British Journal of Surgery 1998, 85, 974977
Malone antegrade continence enema for faecal incontinence andconstipation in adultsK . K R O G H and S . L A U R B E R G
Surgical Research Unit, Department of Surgery L, Section AAS, University Hospital of Aarhus, Tage Hansensgade 2, 8000 Aarhus C, DenmarkCorrespondence to: Dr K. Krogh
Background In the Malone antegrade continence enema (ACE) technique the appendix or aneoappendix created from the caecum is brought to the abdominal wall creating a small stoma.Thereby, antegrade enemas can be administered to empty the colorectum and prevent faecalincontinence or constipation in children with congenital malformations. The aim of this study wasto describe the results of the ACE in adults suffering from faecal incontinence or constipation.
Methods In 16 adult patients (ten women and six men) suffering from severe faecal incontinence (tenpatients) or constipation (six patients) the ACE procedure was performed; the appendix was usedin 12 and a neoappendix was created in four. Patient records were used for the description ofsurgical procedures and complications. Results were evaluated by a structured telephone interview.
Results After a follow-up of 139 (mean 17) months, four patients had stopped using the stomabecause of abdominal pain or lack of effect. Among the other 12 patients overall satisfaction withthe stoma was high or very high. In constipated patients mean time for defaecation was reducedfrom 170 to 45 min. Faecal incontinence was much reduced in eight patients; the impact on socialactivities and quality of life caused by bowel dysfunction was reduced in all 12 patients.
Conclusion The ACE technique can be used to treat selected adult patients suffering from faecalincontinence or constipation.
In 1990 Malone et al.1 described the antegrade continenceenema (ACE) technique, creating a continent stoma byimplanting the tip of the appendix in a non-refluxingmanner into the caecum and bringing the base out ontothe abdominal wall. Through this small appendicostomy,antegrade enemas could be administered to empty thecolorectum and prevent faecal incontinence orconstipation. In several studies the ACE has been safeand effective among children suffering from faecalincontinence or chronic constipation due to spina bifidaor anorectal malformation25. Later reports have indicatedthat reimplantation of the appendix to avoid faecalleakage is unnecessary and most authors simply bring outthe tip of the appendix24,6. The operation can beperformed synchronously with bladder reconstruction2,7and the technique has been modified by creating aneoappendix from a tubularized caecal flap as analternative in patients without an appendix7,8.
Although many adult patients may benefit from theACE, results of its use in adults have only been presentedin a single study. Thus, Hill et al.6 performed theoperation in six adult women suffering from severe slowtransit constipation. Results from the procedure in adultpatients suffering from faecal incontinence have neverbeen described. If useful, it may relieve symptoms inpatients suffering from faecal incontinence or chronicconstipation due to spinal cord lesions, spina bifida,cerebral palsy or thrombosis, lesions to the analsphincters, slow transit constipation and systemic sclerosis.Therefore, more studies of the results of the ACE inadults are necessary.
Patients and methodsFrom January 1993 to June 1996, 16 patients underwent theACE procedure. There were ten women and six men aged 2068(mean 41) years. The clinical problem was faecal incontinence inten patients and chronic constipation in six (Table 1).
Faecal incontinence was caused by cerebral thrombosis orpalsy (two patients), spinal cord lesions (two patients with lesionsat T2 and L1), lumbar myelomeningocele (one patient), andsystemic sclerosis (one patient). In four patients faecalincontinence was due to complicated anal sphincter lesionscaused by fistulas (two patients), traumatic anal injury from amotorcycle accident (one) and haemorrhoidectomy (one). Analsphincter damage was evaluated by anal manometry and analultrasonography. In three patients the damage was too severe toallow sphincter reconstruction and in one patient sphincterreconstruction had failed.
Chronic constipation was caused by spinal cord lesions (twopatients; one with a lesion at C5 and one with a lumbar lesionfollowing five operations for disc prolapse), slow transitconstipation, systemic sclerosis and obstructed defaecation (one
Paper accepted 6 January 1998
Table 1 Patients included in the study
FaecalCause of symptoms incontinence Constipation
Spinal cord lesion/spina bifida 3 2Cerebral thrombosis/palsy 2 Anal sphincter lesion 4 Systemic sclerosis 1 1Slow transit constipation 1Obstructed defaecation 1Sequelae from hysterectomy 1Total 10 6
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patient each). One patient suffered from constipation and severechronic abdominal pain after a radical hysterectomy and hadattempted suicide 6 months previously because of thesesymptoms. The suicide attempt had resulted in a hemiparesisfurther worsening constipation and abdominal pain.
