www.elsevier.com/locate/jpedsurg

Journal of Pediatric Surgery (2009) 44, 783–787

Is the outcome of the left colon antegrade continenceenema better than that of the right colon antegradecontinence enema?Hyun-Young Kima, Sung-Eun Jungb,⁎, Seong-Cheol Leeb, Kwi-Won Parkb, Woo-Ki Kimb

aDepartment of Surgery, Gacheon University of Medicine and Science, Incheon, KoreabDepartment of Surgery, Seoul National University College of Medicine, Seoul 110-744, Korea

Received 21 May 2008; revised 29 August 2008; accepted 29 August 2008

0d

Key words:Fecal incontinence;Left antegradecontinent enema;

Children

AbstractBackground/Purpose: The purpose of this report was to review the results of the antegrade continenceenema (ACE) procedure and to compare the outcomes of right and left colon ACEs in children.Methods: Thirty patients who underwent an ACE between 1998 and 2005 were analyzed. Data wereobtained based on the following parameters: postoperative soiling, catheter insertion time, colonicwashout time, quality of life, and abdominal pain during and after the ACE. Twenty-nine patients werefollowed for an average of 3.8 years (range, 4 months-7.3 years).Results: Right colon ACEs were performed in 23 patients, and left colon ACEs were performed in7 patients. The common complications of the ACE included abdominal pain during and after the ACE(51.7%) and stoma strictures (41.4%). The overall ACE success rate was 24/29 (82.8%; right colonACE, 18/29; left colon ACE, 6/29). Twenty-three patients (95.8%) believed their quality of life wasimproved. There were no significant differences in complications or outcomes between the right andleft ACEs.Conclusions: An ACE is an effective treatment for children with fecal incontinence. A left colon ACEhas similar efficacy as a right colon ACE in managing fecal incontinence in children.© 2009 Elsevier Inc. All rights reserved.

Fecal incontinence is common in children who haveanorectal malformations, Hirschsprung disease, meningo-myeloceles, and spina bifida, and can negatively impact theirquality of life. Although some authors have reported goodresults for fecal incontinence with conservative bowelmanagement, consisting of enemas, laxatives, and medica-tions [1], traditional treatments of fecal incontinence, includ-

⁎ Corresponding author. Tel.: +82 2 2072 2338; fax: +82 2 766 3975.E-mail address: sejung@snu.ac.kr (S.-E. Jung).

022-3468/$ – see front matter © 2009 Elsevier Inc. All rights reserved.oi:10.1016/j.jpedsurg.2008.08.034

ing finger enemas, suppositories, retrograde enemas, andlaxatives, have often provided unsatisfactory results [2-5].

Since the creation of an antegrade continence enema(ACE) conduit using the appendix was first described byMalone et al [6], many modified ACE surgical proceduresusing the appendix or neoappendix of the cecal flap haveclearly been shown to improve the quality of life of manypatients with fecal incontinence [7-15].

However, it is not always possible to use the appendix tocreate a conduit suitable for catheterization; and positioningthe conduit in the appendix or cecum can cause a significant

784 H.-Y. Kim et al.

delay in colonic washout time and abdominal pain duringand/or after the ACE because of the length of the bowel.Recent reports have suggested that a left colon ACE can beperformed to overcome the problem of an ACE conduit usingan appendiceal or cecal flap [16-22].

We report our experience with the ACE procedure in30 patients and compare a right colon ACE (using anappendiceal or cecal flap) with a left colon ACE (using adescending colon flap) with respect to complications andoutcomes of the surgical technique, regulation of fecalsoiling, and improvement in quality of life.

1. Materials and methods

Between 1998 and 2005, the medical records of30 patients who had undergone an ACE procedure werereviewed retrospectively.

The mean age at the time of surgery was 9 years (range,5.8-16.6 years). There were 15 boys and 15 girls in the studygroup. The underlying diagnoses in these patients were allmeningomyeloceles.

Patients in whom the initial conservative treatment (ie,bulking agents and laxatives, antidiarrheals, retrogradeenemas, manual evacuation, rectal washouts, and biofeed-back methods) and/or sphincter reinforcement had failedwere considered candidates for the ACE procedure tomanage fecal incontinence.

