Malone antegrade continence enema (MACE) for fecal incontinence in imperforate anus improves quality of life

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<ul><li><p>ORIGINAL ARTICLE</p><p>Malone antegrade continence enema (MACE) for fecalincontinence in imperforate anus improves quality of life</p><p>Kelly D. Mattix Nathan M. Novotny Anita A. Shelley Frederick J. Rescorla</p><p>Published online: 16 October 2007</p><p> Springer-Verlag 2007</p><p>Abstract The MACE procedure has been used in patients</p><p>with imperforate anus (IA) to improve fecal continence. Our</p><p>aim was to assess the impact of the MACE on the quality of</p><p>life (QOL) in children with IA and fecal incontinence. A</p><p>retrospective review was performed of children with IA that</p><p>underwent the MACE procedure between 1997 and 2004.</p><p>Patients and their parents were contacted by telephone sur-</p><p>vey regarding continence and its psychosocial effects before</p><p>and after MACE. The same survey was given to the patients</p><p>teachers. Responses to 15 questions were compiled and a</p><p>QOL score calculated and significance evaluated by t-test</p><p>(P 0.05). IRB approval was obtained. Thirty-two patientswere identified with a mean age at operation of 9 years (4</p><p>19 years) and mean follow-up of 3.8 years (7 months to</p><p>8 years). Four patients had a low malformation, 8 were</p><p>intermediate, 15 were high, and 5 had a cloacal anomaly.</p><p>Twenty patients had documented sacral/spinal anomalies,</p><p>including five with tethered cord. Post-MACE complica-</p><p>tions included stenosis in 16 (50%), with 11 requiring an</p><p>operative revision at a mean of 21.7 months (2 months to</p><p>6 years), takedown in one at 4 years and volvulus in one at</p><p>18 months. Prior to the MACE, 18/25 (72%) had poor QOL</p><p>scores. Post-MACE QOL results were similar between</p><p>patients, parents and teachers. Patients mean QOL score</p><p>improved from 59.9 to 26.3% (P \ 0.001), with parentsfrom 59.7 to 26.4% (P \ 0.001). QOL score improved[50% in nine families, 2550% in ten and\25% in six. Allpatients and parents interviewed reported an improvement in</p><p>their QOL following the MACE. This procedure should be</p><p>offered to children with IA with the expectation of signifi-</p><p>cant improvement in QOL.</p><p>Keywords Malone antegrade continence enema MACE Antegrade continence enema Ace Quality of life</p><p>Introduction</p><p>Malone first described the antegrade continence enema in</p><p>1990 [1]. The Malone Antegrade Continence Enema</p><p>(MACE) procedure has been utilized in children and adults</p><p>with fecal incontinence and constipation with a wide variety</p><p>of primary diagnoses [27]. The MACE procedure has been</p><p>adopted as an accepted treatment for children with imper-</p><p>forate anus (IA) and poor fecal continence. While studies</p><p>have assessed quality of life (QOL) after repair of IA, none</p><p>has addressed QOL of patients with IA after MACE [812].</p><p>Our aim was to assess the impact of the MACE on the QOL</p><p>in children with IA and fecal incontinence.</p><p>Materials and methods</p><p>A retrospective chart review was performed of children</p><p>with IA undergoing MACE between 1997 and 2004 at</p><p>Presented as an oral presentation at the 14th Annual International</p><p>Colorectal Club Conference and Exhibition in York, England, July</p><p>1416, 2007.</p><p>A. A. Shelley F. J. Rescorla (&amp;)Section of Pediatric Surgery,</p><p>Indiana University School of Medicine and Riley Hospital</p><p>for Children, RH 2500, Indianapolis, IN 46202, USA</p><p>e-mail:</p><p>K. D. Mattix N. M. NovotnyDepartment of Surgery, Indiana University School of Medicine</p><p>and Riley Hospital for Children, 545 N. Barnhill Dr. EH202,</p><p>Indianapolis, IN 46202, USA</p><p>e-mail:</p><p>123</p><p>Pediatr Surg Int (2007) 23:11751177</p><p>DOI 10.1007/s00383-007-2026-3</p></li><li><p>Riley Hospital for Children in Indianapolis, IN, USA.</p><p>Demographic information, type of malformation and</p><p>associated comorbidities, and clinical outcomes including</p><p>need for additional procedures were collected.</p><p>A telephone survey of 15 questions was developed for</p><p>parents, patients, and school teachers of the children to</p><p>assess QOL at home and school. Patients were questioned</p><p>regarding their current situation post-MACE and retro-</p><p>spectively, prior to the MACE procedure. The questionnaire</p><p>administered to the teachers included questions specific to</p><p>post-MACE, as the teacher may or may not have known the</p><p>child prior to the procedure. The questionnaires were</p><p>administered by a surgical resident during a scripted tele-</p><p>phone conversation to confirm willingness to participate in</p><p>the study.