The Malone (Antegrade Colonic Enema) Procedure: Early Experience

By Duncan T. Wilcox and Edward M. Kiely London, England

Purpose:The aim of this study was to assess the results of the Malone (antegrade colonic enema) procedure for fecal incon- tinence.

Iwefhods: By a retrospective review of patients treated be- tween 1990 and 1996 in a tertiary referral center, 36 patients were treated with a Malone procedure. Age at operation was 8.3 (range, 3 to 14) years, the mean period of follow-up was 39 (range, 9 to 72) months. The indication was fecal soiling in 35 and chronic constipation in one. The underlying diagnosis was an anorectal anomaly in the majority of patients. The appendix was used in 30 patients and a cecal flap in six, and a submucosal antireflux procedure was also performed in 10. In 35 patients, a circular stoma was created and in one a V flap was used. Antegrade colonic enemas were performed daily in 10, alternate days in 23, and in three patients the stoma was no longer used. Enemas were performed with a IOF catheter using a mixture of phosphate enema (or liquorice) and saline.

Results: Fecal soiling was completely controlled in 28 pa- tients, and eight children soiled more than once a week.

Complications occurred in 15 patients; the main problem was stenosis of the conduit, which occurred in 9 of 30 appendiceal stomas and three of six cecal stomas. Stoma1 stenosis was treated with surgical revision in eight patients. Additional complications were reflux through the stoma (n = 21, pain on catheterisation (n = I), and small bowel obstruction (n = 1). In one patient the Malone has been converted to a colostomy.

Conclusions: The Malone procedure is a simple technique that can effectively control fecal incontinence in the majority of cases. It appeared to be better in older children. Stoma1 stenosis is a frequently encountered problem that may require surgical revision. J Pediatr Surg 33:204-206. Copyright o 1998 by W.B. Saun- ders Company.

INDEX WORDS: Malone, antegrade colonic enema, fecal incontinence.

F ECAL INCONTINENCE is a devastating problem that affects both the patient and immediate family.

Unfortunately, because of the absence of a competent anal sphincter or sphincter control, it is the inevitable sequelae of many congenital anomalies. Numerous thera- peutic modalities are used to control fecal incontinence including laxatives, manual evacuation, and enemas,’ however, these methods regularly fail. The success of the retrograde enema was greatly enhanced by the Shandling catheter, but many patients still find it difficult or unpleasant to perform the enema using this catheter. Malone described the use of an appendicostomy, which enabled an antegrade colonic enema to be performed overcoming these problems2 This report describes our experience with the Malone procedure.

From the Great Ormond Street Children’s Hospital NHS Trust, London, England.

Presented at the 28th Annual Meeting of The American Pediatric Surgical Association, Naples, Florida, May 18-21, 1997.

Address reprint requests to Duncan 7: Wilcox, Department of Paediatric Surgery, Great Onnond Street Children’s Hospital NHS Trust, Great Ormond St, London WC IN 3 JH, England.

Copyright o I998 by WB. Saunders Company 0022-3468/98/3302-00010$03.00/0

MATERIALS AND METHODS

This was a retrospective review of patient notes from 1990 to 1996. All patients who underwent a Malone procedure by one surgeon (EMK) were included in the study. The indications for surgery were fecal incontinence (n = 35) and idiopathic constipation (n = 1). The underly- ing diagnosis in these patients was anorectal anomaly (n = 28), spina bifida (n = 4), Hirschsprung’s disease (n = 1). sacrococcygeal tera- toma (n = l), anal trauma (n = l), and idiopathic constipation (n = 1). The age at operation was 8.3 with a range of 3 to 14 years.

The operation was performed through a right iliac fossa grid iron incision, unless additional procedures were being performed. In the first three patients, the appendix was resected with a cuff of cecum and then reversed with the cecum sutured to the skin, as originally described by Malone et aL2 This method has been subsequently changed, and the appendix tip was sutured to the skin, without disconnecting the appendix, in 27 patients. In six children, the appendix was not present, or impossible to use, and a caecal flap was constructed. The stoma was created as a circular flush stoma in 35, and a V flap was used in one patient. A catheter (usually 1OF) was left in the conduit for 2 weeks. It was then recommended that the conduit be catheterized each day to maintain patency.