1.1. Surgical technique and postoperativemanagement

Before December 2003, we performed the conduit fromthe appendix or the wall of the cecum in 23 patients asfollows: reversed appendicostomy as described by Maloneet al [6] in 1 patient, a simpler orthotopic appendicostomy[11,21] in 6 patients, and a neoappendicostomy using a cecalflap [12] in 16 patients. A neoappendicostomy using a cecalflap was created in which the appendix had previously beenremoved, the appendix was difficult to mobilize because ofsevere periappendiceal inflammation, or a urologic conduitformation was needed.

After December 2003, new conduits from the wall of thedescending colon, the so-called Macedo-Malone ACE proce-dure, were performed in 7 patients using a method similar to aprevious report [19]. In principle, the stoma openings weremade in the umbilicus for cosmetic reasons. With asimultaneous Mitrofanoff procedure in which the stoma waslocated in the umbilicus, the opening of the right colon ACEstoma was located in the right lower quadrant of the abdomen,whereas the left colon ACE was located in the left lowerquadrant of the abdomen. The conduit was brought out to theskin and 5-0 Vicryl sutures were used to fashion the stoma.Weused 8 interrupted simple sutures between the skin and stomawithout using the Vor V-Y flaps. An 8F to 10F silicone Foley

catheter was placed for 2weeks in the appendix on themucosalsurface or on the flap to allow tubularization. An antirefluxmethod for the continent valve mechanism was made bysimple intussusception of the appendix or a new conduit intothe cecum or descending colon [18,23]. In forming the stoma, asimple suture between the distal end of the conduit and the skinwas placed in all cases.

Antegrade continence enemas were begun 3 weeks aftersurgery with standard saline and phosphate enemas. Thevolume of the enema solution was 4 to 5 mL/kg initially andthen controlled according to the effect of antegrade washoutand concomitant gastrointestinal symptoms. The frequencyof the ACEs was once per 2 to 3 days, and the insertion of theFoley catheter was done once daily.

1.2. Follow-up

Twenty-nine patients with but 1 exception were followedbetween 4 months and 7.3 years (mean follow-up period,3.8 years). Follow-up information was gained by interview-ing the patient or parent with a letter and/or telephone using aquestionnaire. The following items were scored: occurrenceof postoperative soiling, surgical technique success (catheterinsertion time), time required for completion of the washouttime, and postoperative quality of life [7]. We also addedthe score regarding abdominal pain during and/or after theACE (Table 1).

We defined a right colon ACE as the cases in which theconduits were the appendiceal or cecal flaps and a left colon ACEas those in which the conduits were the descending colon flap.

The Mann-Whitney U test was used for comparison of theresults between the right and left colon ACEs. A P value lessthan .05 was considered significant.

2. Results

2.1. Complications

The complications are listed in Table 2.Abdominal pain occurred in 72.4% of the patients, and

severe abdominal pain occurred in 6 patients (20.7%). Threechildren had their enema regimens changed to tap water forresolution of their pain; however, in the other 3 patients, theACE ultimately failed to relieve the abdominal pain. Stomastrictures occurred in 41.4% of the patients; mild stricturesoccurred in 9 patients (31%) and were improved bymechanical dilation. Of the 3 patients with severe strictures,2 patients required surgical revision of the stoma, resulting inimprovement of the stricture in 1 patient and failure of theACE in 1 patient. In 1 patient with a stricture who did notundergo surgical revision, the stricture was improved usingmechanical Hegar dilatation.

Abdominal pain developed in 17 of 23 (73%) and 4 of6 patients (67%) after right and left ACEs, respectively.

Table 2 Comparison of complications between right ACE andleft ACE

Rt ACE(n = 23)

Lt ACE(n = 6)

No. of patients(n = 29)

%

Abdominal painMild 13 2 15 51.7Severe 4 2 6 20.7

Diarrhea 1 0 1 3.4Nausea 1 1 2 6.9Vomiting 1 1 2 6.9Epigastric soreness 1 0 1 3.4Stoma strictureMild 6 3 9 31Severe 2 1 3 10.3

Stoma leakage 2 1 3 10.3Stoma retraction 1 0 1 3.4Stoma prolapse 0 1 1 3.4Peristoma infection 1 1 2 6.9

