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INTRODUCTION

THE ANTEGRADE CONTINENCE ENEMA (ACE) was firstdescribed in 1990 by Malone et al. for intractable fe-

cal incontinence of varying etiology.1 This has dramati-cally improved the life for many fecally incontinent chil-dren. Patient satisfaction with the ACE procedure is veryhigh and complete resolution of fecal soiling has been re-

JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUESVolume 16, Number 2, 2006© Mary Ann Liebert, Inc.

Laparoscopic Antegrade Continence Enema Using a Two-Port Technique

BRICE ANTAO, MBBS, MRCS, JOANNE NG, MBChB, and JULIAN ROBERTS, MS, FRCS (PAED)

ABSTRACT

Background: The antegrade continence enema is an effective method of treatment of fecal inconti-nence. We report our experience of a laparoscopic antegrade continence enema procedure and de-scribe a simple approach to this procedure using a two-port technique.

Materials and Methods: Over a 3-year period, 12 children with intractable constipation and fecalsoiling underwent the antegrade continence enema procedure laparoscopically. All cases had fullbowel preparation the day before surgery. This procedure was done through one 5-mm camera portand two 5-mm working ports in 8 cases, and using the camera port and only one additional 5-mmworking port in 4 cases. The appendix was used in 5 cases and the cecum in 3 cases with the three-port technique while the appendix was used in all 4 cases with the two-port technique. The appen-dix or cecum was delivered extracorporeally through the 5-mm port site in the right lower quad-rant. The mucocutaneous anastomosis was stented using a gastrostomy button.

Results: Between 2001 and 2004, 12 children (10 male, 2 female) underwent a laparoscopic ante-grade continence enema procedure at a median age of 10.5 years (range, 7–14 years). This proce-dure was easy to perform and no case required conversion to an open procedure. The wash-outsvia the MIC-KEY gastrostomy button (MIC-KEY, Kimberly-Clark) were commenced at a medianof 3.5 days (range, 1–5 days). Median postoperative hospital stay was 2 days (range, 1–5 days). Thisprocedure was effective in completely resolving fecal incontinence in 9 cases and partially resolvingit in 3 cases. There were no episodes of stomal stenosis, leakage, or herniation. However, one caserequired a revision of antegrade continence enema due to wound breakdown and leakage of irri-gation fluid around the stoma. The median follow-up period was 15.5 months (range, 5–32 months).

Conclusion: The laparoscopic technique is a simple and effective approach in creating an ante-grade continence enema. The use of a gastrostomy button can potentially reduce some of the com-plications commonly associated with an antegrade continence enema. We describe a procedure thatincorporates the advantages of both laparoscopy and a button device, which is simple and easy toperform using just two ports.

Paediatric Surgical Unit, Sheffield Children’s Hospital, Sheffield, United Kingdom.Presented at the International Pediatric Endosurgery Group 14th Annual Congress for Endosurgery in Children, Venice, Italy,

June 2005.

LAPAROSCOPIC ANTEGRADE CONTINENCE ENEMA 169

ported in as many as 95% of patients.2 However, this pro-cedure is not without significant potential problems suchas stomal stenosis, stomal prolapse, and stool leakage.3

More recently the use of laparoscopic techniques inconstruction of an ACE is evolving as a minimally in-vasive approach to reduce the morbidity commonly as-sociated with this procedure.3–9 We report our experienceof the use of laparoscopy in creating an ACE channel.The technical feasibility of achieving this using two portsis also described, along with the technique and advan-tages of using a button device.

MATERIALS AND METHODS

Over a period of 3 years, 12 children (10 males, 2 fe-males) underwent a laparoscopic ACE procedure. The ap-pendix was used in 9 cases and the cecum in 3 cases. Thisprocedure was done through one 5-mm camera port andtwo 5-mm working ports in 8 cases and using the cameraport and only one additional 5-mm working port in 4 cases.

