USE OF A MONTI CHANNEL FOR ADMINISTRATION OF ANTEGRADECONTINENCE ENEMAS

ELIZABETH B. YERKES, RICHARD C. RINK,* MARK P. CAIN† AND ANTHONY J. CASALE‡From the Department of Urology, Indiana University School of Medicine, Indianapolis, Indiana

ABSTRACT

Purpose: Success with Malone antegrade continence enemas (MACE) requires reliable accessto the colon and a customized enema regimen. Use of the appendix in situ provides a natural andwell-vascularized conduit. When the appendix is absent or inadequate, alternative techniquesare required. We report our experience using Monti channels to administer antegrade continenceenemas.

Materials and Methods: Of the 106 MACE procedures performed in 53 months a Monti-MACEwas created in 13. Indications for use of ileum, technique, ease of catheterization and incidenceof complications were reviewed.

Results: Mean followup was 21.7 months. Two patients had transient difficulty advancing thecatheter into the cecum. Stoma revisions were required for critical stenosis in 2 patients (15.4%).Stoma leakage occurred in 1 patient after multiple stoma revisions.

Conclusions: The Monti-MACE provides continent access to the colon for antegrade enemas.The rate of stomal revision is only slightly higher than that reported for appendicocecostomy.While use of the appendix in situ remains our preference, reconfigured ileum is a reliablesubstitute in patients without a suitable appendix.

KEY WORDS: enema; fecal incontinence; ileum, catheterization

In 1990 Malone et al reported their initial experience withantegrade continence enemas (MACE) for the managementof intractable fecal incontinence in patients with myelodys-plasia and anorectal malformations.1 The initial techniqueinvolved amputation of the appendix on its mesenteric pedi-cle and reimplantation of the reversed appendix into thececum. Since that time, several modifications and other tech-niques have provided continent access to the colon for admin-istration of antegrade enemas.2–13 Our preference has beento leave the appendix in situ and to create a cecal wrapthrough windows in the mesoappendix.12

Unfortunately, the appendix is not universally available,even in the pediatric population, and alternate techniquesare required to allow daily antegrade access to the colon.When the appendix is inadequate, surgically absent or pre-viously committed as a continent urinary channel, furtheroptions for the MACE procedure include button cecostomy orcreation of a neoappendix from ileum or colon. We describeour experience using reconfigured ileum (the Monti-Yangtechnique14, 15) for the administration of daily antegrade con-tinence enemas.

MATERIALS AND METHODS

Between February 1997 and June 2001 the MACE proce-dure was performed in 106 patients at our institution. In 13of these patients the appendix was surgically absent or notsuitable for reconstruction. A Monti channel was fashionedfrom a short ileal segment and implanted into the proximalcolon. We reviewed the indications for use of reconfiguredileum, the specific surgical technique and the surgical out-come, including ease of catheterization and incidence ofstomal complications.

RESULTS

Mean followup was 21.7 months (range 9.5 to 45.5) andmean patient age at the time of Monti-MACE was 179months (range 117 to 277). Indications for substitution ofreconfigured ileum are listed in the table. Of the patients 9underwent concomitant major urinary reconstruction and 4had undergone previous urinary reconstruction.

A standard Monti-Yang channel14, 15 was created in 7 pa-tients, and a spiral Monti16 was created in the remaining 6.In each case the ileal tube was anastomosed to the colonicmucosa in an interrupted fashion either in the cecum or themost proximal remaining segment of the colon. The tenia wasincised to the level of the submucosa and reapproximatedover the ileal tube in 9 patients, and a cecal wrap wasperformed around the ileal tube in 4. The stoma location wasselected to provide the most natural course for catheteriza-tion of the channel. Stomas were matured by insertion of acutaneous V-flap, and placed in the right lower quadrant in 7patients and in the umbilicus or left lower quadrant in 3each.

