LETTER TO THE EDITOR

N. P. Sheth

Comments on ‘‘Application of the Malone antegrade continence enema(MACE) principle in degenerative leiomyopathy’’

Accepted: 10 July 2002 / Published online: 29 July 2004� Springer-Verlag 2004

Sir,In the paper, ‘‘Application of the Malone antegrade

continence enema (MACE) principle in degenerativeleiomyopathy’’ by Chitnis et al. [6], authors have shownthat some modification of MACE is possible. The oldstandard MACE [1, 2] uses the caecum-ascending colonas the site for the stoma; however, certain problems areencountered while using this site and therefore a numberof patients have abandoned the use of MACE [3].

In the absence of dysmotility, the right colon usuallyhas very little fecal residue in a child who has beentreated with suitable laxatives; and is almost never di-lated like the mega-sigmoid and mega-rectum. The rightcolon, which has more absorptive potential, can lead tothe absorption of electrolytes and water. The intestinaltransit study often shows the delay in the lower part ofthe descending and sigmoid colons, except perhaps inthe case of slow-transit constipation. In one-third of thepopulation an incompetent ileocaecal valve may causeenema fluid in the MACE to regurgitate into the ter-minal ileum, causing the need for a large amount ofenema fluid. This larger volume of fluid may causeabdominal pain [4]. The duration of MACE techniquevaries from 1 to 4 h and is associated with substantialmorbidity.

All these points suggest that while using the classicalsite MACE, there is an associated ‘‘dead space’’ in thecaecum, in the ascending colon-hepatic flexure, in thetransverse colon-splenic flexure and in the upper part ofdescending colon. This dead, water-absorbing space canbe avoided by selecting the lowermost part of thedescending colon or the uppermost part of the sigmoidcolon as the site for MACE; after excluding any prob-lems of dysmotility in the right colon by doing bariumand transit studies. This site, in the left lower colonicregion, is more effective and advantageous. Unlike theShandling continent catheter technique [5], a patient can

receive the antegrade enema through this site while sit-ting on the toilet seat. Unlike the Shandling continentcatheter regime this would be more effective, and thiscan report good results. This technique needs smallervolumes of fluid, takes shorter duration to act and is lesslikely to cause late leakage problems. Since fecalimpaction is difficult to treat by the usual MACE tech-nique; a modified MACE, using inflated Foley’s ballooncatheter is more effective in the treatment of fecalimpaction, which, if desired, may be preceded by the useof oil or liquid paraffin instillation.

Some of the points that need to be emphasized aboutthis technique are:

1. The site for the stoma to be selected by barium enemaand transit study.

2. The site for a skin incision to be guided by laparos-copy.

3. The distal part of the descending colon is mobilizedby left paracolic peritoneal incision, so that it can bebrought easily to the posterior surface of theabdominal wall.

4. As in classical MACE, one of the Metrofanoff pro-cedures can be used at the selected stomal site.Alternatively, in a thinly built child, the stoma iscreated by making a keyhole incision, through all thelayers in the bowel, and the mucosa is approximatedwith the serosa, so as to easily accommodate a size 16F catheter. The bowel around the stoma is anchoredto the abdominal wall to prevent separation due torepeated catheterization.

5. To form a skin tube: a U-shaped skin flap, involvingskin, superficial fascia and external oblique apo-neurosis/muscle (en bloc), is fashioned with its openend directed upwards and outwards. This compositeskin flap should be wide enough to be rolled into acomposite skin tube of adequate length so as toallow a 16-F catheter to pass loosely through it.This skin flap is better than the ordinary skin flapsince it is less likely to stenose. The skin tube isanastomosed to the bowel stoma with interrupted

N. P. ShethShivala 203, Khatau Road, 400005 Mumbai, IndiaE-mail: drnsheth@hotmail.com

Pediatr Surg Int (2004) 20: 904–905DOI 10.1007/s00383-002-0948-3

sutures and the indwelling catheter is left in for4 weeks.

References

1. Malone PS, Ransley PG, Kiely (1990) Preliminary report: theantegrade continence enema. Lancet 33:1217–1218

2. Curry JI, Osbome A, Malone PS (1998) How to achieve a suc-cessful Malone antegrade continence enema. J Pediatr Surg33:138–141

3. Driver CP, Barrow C, Fishwick J et al. (1998) The Malone an-tegrade colonic enema procedure: outcome and lessons of 6years’ experience. Pediatr Surg Int 13:370–372

4. Marshall J, Hutson JM, Anticich et al. (2001) Antegrade con-tinence enemas treatment of slow-transit constipation. J PediatrSurg 36:1227–1230

5. Shandling B, Gilmour RF (1987) The enema continence catheterin spina bifida: successful bowel management. J Pediatr Surg22:271–273

6. Chitnis et al. (2002) Application of the Malone antegrade con-tinence enema (MACE) principle in degenerative leiomyopathy.Pediatr Surg Int 17:470–471

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