Patient selection

All children suffered from intractable constipation orencopresis and had failed multiple bowel evacuation reg-imens. These included a combination of different laxa-tives, suppositories, enemas, use of bowel cleansing so-lutions via a nasogastric tube, and manual evacuation offeces under a general anaesthetic. All cases had a detailedassessment by a specialist continence nurse in order toassist with compliance.10

Patient preparation

The children were admitted the day before surgery fora full mechanical bowel preparation using polyethylene

glycol 3350 (Klean-Prep®, Norgine, United Kingdom).This procedure was done using a general anaesthetic andbroad spectrum antibiotics were administered periopera-tively.

Surgical technique

The child was placed in a supine position. The surgi-cal table was positioned so that the patient was in a 45-degree Trendelenburg position with a 45-degree left lat-eral rotation. Pneumoperitoneum was established withcarbon dioxide at a pressure of 12 mm Hg, after openplacement of a 5-mm port through the umbilicus (KarlStorz, Tullingen, Germany). The abdominal contentswere inspected with a camera inserted through this port.An additional 5-mm port was inserted at the level ofMcBurney’s point in the right lower quadrant (Fig. 1).Both port sites were infiltrated with 0.5% Marcaine priorto insertion. The appendix was identified and the tipgrasped with a grasping forceps passed through the rightlower quadrant port. The appendix was then carefullypulled through this port site under direct vision with si-multaneous removal of the port. In cases with a thickerabdominal wall, the port site had to be stretched to fa-cilitate delivery of the appendix.

The appendiceal mesentery was then freed using elec-trocautery 1–2 cm from its base (Fig. 2). The appendixwas then transected at this level and held with 2 or 3 re-traction sutures. The appendicostomy was anastomosedto the skin in a circular fashion using interrupted 4/0polyglactin sutures (Vicryl, Ethicon UK Ltd). A stomameasuring device (MIC-KEY, Kimberly-Clark, USA)was then passed through the appendix into the cecum

FIG. 1. Operative picture showing the site of the two ports.The camera is passed through the umbilical port and the grasp-ing forceps through the right lower quadrant port.

FIG. 2. The appendix delivered through the right lower quad-rant port site and the mesoappendix divided. The clamp on theappendix (A) indicates the level of appendicular stump for cre-ating the antegrade continence enema (ACE) stoma and the for-ceps (B) demonstrates the preserved mesoappendix with vas-culature to the base of the appendix.

170 ANTAO ET AL.

(Fig. 3). Based on this calibration, the ACE stoma wasstented using either a 12Fr or 14Fr (1.5–2.5 cm) low pro-file MIC-KEY gastrostomy button (Fig. 4).

In cases where the cecum was used, this was pulledthrough the right lower quadrant port in a similar fash-ion as above. A purse-string suture using 5/0 polydiox-anone sutures (PDS®II, Ethicon UK Ltd) was placedalong the selected enterostomy site. A MIC-KEY buttonwas then placed into the cecum via a stab wound and thesuture tied around the shaft of the button. Three to fouranchoring sutures were then placed between the intesti-nal wall and under the surface of the abdominal wall sur-rounding the button device. The umbilical port site wasclosed with 3/0 Vicryl polyglactin sutures and cyano-acrylate glue (Liquiband, Medlogic, UK) was applied tothe skin.

Postoperative management

With the dedicated support of a specialist nurse, awashout program was commenced at a median of 3.5days (range, 1–5 days). Most cases had their first washoutwhile in hospital and subsequent washouts at home su-pervised by a specialist nurse. The frequency of washoutswas on alternate days to start with and was then tailoredaccording to individual response to once or twice a week.The washouts were performed using phosphate enema(30–100 mL) followed by a flush (200–1000 mL) using1 teaspoon of table salt per 600 mL of warm tap water.

RESULTS

Between 2001 and 2004, 12 children, median age 10.5years (range, 7–14 years), underwent a laparoscopic ACEprocedure. This procedure was easy to perform and no

case required conversion to an open procedure. In all 4cases using the two-port technique, no technical difficultywas encountered in mobilizing the appendix and form-ing an ACE stoma. An additional port was not necessaryin these 4 cases.

Median postoperative hospital stay was 2 days (range,1–5 days). This procedure was effective in completelyresolving fecal incontinence in 9 cases and partially re-solving the symptoms in 3 cases. The persistent soilingin these 3 cases was due to a lack of compliance with thewashouts. These cases required one or more hospitaliza-tions for bowel clearance using Klean-Prep irrigation,with subsequent improvement in soiling. There were noepisodes of stomal stenosis, leakage, or herniation. How-ever, one case required a revision of ACE due to woundbreakdown and leakage of irrigation fluid around thestoma. The median follow-up period was 15.5 months(range, 5–32 months).