After 3 days, antegrade colonic enemas were started. The enemas were performed using individualized regimens. In general, this was a stimulant enema (phosphate, docusate, or liquorice) followed by salt water in widely variable volumes. The enemas were performed daily by 10 patients, alternate days by 23 patients, and not used by three patients.

The mean follow-up is 39 (range, 9 to 72) months.

204 Journal ofPediatric Surgery, Vol33, No 2 (February), 1998: pp 204-206

THE MALONE (ACE) PROCEDURE 205

RESULTS

Fecal incontinence, which was defined as soiling more than once a week, was completely controlled in 28 pa- tients. Eight children soiled more than once a week, and two of these children had given up using the enemas. One child opted for an end colostomy.

The main complication was skin-level stenosis of the channel. This occurred in 12 of 36 patients: 9 of 30 who had an appendicostomy and three of six who had a cecal flap created. The stomas were initially dilated, which was successful in four children. Eight children have subse- quently required stoma1 revision. The patient who had a V flap required stomal revision for stenosis.

Reflux of fecal content through the stoma occurred in two children; one of these children had undergone an “antireflux” procedure. In addition, one child complains of mild pain in the channel on catheterization, and one presented with small bowel obstruction secondary to adhesions, which required a laparotomy.

DISCUSSION

The Malone procedure is the latest of many treatment modalities used to control fecal incontinence. This study confirms previous reports that in carefully selected pa- tients, the Malone procedure combined with antegrade colonic enemas can provide effective fecal continence.2-5 It is however, imperative that less invasive techniques such as adequate laxatives, bowel training programs, and the use of retrograde enemas are used before resorting to surgical intervention.

Essential for the success of the Malone procedure is proper patient selection. We believe there are three important criteria that need to be fulfilled before this operation is commenced. These include: an appropriate anatomic situation, adequate dexterity and mobility, and, most importantly, a patient and family who insist on being clean. Two anatomic factors are crucial for success. The first is an adequate length of colon, which provides a sufficient reservoir, ensuring that there are clean periods between washouts. Surgically resected long segment Hirschsprung’s disease is an example in which inad- equate bowel length may be a concern. Second, it is important that there is no distal stenosis impairing the washout, because this will result in lengthy enemas and soiling. If the patient is required to perform the enemas alone, then the degree of manual dexterity needs to be assessed. Occasionally it is necessary to site the stoma outside the right iliac fossa to aid with catheterization. As with a colostomy, it is preferable for the stoma site to have been chosen before the operation. The most impor- tant selection criteria is the patient’s desire to be clean. Because the antegrade colonic enemas require surgery and up to 1 hour a day to make them successful, we feel it

is essential that only highly motivated patients and families are offered this procedure. It is our policy to try all other nonoperative modalities first. If the patients are then unhappy with their fecal control, we will offer the Malone procedure. This results in the operation being performed around 8 years of age. Occasionally, with highly motivated parents, we have performed the proce- dure in preschool children. It is however, our opinion that the operation has been most successful in older children.

In Malone’s original description, the appendix was disconnected from the cecum, reversed, and a submuco- sal “antireflux” turmel created.2 We have subsequently changed both of these components of the operation. We now bring the appendix tip out to the skin without reversing it; this enables the operation to be performed more easily and without disturbing the blood supply to the appendix. This method has been performed success- fully by laparoscopy.5 The antireflux procedure was designed to prevent fecal contents refluxing up the appendix. Two methods of creating an antireflux device have been described: the submucosal tunnel2 and intussus- ception of the appendix base into the cecum.4 Both techniques have subsequently been associated with leak- ing stomas. In our series, two patients experience reflux, and one of these patients had an antireflux tunnel formed. In this series, only one patient of 26 who had no antireflux procedure experienced leakage. It is therefore our policy not to perform an antireflux procedure.

The main complication of the Malone procedure is stoma1 stenosis, which occurred in 12 of 36 patients. Two methods of creating the stoma were used: the circular flush stoma and the V flap stoma. Stenosis occurred with both these techniques in our series; this is similar to other reports that have found that both methods can result in stenosis, but the circular stoma had fewer problems.4 Interestingly, when the appendix is used to create a catheterizable channel into the bladder, stoma1 stenosis is less of a problem.6 Catheterizing the bladder usually occurs every 3 to 4 hours, and we speculate that by regularly “dilating” the stoma with the catheter, this prevents stomal stenosis. Despite these problems, we are still using the circular stoma, but we now recommend that the appendicostomy is catheterized twice a day to prevent stenosis.