Table 3 Comparison of outcome between right colon ACE andleft colon ACE

Rt colonACE (n = 18)

Lt colonACE (n = 6)

P value

Mean ± SD Mean ± SD

Occurrence ofpostoperative soiling

7.67 ± 3.08 6.33 ± 2.34 .251

Catheter insertion time 4.28 ± 1.12 4.83 ± 0.40 .31

Table 1 Scoring system of postoperative outcome after ACEprocedure

Item score

Occurrence of postoperative soilingNone 10b1/mo 8b1/wk 6b1/d 4N1/d 2Catheter insertion timeImmediate 5b5 min 4b10 min 3b15 min 2N15 min 1Colonic washout timeb30 min 5b45 min 4b60 min 3b90 min 2N90min 1Postoperative quality of lifeIdeal 5Great improvement 4Definite improvement 3Some improvement 2Little improvement 1No improvement 0Abdominal pain during/post ACENo pain 3Mild pain 2Moderate pain 1Severe pain 0

Optical score: 28.

785Comparing the outcome of right colon ACE with left colon ACE in child

Stoma strictures occurred more frequently after a left ACE(4/6, 66.7%) than a right ACE (8/23, 34.8%), but there wasno statistically significant difference between the 2 groups.

2.2. Analyses of successful cases

The overall ACE success rate was 24 of 29 patients (82.8%).Fecal soiling was completely eliminated in 10 patients

(41.7%). Five patients (20.8%) experienced less than 1 episodeof soiling eachmonth. Twelve patients (50%) believed that theirquality of life was ideal or greatly improved, and 11 patients(45.8%) thought that their quality of life had definitelyimproved compared with their quality of life before surgery.

In comparison of the outcomes based on the scoring system(Table 1), there were no significant differences between a rightcolon ACE and a left colon ACE (P N .05, Table 3).

Colonic washout time 3.67 ± 1.02 3.00 ± 1.26 .343Postoperative qualityof life

3.67 ± 1.03 3.50 ± 0.84 .581

Abdominal painduring/post ACE

1.39 ± 1.09 1.67 ± 1.37 .673

Total score 20.66 ± 5.41 19.33 ± 2.16 .224

3. Discussion

There have been numerous modified surgical proceduressince the first report by Malone et al [6,8,9,12,13,

16-19,21,22,24-29]. When the appendix is inadequate forthe conduit because of adhesions or inappropriate struc-tures, when the appendix is surgically absent, or when theappendix is previously used for a continent urinary channel,alternate techniques are required. Substitutions for theappendix in the Malone ACE procedure have included aportion of the tubularized cecum and the defunctionalizedureter [8,12,24]. Others have reported success with openplacement of gastrostomy buttons or button cecostomies[8,9,25]. The appendix for the ACE conduit can be replacedby a Monti tube, which is an intestinal conduit (ileum orcecum) with longitudinal folds, thus making catheterizationsimpler [12,13,16,28].

As clinical experience with the right colon ACE hasaccumulated, there have been a number of limitations noted,including the proximity of the Mitrofanoff stoma when aconcomitant bladder access is created, prolonged evacuationtime of the ACE, and abdominal pain during and/or afteradministration of the enema [18-20].

786 H.-Y. Kim et al.

To solve these problems, Liloku et al [16] described a leftcontinent access to the large bowel, assuming that theemptiness of the left colon and rectum was adequate toprovide fecal continence. Despite the preliminary results,they found that the left Monti-Malone procedure has had asignificant impact not only on fecal continence, but also onquality of life for these patients. Churchill et al [22] alsoreported that the Monti-Malone ACE procedure, using theleft colon as a source for the intestinal conduit, has theadvantage of predictable bowel evacuation.

Using the Macedo-Malone ACE procedure [19], which isa continent mechanism based on a flap of intestinal tissue,Calado et al [18] suggested that the descending colon ACEwas effective in evacuating the colon and rectum. Otherreports in which tube sigmoidostomy has been performedhave yielded similar results. It has been suggested that tubesigmoidostomy is a simpler technique because of redun-dancy of the mesentery [17,21].

In summary, the left colon ACE procedure has severaladvantages, including gravity-assisted evacuation, avoidanceof the right and transverse portions of the colon (which havea large volume capacity and in which the bulk of waterreabsorption occurs), and predictable bowel movements.