DISCUSSION

Since the first description of the ACE procedure in1990, a number of modifications have been described.Although there are many different techniques to achievean ACE, the common goals are to allow easy access tothe colon, perform a one-way irrigation, and provide areasonable predictability of fecal continence.11,12 Thedisadvantages of the original ACE procedure includetechnical difficulty and high complication rates(30–81%).11 Several studies have reported various com-plications associated with an ACE procedure (Table1).3,11,13–16 Several modifications of the original tech-nique have been described in an attempt to simplify theprocedure and achieve a continent ACE channel withminimal complications. These include application of the

FIG. 3. The stoma measuring device passed through the ap-pendicostomy.

FIG. 4. Antegrade continence enema (ACE) stoma stentedwith a low profile gastrostomy button.

LAPAROSCOPIC ANTEGRADE CONTINENCE ENEMA 171

Boari and Monti principle, variations on the technique ofappendicostomy, performing an antireflux mechanism, aswell as open and percutaneous placement of a cecostomybutton device.17–23

The most common complication of an ACE procedureis stomal stenosis, with an incidence of 55% in one se-ries.24 The majority of these cases can be managed withsimple dilatations. However, revision surgery for stomalstenosis have been necessary in 19–22% of cases.24,25

Various procedures like inverted-V incision, VQZ inci-sion, and Y appendicoplasty have been described to min-imize stomal complications.3,26,27 There is no differencein the stomal stenosis rate depending on its location inthe umbilicus or right lower quadrant.28 Some authorsrecommend using the umbilicus because of its cosme-ically appealing results.3,18,28 We prefer forming thestoma on the right lower abdomen, as this approach re-quires less cecal mobilization and manipulation. Bychoosing the shortest and straightest route of exit to theMcBurney’s point, the common problems of kinking, in-testinal obstruction, and torsion are obviated.11

Redel et al. first described the use of a button devicefor the management of fecal impaction in children in1992.21 We have used this principle to stent the ACEchannel in all our cases, with a good outcome. There havebeen no cases of stomal stenosis in our cohort. Problemssuch as painful or difficult catheterization are avoidedwith the use of a button device. Complications associatedwith the button device include the button falling out, hy-pergranulation tissue around the button, and wound in-fection.15,23,29 These were not encountered in our seriesdue to a good preoperative bowel preparation, perioper-ative antibiotics, and creation of a watertight continentchannel. This was facilitated by using an appropriate sizebutton device through an appendix stump and with metic-

ulous anchoring of the button around the cecal stoma ina fashion to achieve watertight closure.

Stomal leakage is another distressing problem, occur-ring in about 7% of cases with either laparoscopic or openACE.13,30 Some studies have advocated the use of an an-tireflux procedure such as imbrication of the cecum tocontrol leakage from the stoma,3–7 but it is of no majorbenefit and significantly increases the invasiveness andcomplexity of the operation.14,30 It has been suggestedthat the continence mechanism depends on an appen-diceal length between 5–8 cm and small 5–8Fr lumen.8

A longer and narrower appendiceal stump is more likelyto cause stenosis and result in difficult catheterization dueto kinking. Problems such as intestinal obstruction andtorsion are more likely to occur with a longer appendiceallength. ACE procedures using a button device do notseem to have problems with stomal leakage.15 We main-tain a 1–2 cm appendiceal stump, which is sufficient toaccommodate a 1.5–2.5 cm gastrostomy button withoutany stomal leakage. One case developed leakage of irri-gation fluid around the button device in the cecum. Thiswas due to breakdown of the skin around the device andrequired a revision of the ACE stoma. This was secondaryto sutures cutting through the edges of the cecostomyaround the button, as a result of too-tight application ofthe anchoring sutures. With a button in situ, appendicitis(as has been reported in an unused appendicocecostomy)can be avoided.16 The common complications of stomalstenosis, leakage, and herniation were not seen in ourstudy. This could be attributed to our approach to creat-ing an ACE channel with a button device. The principleof maintaining a short appendicular stump and creatinga watertight channel by stenting the appendix are impor-tant factors in minimizing the complications associatedwith an ACE.