All patients had been treated with increased fibre intake andlaxatives or suppositories for several years without effect.
Patients records were used to ascertain the indications for theprocedure, surgical procedure and postoperative complications.Thirteen patients available for follow-up underwent a structuredtelephone interview to describe symptoms before treatment andat follow-up, bowel emptying procedures and satisfaction withthe result. The follow-up period was 139 (mean 17) months.Results for three patients, not available for follow-up and nolonger using the procedure, were drawn from hospital records.
Interviews were taped and a questionnaire was filled out bythe interviewer during the interview. To minimize observer biasthe interviewer (K.K.) was not the one who had operated on thepatients.
Standard bowel preparation and prophylactic antibioticswere given. A midline incision was used and, in 12patients with an appendix, the tip of the appendix wasdelivered through a right iliac fossa incision. Then a smallstoma was created from the appendix using a V-Y plastyin the skin2 (Fig. 1), and the caecum was fixed to theabdominal wall. One patient had a bladder augmentingprocedure during the same operation.
In four patients without an appendix a neoappendixwas created for the procedure from a tubularized caecalflap as described previously6,8. All procedures wereperformed by the same surgeon (S.L.).
Following both procedures a silicone catheter (6 or8 Fr) was left in situ for 2 weeks. Colonic wash-outs werestarted after 10 days.
ResultsComplicationsSuperficial infection around the outer opening of thestoma occurred in four patients, but all were successfullytreated with oral antibiotics for a few days.
Stenosis of the appendicostomy occurred in fourpatients. These were all treated using Hegars dilators upto three or four times. In one of these patients the stomawas revised. Stenosis of the stoma resulted in one patientdiscontinuing its use because of abdominal pain duringwash-outs. During the operation it had been noted thatthe patient had a very narrow appendix possiblyexplaining the complication.
Faecal incontinenceAmong ten patients having the ACE because of faecalincontinence six were still using the stoma at follow-up.One patient with sphincter lesions due to fistula surgeryhad stopped using the appendicostomy after 3 monthsbecause he was no longer incontinent even if he did notuse it. One patient with disseminated mammary cancerhad become too weak to perform the daily procedure. Shewas, however, very satisfied with the stoma because shehad not suffered from faecal incontinence while using it.
Two patients had stopped using the stoma because ofabdominal pain during wash-outs; in one of these this wascaused by stenosis of the stoma
Among the six patients still using the stoma, five hadsuffered from faecal incontinence daily and one severaltimes each week before the operation. At follow-up thefrequency of incontinence episodes was much reduced inall six patients. Thus, two patients were never incontinent,three were incontinent less than once every month andone was incontinent once or more every week. Fivepatients used pads before the operation, but only onecontinued to do so at follow-up.
ConstipationFour of six patients operated on for constipation orobstructed defaecation still used the stoma at follow-up.One patient suffering from systemic sclerosis experiencedno effect of the treatment. The patient who suffered fromconstipation and severe neurogenic abdominal pain due toa radical hysterectomy and hemiparesis had not yet triedusing the stoma at follow-up because of pain around thesite of incision.
Among the four patients still using the ACE, mean timefor defaecation was reduced from 170 to 45 min. All feltthat their problems from constipation were very muchimproved since the operation.
Use of the antegrade continence enema and patientsatisfactionAmong the ten patients still using the stoma, four used itevery day, five every second day and one every third day.Time taken to perform the enema was 1560 (mean 30)min. All used tap water, two adding a phosphate enema tothis. The volume of water used was 5002000 (mean 967)ml. One patient with tetraplegia needed help for theprocedure.
