Antegrade Continence Enema and Its Application in Africa By B. Banieghbal and M.R.Q. Davies

Johannesburg, South Africa

Background: Antegrade continent enema (ACE) procedure has been accepted worldwide as the salvage procedure for intractable constipation and faecal incontinence after anorec- tal malformation surgery. Its application only has been re- ported from the developed countries.

Methods: The authors performed four such operations on incontinent children in a poor socioeconomic group in South Africa.

Results: Three patients had previous surgery for anorectal malformation, and one had intractable encopresis. The pa- tients kept clean with water washouts only, starting 1 week after the operation.

Conc/usions: The ACE procedure can be used easily by patients in disadvantaged communities of Africa, and its use requires minimal but sympathetic supervision only. The

authors recommend that all pediatric surgeons dealing with these unfortunate children should perform this procedure after a trial period of medical treatment. This is also the first report of the ACE procedure performed for an encopretic

child. J Pediatr Surg 34:390-391. Copyright o 1999 by W.B. Saun- ders Company.

INDEX WORDS: Fecal incontinence, colonic irrigation.

NORECTAL MALFORMATION (ARM) in a new- A born is a commonly encountered condition seen by all pediatric surgeons. Fecal incontinence can develop later in life, and its severity largely depends on the type of the anomaly.1,2

In 1990, Malone et al3 introduced a new technique for managing faecal soiling in children. It involves the formation of a continent appendicostomy through which the cecum could be intermittently catheterized to admin- ister antegrade washouts to prevent soiling.3 The opera- tion was termed antegrade continence enema (ACE) procedure. This technique has been adopted by many surgeons but only in the developed countries.4-7

MATERIALS AND METHODS

Baragwanath Hospital is a 3,200-bed hospital &liated with the University of the Witwatersrand, Johannesburg and serves the black township of Soweto and the surrounding regional hospitals. Our unit deals with 20 new cases of anorectal malformations per year. One quarter of these babies have low anomaly and are treated by immediate anoplasty or miniposterior sagittal anorectoplasty (PSARP). The remain- ing three quarters have high or intermediate anomaly, and these neonates undergo colostomy and subsequent PSARP at 6 to 8 months of age. Satisfactory control develops in most of the patients; however, because of a combination of uncontrollable factors, about one third of the high-intermediate anomaly group of patients return with varying

From the Division of Paediatric Surgery, CH Baragwanath Hospital, Witwatersrand University, Johannesburg, Republic of South Africa.

Address reprint requests to B. Banieghbal MB, FRCSI, Consultant in Paediatric Surgery, CH Baragwanath Hospital, Soweto, Johannesburg, Republic of South Africa.

Copyright o 1999 by WB. Saunders Company

0022.3468/99/3403-0004$03.00/O

degrees of fecal incontinence later in life. This group of patients requires further treatment, with a small number remaining unresponsive to medical treatment. Four patients with severe fecal incontinence were seen in a 2-year period, and all underwent the ACE procedure after detailed discussions with the parents. Three patients had previous surgery for anorectal malformation. These three patients had significant fecal soiling and were unresponsive to medical treatment for at least 2 years before the ACE procedure. This modality of treatment included dietary manipulation, suppositories, manual disimpaction, and enema therapy. The fourth patient had no anatomic abnormalities but had significant fecal soiling (encopresis) and was unresponsive to medical and psychological treatment for 6 years.

The surgical technique was similar to those described by Malone.9 We used a tubularized cecal flap in one case because the appendix was unavailable.

RESULTS

All four patients are from poor socioeconomic circum- stances and living in poor townships surrounding the city of Johannesburg. They all had good results from their ACE procedure.

For bowel washouts, the patients use a large feeding tube to intubate the stoma and a 60-mL bladder syringe for washouts. The washouts were performed using clean water with amounts varying from 750 mL to 1,500 mL per washout. The follow-up period was from 1 to 2 years.

Stoma1 stenosis developed in two patients within 6 months of surgery, one of which required the revision of the ACE stoma. There were no other significant complica- tions.

DISCUSSION

The ACE procedure, since its introduction 8 years ago, has been adopted and modified by many pediatric sur-

Journal of Pediatric Surgery, Vol 34, No 3 (March), 1999: pp 390-391

ANTEGRADE CONTINENCE ENEMA 391

geons around the world. It has proven to be a useful method in dealing with patients with intractable constipa- tion and fecal incontinence. It yields good results, which satisfies both the patients and their families. Unfortu- nately, the international experience has been reported only from the developed countries,4,5,7,8 with no reported cases from Africa or other underdeveloped countries.

One of our patients had unresponsive encopresis. The ACE procedure has not been described previously for this condition, and we do not recommend such an operation routinely for this condition, but it has some merit if all other modalities of treatment have failed.

Our initial experience from South Africa confirms that the ACE procedure has an excellent long-term result, and we find that the poor socioeconomic status of our patients serves as no contraindication to this procedure. More importantly, minimal training of the patients and their parents is required for its acceptance and use.

Caution should be applied in performing this proce- dure (1) too early in life because participation of the child is essential for its continuing success and (2) for those who have poor family support for obvious reasons.

Our patients and their families have been very grateful after the ACE procedure, and they have managed to perform the washouts adequately, even though all of them live in homes with no running water and poor sanitation.

REFERENCES

1. Perk A: Anorectal malformation. Sem Paed Surg 4:35-47, 1995 2. Langemeijer RA, Molenaar JC: Continence after posterior sagittal

anorectoplasty. J Pediatric Surg 26:587-590, 1991 3. Malone PS, Ransley PG, Kiely EM: Preliminary report: The

antegrade continence enema. Lancet 2:1217-1218, 1990 4. Koyle MA, Kaji DM, Dugue M, et al: The Malone antegrade

continence enema for neurogenic and structural incontinence and constipation. J Urol 154:756-61, 1995

5. Ehrlich RM (ed): Bowel management after surgery for imperfo- rate anus. Dialogues in Pediatric Urology 12:1-g, 1995

6. Malone PSJ: The management of bowel problems with urological disease. Br J Urol76:220-223, 1995

7. Chait PG, Shandling B, Richards HF: The Caecostomy button. J Pediatr Surg 32:849-851, 1997

8. Yammamoto T, Kubo H, Honzumi F: Fecal incontinence success- fully managed by antegrade continence enema in children: A report of two cases. Surg Today 26:1024-1028, 1996

9. Malone PS: Malone procedure for antegrade continence enema, in Rob & Smith’s Operative Surgery. Paediatric Surgery, London, En- gland, Chapman and Hall Medical Pub, 1995, pp 459-467