The laparoscopic ACE may offer the advantages ofa shorter hospital stay, faster recovery, less postopera-tive pain, and better cosmesis. This procedure is sim-ple to perform and can be achieved with the use of onlytwo ports. In our cohort no cases required conversionto an open procedure. In the 4 cases where this wasdone using 2 ports, no difficulties were encountered ne-cessitating the need for an additional port. This was fa-cilitated by adequate preoperative bowel preparationand positioning the patient in a head-down left lateralposition. More complex and invasive procedures sig-nificantly delay the commencement of colonic irriga-tion.2 In our study, irrigations were commenced at amedian of 3.5 days. In the 4 cases in which the ap-pendix was used with a two-port technique, irrigationswere commenced on the postoperative day (POD) 1. Inthe cases in which the cecum was used, irrigation com-menced on POD 5.

Minimizing postoperative ileus is especially impor-tant in patients with bowel motility problems. With a

TABLE 1. COMPLICATIONS OF ANTEGRADE

CONTINENCE ENEMA (ACE)

Stoma stenosis/necrosisStoma leakageStomal prolapseKinking of the ACE channelDifficulty catheterizing the stomaPain with enema administrationWound infectionAdhesive bowel obstructionTorsion of the ACE channelAppendiceal necrosis and gangrenous channelHypertrophic granulation tissue at the stomaSkin dermatitis around the stomaCecal volvulusPhosphate toxicityButton falling outFalse passage around the ACE channelAppendicitis in an unused appendicocecostomy

172 ANTAO ET AL.

minimally invasive approach there is less bowel han-dling and less postoperative adhesive obstruction,which can be potentially life threatening in these pa-tients. As our approach involves incising and cannu-lating the appendix extracorporeally, the potential riskof stool spillage is also decreased. This procedure wassuccessful in all 12 cases. Partial resolution of symp-toms were seen in 3 cases mainly due to lack of com-pliance. This included one case that required revisionof the ACE stoma. With ongoing support and motiva-tion from a specialist nursing team, further improve-ments in fecal incontinence and constipation are beingachieved in these cases.

The ACE procedure described here incorporates theadvantages of both laparoscopy and a button devicewhich is simple and easy to perform using just twoports. The low profile button device achieves a conti-nent ACE and minimizes the common stomal compli-cations associated with an ACE. In addition to a satis-factory operative result, motivation and compliance areessential to long-term success. This is facilitated by cre-ating an ACE channel which is easy to use and free ofcomplications, and the dedicated support from a spe-cialist nurse.

REFERENCES

1. Malone PS, Ransley PG, Kiely EM. Preliminary report:the antegrade continence enema. Lancet 1990;336:1217–1218.

2. Levitt MA, Soffer SZ, Pena A. Continent appendicostomyin the bowel management of fecally incontinent children.J Pediatr Surg 1997;32:1630–1633.

3. Karpman E, Das S, Kurzrock EA. Laparoscopic antegradecontinence enema (Malone) procedure: description and il-lustration of technique. J Endourol 2002;16:325–328.

4. Casale P, Grady RW, Waldo FC, Joyner BD, Mitchell ME.A novel approach to the laparoscopic antegrade continenceenema procedure: intracorporeal and extracorporeal tech-niques. J Urol 2004;171:817–819.

5. Webb HW, Barraza MA, Crump JM. Laparoscopic appen-dicostomy for management of fecal incontinence. J Pedi-atr Surg 1997;32:457–458.

6. Philip I, Nicholas JL. Laparoscopic appendicostomy formanagement of fecal incontinence. J Pediatr Surg 1998;33:670 [letter].

7. Cromie WJ, Goldfischer ER, Kim JH. Laparoscopic cre-ation of a continent cecal tube for antegrade colonic irri-gation. Urology 1996;47:905–907.

8. Van Savage JG, Yohannes P. Laparoscopic antegrade con-tinence enema in situ appendix procedure for refractoryconstipation and overflow fecal incontinence in childrenwith spina bifida. J Urol 2000;164:1084–1087.