The appendix is the most usual conduit to create a catheterizable channel. Occasionally the appendix is not available. In these situations, a number of options are available: a cecal flap, used in six patients,7 tubularised ileum,3 an ileocecostomy,* and a permanent indwelling catheter. All three alternative catheterizable channels have had significant complication rates. These complica- tions include stoma1 stenosis and difficulty in catheteriz- ing because of excess mucosa, which hinders the passage

206 WILCOX AND KIELY

of the catheter. Consequently, the appendix remains our first choice.

The enema regimen is subject to considerable indi- vidual variation. We start with phosphate enema followed by saline. Care is needed with continual phosphate use because phosphate poisoning has been described.9 In addition to phosphate, we have used docussate enemas with saline, liquorice and saline, and saline alone. Others have described polyethylene glycol with or without saline.4 For an individual to find the right combination of medication and volume of fluid requires expertise and time. In our unit, we have a clinical nurse specialist who

has a specific interest in these difficult problems and is available for advice throughout the week. Much of the success of the Malone procedure depends on this continu- ing postoperative care, which may be necessary for many months.

The Malone procedure combined with antegrade co- ionic enemas, as shown by this and other series, provides us with an additional tool for controlling fecal inconti- nence. Although stoma1 complications are common, when used in highly motivated children it provides the majority of patients with an effective method of maintain- ing fecal control.

REFERENCES

1. Shandling B, Gilmore RF: The enema continence catheter in spina bifida: Successful bowel management. J Pediatr Surg 22:271-273, 1987

2. Malone PS, Ransley PG, Kiely EM: Preliminary report: The antegrade continence enema. Lancet 336:1217-1218,199O

3. Squire R, Kiely EM, Carr B, et al: The clinical application of the Malone antegrade colonic enema. J Pediatr Surg 28:1012-1015, 1993

4. Dick AC, McCallion WA, Brown S, et al: Antegrade colonic enemas. Br J Surg 83:642-643,1996

5. Ellsworth PI, Webb HW, Grump JM, et al: The Malone antegrade

colonic enema enhances the quality of life in children undergoing urological incontinence procedures. J Urol 155:1416-1418, 1996

6. Mitrofanoff P: Cystostomie continente tram-appendiculare dam le traitement des vessies neurologiques. Chir Pediatr 21:297-305, 1980

7. Kiely EM, Ade-Ajayi N, Wheeler RA: Cecal flap conduit for antegrade continence enemas. Br J Surg 81:1215, 1994

8. Marsh PJ, Kiff ES: Ileocaecostomy: An alternative surgical procedure for antegrade colonic enema. Br J Surg 83:507-508, 1996

9. Craig JC, Hodson EM, Martin HC: Phosphate enema poisoning in children. Med JAust 160:347-51, 1994

Discussion

F!J. Wolfson (Wilmington, DE): We’ve done a few of these procedures and have been very gratified with the results. Have you done any laparoscopically? We found that it really seems to lend itself to that and it is one of the few laparoscopic procedures that actually doesn’t take any longer than to perform open.

D.I: Wikox (response): No, we haven’t performed it laparoscopically but we are aware that good results of this have been published.

TC. Moore (Pales Verdes Estates, CA): This excellent study illustrates that improvement in the management of imperforate anus in the newborn is much needed to reduce, and hopefully eliminate, fecal incontinence. In newborn humans, rats, cats, and monkeys a very limited and critical period immediately after birth exists for the

development of hard-wired neurocircuitry from the periph- eral areas to the brain sensory neocortex. Colostomy and delayed repair in the imperforate anus greatly exceeds this critical period. How many of your patients with imperforate anus and incontinence were treated by repair at birth without a prior colostomy and how many by colostomy and delayed repair?

D. 27 Wilcox (responsej: It is our policy to treat them all with colostomy followed by repair unless there is a perineal fistula, and this is usually done at 3 months of age; however, some of these patients weren’t initially treated at our institution. The Malone procedure is kept in reserve for those patients who unfortunately do not get a good result from their initial surgery.