</p><p>The data were subjected to statistical analysis with the</p><p>Students t-test. P values of \0.05 were considered statis-tically significant. IRB approval was obtained from the</p><p>participating institution.</p><p>Results</p><p>Patients</p><p>Thirty-two patients were identified with IA who underwent</p><p>MACE procedures. (Table 1) Fifty-three percent (17/32) of</p><p>the children were females. Mean age at MACE was 9 years</p><p>(range 419 years). Four children had low, 8 had inter-</p><p>mediate, 15 had high malformations, and 5 had cloacal</p><p>anomaly. Associated anomolies included sacral/spinal</p><p>(n = 20), genitourinary (n = 28), cardiac (n = 7), gastro-</p><p>intestinal (gastroschisis n = 1, trachoesophageal fistula</p><p>n = 2, duodenal atresia n = 1), and chromosomal (n = 1).</p><p>Mean follow up was 3.8 years (range 7 months to 8 years).</p><p>Complications associated with the MACE procedure are</p><p>summarized in Table 2. They included: stenosis in 16/32</p><p>patients (50%) with 11 requiring operative revision, rang-</p><p>ing from 2 months to 6 years after their MACE (average</p><p>21.7 months); takedown at 4 years in one (secondary to</p><p>a dysmotile colonic segment); and volvulus in one at</p><p>18 months.</p><p>QOL</p><p>Twenty-five (78% of the total number of patients with IA</p><p>who underwent MACE) patients or parents participated in</p><p>the QOL survey. Twelve teachers participated. Prior to the</p><p>MACE, 18/25 (72%) had poor QOL scores. Answers related</p><p>to post-MACE questions were similar among patients, par-</p><p>ents, and teachers. Patients QOL scores significantly</p><p>improved (P \ 0.001) from 59.9 (range 2976 %) to 26.3%(range 650%). Parents, also reported a significant increase</p><p>in QOL (P \ 0.001) from 59.7 (range 1894%) to 26.4%(range 453%). All patients reported an improvement in</p><p>QOL. QOL improved[50% for nine families, 2550% forten, and\25% for six.</p><p>Discussion</p><p>The MACE procedure has been utilized in patients with IA</p><p>as an adjunct treatment for treating continence issues. Few</p><p>studies have assessed the relationship to the patients QOL</p><p>following this procedure [7, 13, 14]. Others have studied</p><p>both the complications related to the procedure including</p><p>reoperation, stomal stenosis and volvulus, and the devel-</p><p>opment of continence [5, 6, 1418]. Our study focused</p><p>specifically on patients with IA who have been treated with</p><p>the MACE procedure.</p><p>The MACE has been shown to significantly improve</p><p>continence in varied patient populations, including children</p><p>with fecal incontinence [6, 13], adults with idiopathic</p><p>constipation [5] and patients with myelomeningocele [7].</p><p>Likewise, we saw a significant improvement in continence</p><p>in our patient population with 22 of 25 having staining less</p><p>than once per week with no need for underwear changes.</p><p>Similar to prior studies, our patient population had a high</p><p>stomal stenosis rate. Malone initially described frequent</p><p>catheterizations, at least daily, to prevent this complication</p><p>[15]. Other studies have seen similar results in stomal stenosis</p><p>rates of 1839% [6, 7, 16, 17, 19]. This complication appears</p><p>to be decreased with frequent dilations/catheterizations and</p><p>the inlay of skin at the cutaneous stomal anastomsosis.</p><p>Table 1 Patient demographics</p><p>No. of patients</p><p>n 32</p><p>Male 15</p><p>Female 17</p><p>Low malformation 4</p><p>Intermediate malformation 8</p><p>High malformation 15</p><p>Cloacal anomaly 5</p><p>Age (years) at MACE 9 (419)</p><p>Table 2 Complications experienced after MACE procedure</p><p>Complication No. of patients</p><p>Stenosis 16 (50%)</p><p>Operative reintervention 11</p><p>Volvulus 1 (3%)</p><p>Takedown 1 (3%)</p><p>1176 Pediatr Surg Int (2007) 23:11751177</p><p>123</p></li><li><p>Assessment of QOL has been performed by many</p><p>methods. Our data demonstrated a significant improvement</p><p>in QOL by both the patients and their parents. This was</p><p>confirmed by a third party, in that the QOL score given by</p><p>the teachers was similar to that of the patient and parent.</p><p>The limitations to this method include the need for retro-</p><p>spective data by requiring the patients to answer questions</p><p>regarding their lifestyle pre-MACE. Additionally, the data</p><p>would be strengthened by annual measurements of QOL as</p><p>performed by Ditesheim et al. [10].