Left colonic antegrade continence enema: experience gained from 19 cases page 1
Left colonic antegrade continence enema: experience gained from 19 cases page 2
Left colonic antegrade continence enema: experience gained from 19 cases page 3
Left colonic antegrade continence enema: experience gained from 19 cases page 4
Left colonic antegrade continence enema: experience gained from 19 cases page 5

Left colonic antegrade continence enema: experience gained from 19 cases

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  • neas

    aDivision of Pediatric Surgery, DbDepartment of Urology, Yonsei

    dure is an effective treatment modality in patients with

    biofeedbacks. Until 1990, when Malone et al devised the

    continence enema [MACE]), the progression of such con-

    off procedure. Moreover, the failure rate of MACE increases

    if the blood supply to the appendix is inadequate. Monti et al

    modified the MACE procedure by using a retubularized ileal

    segment, instead of the appendix, for the continence stoma

    Index words:Left antegrade

    continence enema;

    Fecal incontinence;


    Retubularized ileum;


    sigmoid colon

    Journal of Pediatric Surgery (2006) 41, 17501754* Corresponding author. Tel.: +82 2228 2116; fax: +82 313 8289.intractable constipation and fecal incontinence, including

    meningomyelocele, high anorectal malformation, cloacal

    anomaly, or traumatic spinal neuropathy [1-3]. These patients

    generally have a history of failed medical management by

    way of anorectal suppositories, conventional enemas, and

    ditions was to persistent defecation problems or permanent

    colostomy [2-4]. Yet MACE was not problem-free. The

    MACE procedure is impossible in patients lacking an

    appendix because of previous appendectomy or whose

    appendix has been used for urinary conduit during Mitrofan-The colonic antegrade continence enema (ACE) proce- antegrade continence enema procedure (Malones antegrademalformations or any other condition predisposing to fecal incontinence or constipation intractable to

    conventional treatment.

    D 2006 Elsevier Inc. All rights reserved.0022-3468/$ see front matter D 2006


    E-mail address: shchoi@yumc.yonseWon Han , Seung Hoon Choi

    epartment of Surgery, Yonsei University College of Medicine, Seoul 120-752, South Korea

    University College of Medicine, Seodaemun-gu, Seoul 120-752, South Korea

    AbstractPurpose: As problems have developed with the right colonic antegrade continence enema procedure(Malones procedure/Montis retubularized ileocolostomy), left colonic antegrade continence enema

    (LACE) procedure, in which retubularized ileum or sigmoid colon is anastomosed into the sigmoid colon,

    has gained popularity. The aim of the study was to describe our experience with the LACE procedure.

    Methods: We retrospectively reviewed 19 LACE procedures that were performed at the YonseiUniversity College of Medicine Hospital (Seoul, Korea) from March 2001 to March 2005.

    Results: Male-to-female ratio was 11:8, with median age of 10 years (range, 3-34 years). Most commondiagnosis was meningomyelocele (78.9%, 15/19). The median total follow-up period was 23 months

    (range, 3-37 months); median antegrade continence enema volume used was 600 mL (range, 250-

    1500 mL); and median transit time was 30 minutes (range, 15-60 minutes). Patients performed antegrade

    continence enema with an average of once every 2 days (range, 0.3-3 days). Social continence was

    achieved in 14 patients (73.7%). Regurgitation of fecal material through stoma was not reported at all in

    17 patients (89.5%).

    Conclusions: We recommend LACE as the procedure of choice for children with congenitalLeft colonic antegrade contiexperience gained from 19 c

    Seong Min Kima, Sang bElsevier Inc. All rights reserved.

    i.ac.kr (S.H. Choi).nce enema:es


    www.elsevier.com/locate/jpedsurg[5,6]. Still, however, there were complications. The right side

  • of the colon or cecum is inherently dilated in neuropathic

    bowel disorders and so required larger ACE volumes or

    longer ACE transit times. Patients or their caregivers

    frequently complained of moderate to severe abdominal

    pain or nausea during the ACE procedure [7].

    Liloku et al [8] reported a left Monti-Malone procedure

    to overcome the problems associated with MACE. Since

    that report, other authors have reported good results [9,10].

    In this article, we present the clinical consequences in 19

    patients who underwent left colonic antegrade continence

    enema (LACE) and an analysis of the treatment outcomes

    and complications.