All catheters were left in place for 3 weeks after surgery.Two patients had intermittent difficulty guiding the catheterinto the colon during the first 2 weeks after catheter removal.Both patients had standard length Monti channels im-planted into the tenia of the cecum and the point of hang-upwas in the terminal aspect of the tunnel. The catheter wasreplaced for 1 week and they have had no further difficultycatheterizing.

Two patients (15.4%) required surgical revision of the

* Financial interest and/or other relationship with Alza and Qmed.† Financial interest and/or other relationship with Aventis and

Pharmacia.‡ Financial interest and/or other relationship with Aventis-

Pasteur, Bayer and Pharmacia.

Indications for Monti-MACE

No.

Previous appendectomy 4Previous appendicovesicostomy 4Inadequate appendix/mesentery 2Previous ileocecal augmentation 2Obliterated appendicocecostomy 1

0022-5347/02/1684-1883/0 Vol. 168, 1883–1885, October 2002THE JOURNAL OF UROLOGY® Printed in U.S.A.Copyright © 2002 by AMERICAN UROLOGICAL ASSOCIATION, INC.® DOI: 10.1097/01.ju.0000028005.04404.a1

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stoma for critical stenosis. A spiral Monti-MACE requiredrevision after 4 months and there has been no recurrence ofstenosis 15 months after the initial surgical procedure. Theother patient had a standard length Monti-MACE, and re-quired revision of the stoma 5, 17 and 41 months after theinitial procedure. The channel was ultimately replaced witha new Monti-MACE due to leakage through the stoma afterthe third revision. No other patient experienced leakage offecal material or irrigation fluid through the stoma.

DISCUSSION

Administration of routine antegrade continence enemashas improved continence in patients with fecal soiling asso-ciated with neuropathic or structural abnormalities of theanal sphincter.1–2, 6, 12, 17–21 Since the initial description ofMalone et al in 19901 a variety of other surgical techniqueshave been described.2–13 Gerharz et al described use of theappendix in situ with incision of the tenia and closure of theseromuscular layer through windows in the mesoappendix.7It has been our preference to use the appendix in situ withouttenia tunneling but with a cecal plication through the mes-enteric windows, as described by Rink et al.12 However, whenthe appendix is surgically absent or unsatisfactory, alterna-tive techniques must be used.

Cecostomy tubes may be placed by either a percutaneous oropen approach and have had results comparable to the orig-inal Malone procedure.5, 8, 11, 22, 23 This technique has beenproposed not only as a substitute for the appendix, but also tospare the appendix for urinary reconstruction. It can also beused in patients who do not require laparotomy for simulta-neous reconstructive procedures. These techniques offer theadvantage of being less invasive but do require an indwellingcatheter or button on the abdominal wall. Chait et al havefound percutaneous placement of low profile catheters to bereliable and well accepted by patients and families.8 Othershave reported success with open placement of gastrostomybuttons.5, 22, 23 Granulation tissue and superficial infectionsat the cecostomy site have been reported.8, 22, 23 While somedegree of fecal incontinence might be expected around thececostomy device, this has not been reported in any of theseseries. After tunneling a cuffed silicone catheter subcutane-ously to secure and conceal the cecostomy, however,Fonkalsrud et al noted tract and cuff infections, which werelikely due to cecal contamination, in 3 patients (12.5%).11

Sheldon et al described a cecal stapling technique to extendthe functional length of appendix.13 This technique may per-mit use of an appendix that was otherwise unsuitable for theMACE procedure or may allow the appendix to be used forurinary reconstruction and MACE.

An absent appendix can be recreated from a cecal flap orfrom reconfigured ileum. Meticulous attention to the flapblood supply is required for optimal results.3, 6 Tubulariza-tion of a cecal flap was the technique of choice in severalseries when the appendix was either absent or committed tocontinent urinary diversion.3, 6, 19–21, 24 Cromie et al success-fully performed laparoscopic cecal tubularization in dogs.25

Unfortunately, stomal stenosis19, 20, 24 and leakage from thestoma6 have been significant problems in the clinical series.Several groups have used ileum for continent access to thecolon. Marsh and Kiff performed ileocolostomy and broughtthe terminal ileum up to the skin, and a competent ileocecalvalve produced a continent stoma in 6 of 7 patients.4 Sheldonet al had good results with cecal implantation of long taperedileal segments.18