</p><p>Patients with IA have significantly improved QOL fol-</p><p>lowing the Malone antegrade continence enema. They</p><p>report improved continence with the most frequent com-</p><p>plication of stomal stenosis able to be treated without</p><p>surgical intervention in the majority of cases. This proce-</p><p>dure can be offered to patients with IA suffering from</p><p>incontinence with the expectation of improvement in their</p><p>QOL.</p><p>References</p><p>1. Malone PS, Ransley PG, Kiely EM (1990) Preliminary report: the</p><p>antegrade continence enema. Lancet 336:12171218</p><p>2. Gerharz EW et al (1997) The value of the MACE (Malone</p><p>antegrade colonic enema) procedure in adult patients. J Am Coll</p><p>Surg 185:544547</p><p>3. Lefe`vre J et al (2006) Outcome of antegrade continence enema</p><p>procedures for faecal incontinence in adults. Br J Surg 93:1265</p><p>1269</p><p>4. Curry JI, Osborne A, Malone PSJ (1998) How to achieve a</p><p>successful Malone antegrade continence enema. J Pediatr Surg</p><p>33:138141</p><p>5. Hill J, Stott S, MacLennan I (1994) Antegrade enemas for the</p><p>treatment of severe idiopathic constipation. Br J Surg 81:1490</p><p>1491</p><p>6. Dick AC et al (1996) Antegrade colonic enemas. Br J Surg</p><p>83:642643</p><p>7. Ellsworth PI et al (1996) The Malone antegrade colonic enema</p><p>enhances the quality of life in children undergoing urological</p><p>incontinence procedures. J Urol 155:14161418</p><p>8. Rintala RJ, Lindahl HG (2001) Fecal continence in patients</p><p>having undergone posterior sagittal anorectoplasty procedure for</p><p>a high anorectal malformation improves at adolescence, as con-</p><p>stipation disappears. J Pediatr Surg 36:12181221</p><p>9. Pena A, Hong A (2000) Advances in the management of ano-</p><p>rectal malformations. Am J Surg 180:370376</p><p>10. Ditesheim JA, Templeton JM (1987) Short-term v. long-term</p><p>quality of life following repair of high imperforate anus. J Pediatr</p><p>Surg 22:581587</p><p>11. Rintala R, Mildh L, Lindahl H (1994) Fecal continence and</p><p>quality of life for adult patients with an operated high or inter-</p><p>mediate anorectal malformation. J Pediatr Surg 29:777780</p><p>12. Rintala R, Lindahl H (1995) Is normal bowel function possible</p><p>after repair of intermediate and high anorectal malformations?</p><p>J Pediatr Surg 30:491494</p><p>13. Toogood GJ, Bryant PA, Dudley NE (1995) Control of faecal</p><p>incontinence using the Malone antegrade continence enema</p><p>procedure: a critical appraisal. Pediatr Surg Int 10:3739</p><p>14. Wilcox DT, Keily EM (1998) The Malone antegrade colonic</p><p>enema procedure: early experience. J Pediatr Surg 33:204206</p><p>15. Griffiths DM, Malone PS (1995) The Malone antegrade conti-</p><p>nence enema. J Pediatr Surg 30:6871</p><p>16. Graf JL et al (1998) The antegrade continence enema procedure:</p><p>a review of the literature. J Pediatr Surg 33:12941296</p><p>17. Kokoska ER et al (2001) Outcome of the antegrade colonic</p><p>enema procedure in children with chronic constipation. Am J</p><p>Surg 182:625629</p><p>18. Kokoska ER et al (2004) Cecal volvulus: a report of two cases</p><p>occurring after the antegrade colonic enema procedure. J Pediatr</p><p>Surg 39:916919</p><p>19. Curry JI, Osborne A, Malone PSJ (1999) The MACE procedure:</p><p>experience in the United Kingdom. J Pediatr Surg 34:338340</p><p>Pediatr Surg Int (2007) 23:11751177 1177</p><p>123</p><p>Malone antegrade continence enema (MACE) for fecal incontinence in imperforate anus improves quality of lifeAbstractIntroductionMaterials and methodsResultsPatientsQOL</p><p>DiscussionReferences</p><p> /ColorImageDict &gt; /JPEG2000ColorACSImageDict &gt; /JPEG2000ColorImageDict &gt; /AntiAliasGrayImages false /DownsampleGrayImages true /GrayImageDownsampleType /Bicubic /GrayImageResolution 150 /GrayImageDepth -1 /GrayImageDownsampleThreshold 1.50000 /EncodeGrayImages true /GrayImageFilter /DCTEncode /AutoFilterGrayImages true /GrayImageAutoFilterStrategy /JPEG /GrayACSImageDict &gt; /GrayImageDict &gt; /JPEG2000GrayACSImageDict &gt; /JPEG2000GrayImageDict &gt; /AntiAliasMonoImages false /DownsampleMonoImages true /MonoImageDownsampleType /Bicubic /MonoImageResolution 600 /MonoImageDepth -1 /MonoImageDownsampleThreshold 1.50000 /EncodeMonoImages true /MonoImageFilter /CCITTFaxEncode /MonoImageDict &gt; /AllowPSXObjects false /PDFX1aCheck false /PDFX3Check false /PDFXCompliantPDFOnly false /PDFXNoTrimBoxError true /PDFXTrimBoxToMediaBoxOffset [ 0.00000 0.00000 0.00000 0.00000 ] /PDFXSetBleedBoxToMediaBox true /PDFXBleedBoxToTrimBoxOffset [ 0.00000 0.00000 0.00000 0.00000 ] /PDFXOutputIntentProfile (None) /PDFXOutputCondition () /PDFXRegistryName ( /PDFXTrapped /False</p><p> /Description &gt;&gt;&gt; setdistillerparams&gt; setpagedevice</p></li></ul>


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