9. Robertson RW, Craig Lynch A, Beasley SW, Morreau PN.Early experience with the laparoscopic ACE procedure.ANZ J Surg 1999;69:308–309.

10. Searles JM, Roberts JP, Mackinnon AE. The ACE proce-dure: problems behind the success. Eur J Pediatr Surg2000;10:I51–I52.

11. Griffiths DM, Malone PS. The Malone antegrade conti-nence enema. J Pediatr Surg 1995;30:68–71.

12. Squire R, Kiely EM, Carr B, Ransley PG, Duffy PG. Theclinical application of Malone antegrade colonic enema. JPediatr Surg 1993;28:1012–1015.

13. Graf JL, Strear C, Bratton B, et al. The antegrade conti-nence enema procedure: a review of the literature. J Pedi-atr Surg 1998;33:1294–1296.

14. Curry JI, Osborne A, Malone PS. The MACE procedure:experience in the United Kingdom. J Pediatr Surg1999;34:338–340.

15. Chait PG, Shandling B, Richards HF. The cecostomy but-ton. J Pediatr Surg 1997;32:849–851.

16. McAndrew HF, Griffiths DM, Pai KP. A new complica-tion of the Malone antegrade continence enema. J PediatrSurg 2002;37:1216.

17. Sugarman ID, Malone PS, Terry TR, Koyle MA. Trans-versely tubularized segments for the Mitrofanoff or Mal-one antegrade colonic enema procedures: the Monti prin-ciple. Br J Urol 1998;81:253–256.

18. Wedderburn A, Lee RS, Denny A, Steinbrecher HA,Koyle MA, Malone PS. Synchronous bladder recon-struction and antegrade continence enema. J Urol 2001;165:2392–2393.

19. Goepel M, Sperling H, Stohrer M, Otto T, Rubben H.Management of neurogenic fecal incontinence inmyelodysplastic children by a modified continent ap-pendiceal stoma and antegrade colonic enema. Urology1997;49:758–761.

20. Hensle TW, Reiley EA, Chang DT. The Malone ante-grade continence enema procedure in the management ofpatients with spina bifida. J Am Coll Surg 1998;186:669–674.

21. Redel CA, Motil KJ, Bloss RS, Dubois JJ, Klish WJ. Intestinal button implantation for obstipation and fecalimpaction in children. J Pediatr Surg 1992;27:654–656.

22. Shandling B, Chait PG, Richards HF. Percutaneous cecos-tomy: a new technique in the management of fecal incon-tinence. J Pediatr Surg 1996;31:534–537.

23. Roberts JP, Broadley P, Searles J, Mackinnon AE. Percu-taneous tube caecostomy for antegrade continence enema(ACE). Eur J Pediatr Surg 1999;9:I47–I48.

24. Curry JI, Osborne A, Malone PS. How to achieve a suc-cessful Malone antegrade continence enema. J Pediatr Surg1998;33:138–141.

25. Koyle MA, Kaji DM, Duque M, Wild J, Galansky SH. TheMalone antegrade continence enema for neurogenic andstructural fecal incontinence and constipation. J Urol1995;154:759–761.

26. Malone PS, Curry JI, Osborne A. The antegrade continenceenema procedure: Why, when and how? World J Urol1998;16:274–278.

27. Tam PK. Y-appendicoplasty: technique to minimize stomalcomplications in antegrade continence enema. J PediatrSurg 1999;34:1733–1735.

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28. Glassman DT, Docimo SG. Concealed umbilical stoma:long-term evaluation of stomal stenosis. J Urol 2001;166:1028–1030.

29. Duel BP, Gonzalez R. The button cecostomy for manage-ment of fecal incontinence. Pediatr Surg Int 1999;15:559–561.

30. Lynch AC, Beasley SW, Robertson RW, Morreau PN.Comparison of results of laparoscopic and open antegradecontinence enema procedures. Pediatr Surg Int 1999;15:343–346.

Address reprint requests to:Brice Antao, MBBS, MRCS

Paediatric Surgical UnitSheffield Children’s Hospital

Western BankSheffield S10 2TH

United Kingdom

E-mail: briceantao@doctors.org.uk