Abdominal discomfort during the enema wasexperienced by four patients. Five patients regularly hadreflux of small amounts of water and faeces after wash-
Fig. 1 Creation of a stoma from the appendix using a V-Y plastyin the skin. The V-Y plasty increases the diameter of the outeropening of the stoma and embeds it in a cutaneous fold. Asilicone catheter is left in the lumen of the stoma for 2 weeks
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1998 Blackwell Science Ltd, British Journal of Surgery 1998, 85, 974977
outs; however, in all five this could be controlled by anordinary plaster. Four patients occasionally had reflux ofsmall amounts of air from the appendicostomy. Nopatient felt that the appendicostomy was a major cosmeticor psychological problem.
Before the operation nine of these ten patients felt thatcolorectal dysfunction imposed a major restriction ontheir quality of life or social activities and one patientreported some restriction. At follow-up one reported thatcolorectal dysfunction caused some restriction while ninereported little or no restriction.
Overall satisfaction was very high in eight and high intwo of the ten patients still using the procedure.Furthermore, two patients no longer using the stomabecause the symptoms had disappeared or because ofserious illness were very satisfied with the procedure.Thus, 12 of 16 patients operated were satisfied with theresult.
Patients still using the ACE were asked to comparebowel function before the operation and at follow-up,using a scale in which 0 was the worst possible and 100ideal. Before operation the mean score was 12 (range030) while at follow-up it was 85 (range 70100).
In the subgroup of patients with colorectal problemsdue to neurogenic lesions (seven patients) satisfactionwith the ACE was high or very high in the six patients stillusing it. Among four patients with faecal incontinence dueto complicated anal sphincter lesions patient satisfactionwas high or very high in the three patients still using thestoma. In the mixed group of five patients with severecolorectal problems caused by systemic sclerosis, slowtransit constipation, obstructed defaecation or hysterec-tomy the procedure was successful in three.
DiscussionThis study shows that the Malone antegrade continenceenema is a safe and effective treatment for selected adultpatients suffering from severe faecal incontinence orconstipation. Overall, the ACE was successful in 12 of 16patients over a mean follow-up of 17 months. This is inaccordance with some previous results from childrensuffering from faecal incontinence2, while others havereported a higher success rate but after a shorter follow-up3,6,7.
These preliminary results indicate that the ACE canrelieve colorectal problems in patients with neurologicallesions who often suffer from severe constipation or faecalincontinence9,10. Furthermore, the results in patients withincontinence due to severe anal sphincter lesions orneurological lesions are comparable to results from thecreation of a neosphincter from the gracilis muscle11,12 orthe implantation of an artificial anal sphincter13,14.Therefore, the ACE technique, as a smaller operation,may be an alternative to these more extensive procedures.Furthermore, no major complications were observed andif patients find the side-effects unacceptable they candiscontinue using the stoma. It will then obliterate,leaving the patient no worse than before the operation.
As in previous studies, the present results indicate thatreimplanting the appendix is unnecessary. The tip of theappendix was simply brought out. The rate of success washigher among patients having an appendicostomy (ten of12) than in patients having a neoappendicostomy (two offour). Because so few patients had a neoappendicostomyno explanation can be given for this difference. However,
one must expect more complications, especially stenoses,in patients having a neoappendicostomy since the stomais not created from a natural luminal organ.
The most common complication was stenosis of theappendix occurring in four of 16 patients; however, thisonly caused one patient to discontinue use of the stoma.The frequency of stenosis is in accordance with severalprevious studies2,3,6 and lower than in another 8. Theoccurrence of stenoses may be reduced by instructingpatients to insert a catheter through the stoma once ortwice every day, even if they only use it for wash-outsevery second day2. Also, the frequency of stenoses may bereduced by decreasing the number of superficial infectionsaround the stoma and by ensuring that the flaps used forthe creation of the V-Y plasty are well vascularized.
Most failures occurred within a few months after theoperation and were caused by pain during wash-outs. Thenumber of patients experiencing abdominal discomfortduring wash-out was higher than in previous studies. Thiscould be because a larger volume of water was used bythe present patients than was used in the only other studyof this procedure in adult patients6.
The mean time required for the enema was 30 min eachor every other day. This is in accordance with previousstudies13 and less than in another study6. As in previousstudies1,2,4,7, the frequency of wash-outs and the volume ofwater used in each individual patient was determined bytrial and error during the first months after the operation.Therefore, it is most important that all patients are wellmotivated and understand that some time is necessary tolearn the procedure. During this initial period,instructions from an experien...