic constipation (CIC), 71.4% for anorectal malformation (ARM), and 70% for Hirschsprung disease (HD). Overall success rates (full and partial outcomes combined) were 87.5% for CIC, 92.8% for ARM, 100% for HD, and 92.5% for all diagnoses taken together. Eleven MACE procedures (27.5%) were reversed, in seven (17.5%) due to the return of spontaneous and regular bowel movements and in four (10%) due to stomal problems.
Conclusion This study identified a high success rate (combining full and partial outcomes) of 92.5% for MACE procedures within our unit. An encouraging finding is that the procedure was reversed in a significant proportion of patients following the return of normal bowel habits.
- 1 National Institute for Health and Care Excellence. Constipation in Children and Young People: NICE Guidance. London: National Institute for Health and Care Excellence; 2010
- 2 Shankar KR, Losty PD, Kenny SE , et al. Functional results following the antegrade continence enema procedure. Br J Surg 1998; 85 (7) 980-982
- 3 Bau MO, Younes S, Aupy A , et al. The Malone antegrade colonic enema isolated or associated with urological incontinence procedures: evaluation from patient point of view. J Urol 2001; 165 (6 Pt 2) 2399-2403
- 4 Aksnes G, Diseth TH, Helseth A , et al. Appendicostomy for antegrade enema: effects on somatic and psychosocial functioning in children with myelomeningocele. Pediatrics 2002; 109 (3) 484-489
- 5 Curry JI, Osborne A, Malone PS. The MACE procedure: experience in the United Kingdom. J Pediatr Surg 1999; 34 (2) 338-340
- 6 Squire R, Kiely EM, Carr B, Ransley PG, Duffy PG. The clinical application of the Malone antegrade colonic enema. J Pediatr Surg 1993; 28 (8) 1012-1015
- 7 Koyle MA, Kaji DM, Duque M, Wild J, Galansky SH. The Malone antegrade continence enema for neurogenic and structural fecal incontinence and constipation. J Urol 1995; 154 (2 Pt 2) 759-761
- 8 Dick AC, McCallion WA, Brown S, Boston VE. Antegrade colonic enemas. Br J Surg 1996; 83 (5) 642-643
- 9 Ellsworth PI, Webb HW, Crump JM, Barraza MA, Stevens PS, Mesrobian HG. The Malone antegrade colonic enema enhances the quality of life in children undergoing urological incontinence procedures. J Urol 1996; 155 (4) 1416-1418
- 10 Schell SR, Toogood GJ, Dudley NE. Control of fecal incontinence: continued success with the Malone procedure. Surgery 1997; 122 (3) 626-631
- 11 Goepel M, Sperling H, Stöhrer M, Otto T, Rübben H. Management of neurogenic fecal incontinence in myelodysplastic children by a modified continent appendiceal stoma and antegrade colonic enema. Urology 1997; 49 (5) 758-761
- 12 Sheldon CA, Minevich E, Wacksman J, Lewis AG. Role of the antegrade continence enema in the management of the most debilitating childhood recto-urogenital anomalies. J Urol 1997; 158 (3 Pt 2) 1277-1279 , discussion 1279–1280
- 13 Malone PS, Ransley PG, Kiely EM. Preliminary report: the antegrade continence enema. Lancet 1990; 336 (8725) 1217-1218
- 14 Dey R, Ferguson C, Kenny SE , et al. After the honeymoon—medium-term outcome of antegrade continence enema procedure. J Pediatr Surg 2003; 38 (1) 65-68 , discussion 65–68
- 15 Yardley IE, Pauniaho S-L, Baillie CT , et al. After the honeymoon comes divorce: long-term use of the antegrade continence enema procedure. J Pediatr Surg 2009; 44 (6) 1274-1276 , discussion 1276–1277
- 16 Curry JI, Osborne A, Malone PS. How to achieve a successful Malone antegrade continence enema. J Pediatr Surg 1998; 33 (1) 138-141
- 17 Nanigian DK, Kurzrock EA. Intermediate-term outcome of the simplified laparoscopic antegrade continence enema procedure: less is better. J Urol 2008; 179 (1) 299-303
- 18 Rajimwale A, Malone PS. The Malone antegrade continence enema (MACE) procedure. In: Stringer MD, Oldham KT, Mouriquand PDE. Pediatric Surgery and Urology: Long-Term Outcomes. 2nd ed. Cambridge: Cambridge University Press; 2006: 429-434
- 19 Heshmat S, DeFoor W, Minevich E, Reddy P, Reeves D, Sheldon C. Use of customized MIC-KEY gastrostomy button for management of MACE stomal complications. Urology 2008; 72 (5) 1026-1029