    1. Materials and methods

    Between March 1999 and March 2005, antegrade

    continence enema (ACE) procedure was performed on

    23 patients. Of these, Malones procedure was performed

    on 4 patients, with their own appendices for cutaneous

    stoma (appendicocutaneostomy), and the LACE procedure

    was performed on 19 patients with retubularized segments

    of ileum (ileal Montis tube) or sigmoid colon (left Monti-

    Malone procedure) (Table 1). Our analysis here is of the

    19 patients who received LACE procedure. All LACE

    procedures were performed by the same pediatric surgeon

    (SH Choi). Segments of ileum or sigmoid colon with a

    length 2.5 to 3.0 cm were made with care to preserve their

    vascular arcades, and the remaining bowel was anasto-

    mosed in an end-to-end fashion (hand-sewn). A previously

    made ring of bowel segments was opened along the

    antimesenteric border using a Bovie coagulator (detubula-

    rization) with the rectangular bowel flap plate wrapped

    lengthwise around a 16F Foley catheter. The detubularized

    bowel was retubularized with multiple interrupted absorb-

    able sutures under the guidance of a 16F Foley catheter.

    One end of the retubularized bowel was anastomosed to

    the sigmoid colon and the other was exteriorized as a

    cutaneous stoma into the umbilicus and anastomosed to an

    umbilical stab incision. Witzel-type anti-refluxing sero-

    muscular reinforcement was performed with several

    sutures in the sigmoid colon. Antimesenteric border of a

    20- to 30-cm segment of the ileum (for ileocystoplasty) or

    sigmoid colon (sigmoidocystoplasty) was detubularized

    with electrical cutting after meticulous povidone-iodine

    irrigation. By sweeping with dry gauze, the mucosal layer

    of the bowel segment was removed. This bowel segment

    was taken down onto the bladder mucosa, then anasto-

    mosed with bladder muscle from posterior to anterior using

    absorbable interrupted sutures (Fig. 1) An ACE test via

    Foley catheter was performed 10 to 12 days after the

    operation with 50 to 100 mL of normal saline. The ACE

    volume and interval were adjusted until proper bowel

    movement was observed.

    The treatment outcomes of colonic ACE procedures were

    evaluated in terms of ACE volume, interval, and transit time














    11 F 5 MMC IC RI 3 500












    id co

    Left colonic antegrade continence enema 175112 F 4 MMC SC RS 35 6

    13 F 8 MMC IC RI 16 10

    14 M 7 HS SC RS 24 5

    15 M 26 SL SC RS 25 2

    16 M 4 MMC IC RI 20 7

    17 M 11 MMC SC RS 7 15

    18 F 4 MMC SC RS 26 5

    19 M 34 MMC SC RS 15 15

    MMC indicates meningomyelocele; SC, sigmoidocystoplasty; IC, ileocys

    lipoma; CA, cloacal anomaly; HS, Hinman syndrome; ARM, anorectal ma Left colonic antegrade continence enema stoma function checkup atb Retubularized ileum was closed and changed to retubularized sigmoTable 1 Characteristics of 19 patients who underwent LACE p



    Sex Age






    LACE Follow-up




    1 M 8 MMC IC RSb 18 10

    2 M 7 MMC SC RS 23 9

    3 M 12 MMC SC RS 25 5

    4 M 5 MMC SC RS 37 2

    5 M 10 ARM RS 11 7

    6 F 9 MMC SC RS 19 5

    7 F 6 MMC SC RS 4 5

    8 F 19 MMC SC RS 31 10

    9 M 3 MMC SC RS 30 6

    10 F 7 CA RS 25 9ure





    Soilinga Regurgitationa Stenosisa Paina

    30 0.3 + + 15 2 +/30 2 20 2 + 30 3 30 1 30 1 +/ 20 3 60 2 + 15 2 15 3 +/ +20 2 +/ 30 1 30 2 30 1 20 3 +/30 1 30 1 +/60 2 + +

    ty; RS, retubularized sigmoid colon; RI, retubularized ileum; SL, spinal



    lon because of stomal obstruction.

  • (time from enema fluid administration to bowel move-

    ments). The degree of social continence and complications

    after LACE procedure were also evaluated.

    2. Results

    2.1. Demographic data of the patients

    The male-to-female ratio was 11:8, with a mean age of 10

    years (range, 3-34 years). Diagnoses were of meningomye-

    locele in 15 (78.9%) patients, anorectal malformation in 2

    (10.5%) patients, Hinman syndrome in 1 patient, and spinal

    lipoma in 1 patient. Sigmoidocystoplasty was performed by

    a urologist concomitantly with LACE in 13 (68.4%)

    patients, followed by ileocystoplasty in 4 (21.1%) of these

    patients. Operations other than LACE were not performed in

    2 (10.5%) patients.

    2.2. Volume, transit time, and interval of LACE

    After a period of adjustment, all 19 patients were able to

    perform LACE regularly without any problems with an

    average of once every 2 days (range, 0.3-3 days). These

    patients received regular follow-up care every 2 or 3 months

    after the LACE procedure. The median total follow-up

    period was 23 months (range, 3-37 months), the median

    LACE volume requirement was 600 mL (range, 250-1500

    .5 to


    ) wit


    catheter (C). One end of the retubularized bowel was anastomosed to th



    S.M. Kim et al.1752stoma into t