In 2003, we introduced the descending colon ACEprocedure (ie, the Macedo-Malone procedure) [18,19] toreduce the colonicwashout time and abdominal pain.However,we did not confirm that the left ACE is superior to the rightACE in reducing the colonicwashout time and abdominal pain.The outcome of the left ACEwas just similar to that of the rightACE. The smaller number and the shorter-term follow-upperiods of left ACE are possible causes of that result.

In analysis of complications in ACE procedure, thepresent results showed that stoma strictures occurred in 41%of patients and were thus more frequent than reported inprevious series, ranging between 0 and 40% of cases[13,14,24,30-32]. We postulate that mild stoma strictureswere underestimated in other studies because strictures areeasily resolved by simple dilatation. In our study, most stomastrictures (10/12) were improved by Hegar dilatation. Theoccurrence of a stoma stricture may be reduced by gentledilatation and instructing patients to insert a catheter throughthe stoma once or twice everyday [33]. Furthermore, thelower frequency of stoma strictures in other studies may havereflected the shorter length of follow-up compared with ourstudy. In fact, when we followed our patients over the shortterm, we misjudged the results of simple sutures in formationof the stoma and not using a V or V-Y flap. However, afterlong-term follow-up, we determined that simple suturescould lead to stoma strictures more frequently than the V orV-Y flap methods. Although there were no statisticallysignificant differences between the complications with rightand left ACEs, our results indicated a tendency toward morefrequent stoma strictures after a left ACE. We presume thatthe original appendix was used as a conduit in some cases ofright ACEs in contrast to left ACEs in which the conduitswere all colon flaps. Actually, most of the stoma strictures

after right ACEs developed in cecal flaps in the presentstudy. Therefore, to avoid devascularization during thetubularization portion of the procedure, it is most importantto prevent stoma strictures. The surgeon must realize that asimple stitch may make the lumen of the conduit narrowenough to interfere with catheterization.

In summary, there was no significant difference ofoutcome and complication between right ACE and left ACE.

This is the first study in which the outcomes werestatistically evaluated between the 2 ACE procedures (ie, theleft vs right colon ACE procedures) when performed by1 surgeon and in 1 center. Larger studies are needed forfurther evaluation of the ACE procedure, and the long-termresults have yet to be verified.

References

[1] Peña A, Guardino K, Tovilla JM, et al. Bowel management for fecalincontinence in patients with anorectal malformations. J Pediatric Surg1998;33:133-7.

[2] Malones PS, Wheeler RA, Williams JE. Continence in spina bifidapatients: long-term results. Arch Dis Child 1994;70:107-10.

[3] Glickman S, Kamm MA. Bowel dysfunction in spinal cord-injurypatients. Lancet 1996;1651:347.

[4] Hassink EA, Rieu PN, Brugman AT. Quality of life afteroperatively corrected high anorectal malformation: a long termfollow up study of patients aged 18 years and older. J PediatricSurg 1994;29:773-6.

[5] Rintala R, Mildh L, Lindahl H. Fecal continence and quality of life foradult patients with an operated high or intermediate anorectalmalformation. J Pediatric Surg 1994;29:777-80.

[6] Malone PS, Ransley PG, Kiely EM. Preliminary report: the antegradecontinence enema. Lancet 1990;336(8725):1217-8.

[7] Schell SR, Toogood GJ, Dudley NE. Control of fecal incontinence:continued success with the Malone procedure. Surgery 1997;122(3):626-31.

[8] De Peppo F, Iacobelli BD, De Gennaro M, et al. Percutaneousendoscopic cecostomy for antegrade colonic irrigation in fecallyincontinent children. Endoscopy 1999;31(6):501-3.

[9] Shandling B, Chait PG, Richards HF. Percutaneous cecostomy: a newtechnique in the management of fecal incontinence. J Pediatr Surg1996;31(4):534-7.

[10] Monti PR, Lara RC, Dutra MA, et al. New techniques for constructionof efferent conduits based on the Mitrofanoff principle. Urology 1997;49(1):112-5.

[11] Gerharz EW, Vik V, Webb G, et al. The in situ appendix in the Maloneantegrade continence enema procedure for faecal incontinence. Br JUrol 1997;79(6):985-6.