Since independently described by Yang14 and Monti et al15

reconfiguration of short, detubularized ileal segments hasbeen embraced as a substitute for the appendix in continenturinary reconstruction.26, 27 The Monti technique has alsobeen used in small numbers for administration of antegradecontinence enemas.10, 27 As when incorporated into the uri-

nary tract, the ileal tube is reimplanted into the colon in anonrefluxing fashion based on the Mitrofanoff principle.28

Compared with long tapered ileal segments, the Monti-MACE offers the advantages of using only a small segment ofbowel and allowing catheterization parallel to the valvulaeconniventes.10 In the largest previously published seriesSugarman et al used Monti channels for antegrade enemas in8 patients. At a maximum follow of 6 months they hadfavorable results with no significant stomal complications.10

The appendix was absent or unsuitable in 12% of our cases.A Monti-MACE was constructed from ileum in these 13 pa-tients. At a mean followup of 22 months we have foundreconfigured ileum to be a reliable and continent substitutefor appendix.

Whether a standard or spiral Monti was used the ease ofcatheterization was durable. Any early transient difficultywith intubation resolved after another week with a catheterindwelling. Nearly all stomas visibly narrow somewhat asthey heal but it is rare to have functional narrowing thatprecludes insertion of a catheter suitable for efficient enemaadministration. Critical stenosis, superficial narrowing thatprecludes adequate catheter insertion or results in signifi-cant discomfort due to dilatation with each insertion, re-quires surgical revision. Critical stomal stenosis occurredslightly more frequently with the Monti-MACE than in ourseries of appendicocecostomies (15.4% versus 10%).29 Onechannel ultimately was replaced after several revisions forstenosis. In this initial experience the technique used toreconfigure the short ileal segment (spiral versus standardMonti) did not appear to have any bearing on stomal stenosis.

Leakage of fecal material or irrigation fluid through thestoma is generally not a problem. However, after the thirdrevision for stenosis 1 patient experienced fecal incontinenceat the stoma. There are several pertinent points about thiscase with regard to critical stenosis and stomal incontinence.After the initial procedure he had abnormal scarring similarto keloid formation. The first 2 revisions involved mobiliza-tion of the Monti-MACE above the fascia and deep insertionof a cutaneous V-flap. After recurrent stenosis daily use of agastrostomy button through the channel was attempted butthe patient found the device uncomfortable. During the thirdrevision the channel was mobilized to the level of the fasciaand a V-flap was tacked to the fascia and spatulated channel.Postoperatively stool leaked through the stoma, and uponexploration for creation of a new channel, the flap had beenbrought to the level of the cecum. With routine fixation of thececum to the posterior fascia during the initial procedure, thececum is at risk after multiple revisions and extensive mobi-lization of the channel. The need for multiple revisions maybe a poor sign for long-term use of the channel, and thesurgeon may consider replacement of the channel.

CONCLUSIONS

Although use of the appendix in situ remains our prefer-ence for the MACE procedure, reconfigured ileum providesconsistent results and is a reliable substitute when the ap-pendix is absent or otherwise unsuitable. With several op-tions available to administer antegrade enemas, the mostappropriate technique should be determined on a case bycase basis. The Monti-MACE is particularly useful in pa-tients who will have intestine isolated for a concomitantreconstructive procedure. We will continue to use the Montitechnique in these patients when the appendix is not avail-able for the MACE procedure.

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DISCUSSION

Dr. Stuart Bauer. You have shown that there was a 15% incidence of stomal stenosis with the Monti-MACE.Yet you did not have the same degree of complications when the Monti was used for a continent urinary stoma.Why is there a difference when you put in into the bowel as opposed to putting it into the bladder?

Dr. Elizabeth Yerkes. I think the difference may be that when the Monti is used in the urinary tract, it is beingcatheterized more frequently that it is for the MACE.

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