[12] Kiely EM, Ade-Ajayi N, Wheeler RA. Caecal flap conduit forantegrade continence enemas. Br J Surg 1994;81(8):1215.

[13] Ellsworth PI, Webb HW, Crump JM, et al. The Malone antegradecolonic enema enhances the quality of life in children undergoingurological incontinence procedures. J Urol 1996;155(4):1416-8.

[14] Levitt MA, Soffer SZ, Pena A. Continent appendicostomy in the bowelmanagement of fecally incontinent children. J Pediatr Surg 1997;32(11):1630-3.

[15] Goepel M, Sperling H, Stohrer M, et al. Management of neurogenicfecal incontinence in myelodysplastic children by a modified continentappendiceal stoma and antegrade colonic enema. Urology 1997;49(5):758-61.

[16] Liloku RB, Mure PY, Braga L, et al. The left Monti-Malone procedure:preliminary results in seven cases. J Pediatr Surg 2002;37(2):228-31.

787Comparing the outcome of right colon ACE with left colon ACE in child

[17] Whineray Kelly E, Bowkett B. Tube sigmoidostomy: a modification ofthe antegrade colonic evacuation. ANZ J Surg 2002;72(6):397-9.

[18] Calado AA, Macedo Jr A, Barroso Jr U, et al. The Macedo-Maloneantegrade continence enema procedure: early experience. J Urol 2005;173(4):1340-4.

[19] Macedo Jr A. Re: use of a colon based tubularized flap for an antegradecontinence enema. J Urol 2003;170(1):193.

[20] Diamond DA, Pohl HG. Use of a colon based tubularized flap for anantegrade continence enema. J Urol 2003;169(1):324-6.

[21] Ahn SM, Han SW, Choi SH. The results of antegrade continenceenema using a retubularized sigmoidostomy. Pediatr Surg Int 2004;20(7):488-91 [Epub 2004 Jul 28].

[22] Churchill BM, De Ugarte DA, Atkinson JB. Left-colon antegradecontinence enema (LACE) procedure for fecal incontinence. J PediatrSurg 2003;38(12):1778-80.

[23] Kajbafzadeh AM, Chubak N. Simultaneous Malone antegradecontinent enema andMitrofanoff principle using the divided appendix:report of a new technique for prevention of stoma complications.J Urol 2001;165(6 Pt 2):2404-9.

[24] Griffiths DM, Malone PS. The Malone antegrade continence enema.J Pediatr Surg 1995;30(1):68-71.

[25] Chait PG, Shandling B, Richards HF. The cecostomy button. J PediatrSurg 1997;32(6):849-51.

[26] Kajbafzadeh AM, Sina AR, Moradi A, et al. Laparoscopic antegradecontinent enema through VQ stoma skin flaps using two ports: long-term follow-up. J Endourol 2007;21(1):78-82.

[27] Shadpour P, Simforoosh N, Magsudi R, et al. Totally laparoscopiccombined freehand ileocystoplasty and Malone procedures.J Endourol 2005;19(4):471-5.

[28] Perez M, Lemelle JL, Barthelme H, et al. Bowel management withantegrade colonic enema using a Malone or a Monti conduit—clinicalresults. Eur J Pediatr Surg 2001;11(5):315-8.

[29] Yerkes EB, Rink RC, Cain MP, et al. Use of a Monti channel foradministration of antegrade continence enemas. J Urol 2002;168(4 Pt 2):1883-5 [discussion 1885].

[30] Thomas JC, Dietrich MS, Trusler L, et al. Continent catheterizablechannels and the timing of their complications. J Urol 2006;176(4 Pt 2):1816-20.

[31] Curry JI, Osborne A, Malone PS. The MACE procedure: experience inthe United Kingdom. J Pediatr Surg 1999;34(2):338-40.

[32] Squire R, Kiely EM, Carr B, et al. The clinical application of theMalone antegrade colonic enema. J Pediatr Surg 1993;28(8):1012-5.

[33] Hunter MF, Ashton MR, Griffiths DM, et al. Hyperphosphataemiaafter enemas in childhood: prevention and treatment. Arch Dis Child1993;68(2):233-4.