www.elsevier.com/locate/jpedsurg

Left colonic antegrade continence enema:experience gained from 19 cases

Seong Min Kima, Sang Won Hanb, Seung Hoon Choia,*

aDivision of Pediatric Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul 120-752, South KoreabDepartment of Urology, Yonsei University College of Medicine, Seodaemun-gu, Seoul 120-752, South Korea

0022-3468/$ – see front matter D 2006

doi:10.1016/j.jpedsurg.2006.05.048

* Corresponding author. Tel.: +82 2

E-mail address: shchoi@yumc.yonse

Index words:Left antegrade

continence enema;

Fecal incontinence;

Constipation;

Retubularized ileum;

Retubularized

sigmoid colon

AbstractPurpose: As problems have developed with the right colonic antegrade continence enema procedure

(Malone’s procedure/Monti’s retubularized ileocolostomy), left colonic antegrade continence enema

(LACE) procedure, in which retubularized ileum or sigmoid colon is anastomosed into the sigmoid colon,

has gained popularity. The aim of the study was to describe our experience with the LACE procedure.

Methods: We retrospectively reviewed 19 LACE procedures that were performed at the Yonsei

University College of Medicine Hospital (Seoul, Korea) from March 2001 to March 2005.

Results: Male-to-female ratio was 11:8, with median age of 10 years (range, 3-34 years). Most common

diagnosis was meningomyelocele (78.9%, 15/19). The median total follow-up period was 23 months

(range, 3-37 months); median antegrade continence enema volume used was 600 mL (range, 250-

1500 mL); and median transit time was 30 minutes (range, 15-60 minutes). Patients performed antegrade

continence enema with an average of once every 2 days (range, 0.3-3 days). Social continence was

achieved in 14 patients (73.7%). Regurgitation of fecal material through stoma was not reported at all in

17 patients (89.5%).

Conclusions: We recommend LACE as the procedure of choice for children with congenital

malformations or any other condition predisposing to fecal incontinence or constipation intractable to

conventional treatment.

D 2006 Elsevier Inc. All rights reserved.

The colonic antegrade continence enema (ACE) proce-

dure is an effective treatment modality in patients with

intractable constipation and fecal incontinence, including

meningomyelocele, high anorectal malformation, cloacal

anomaly, or traumatic spinal neuropathy [1-3]. These patients

generally have a history of failed medical management by

way of anorectal suppositories, conventional enemas, and

biofeedbacks. Until 1990, when Malone et al devised the

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228 2116; fax: +82 313 8289.

i.ac.kr (S.H. Choi).

antegrade continence enema procedure (Malone’s antegrade

continence enema [MACE]), the progression of such con-

ditions was to persistent defecation problems or permanent

colostomy [2-4]. Yet MACE was not problem-free. The

MACE procedure is impossible in patients lacking an

appendix because of previous appendectomy or whose

appendix has been used for urinary conduit during Mitrofan-

off procedure. Moreover, the failure rate of MACE increases

if the blood supply to the appendix is inadequate. Monti et al

modified the MACE procedure by using a retubularized ileal

segment, instead of the appendix, for the continence stoma

[5,6]. Still, however, there were complications. The right side

Journal of Pediatric Surgery (2006) 41, 1750–1754

Left colonic antegrade continence enema 1751

of the colon or cecum is inherently dilated in neuropathic

bowel disorders and so required larger ACE volumes or

longer ACE transit times. Patients or their caregivers

frequently complained of moderate to severe abdominal

pain or nausea during the ACE procedure [7].

Liloku et al [8] reported a left Monti-Malone procedure

to overcome the problems associated with MACE. Since

that report, other authors have reported good results [9,10].

In this article, we present the clinical consequences in 19

patients who underwent left colonic antegrade continence

enema (LACE) and an analysis of the treatment outcomes

and complications.

1. Materials and methods

Between March 1999 and March 2005, antegrade

continence enema (ACE) procedure was performed on

23 patients. Of these, Malone’s procedure was performed

on 4 patients, with their own appendices for cutaneous

stoma (appendicocutaneostomy), and the LACE procedure

was performed on 19 patients with retubularized segments

of ileum (ileal Monti’s tube) or sigmoid colon (left Monti-

Malone procedure) (Table 1). Our analysis here is of the

19 patients who received LACE procedure. All LACE

procedures were performed by the same pediatric surgeon

(SH Choi). Segments of ileum or sigmoid colon with a

length 2.5 to 3.0 cm were made with care to preserve their

Table 1 Characteristics of 19 patients who underwent LACE proced

Patient

no.

Sex Age

(y)

Original

diagnosis

Urologic

procedure

LACE Follow-up

(mo)

Volume

(mL)

1 M 8 MMC IC RSb 18 1000

2 M 7 MMC SC RS 23 900

3 M 12 MMC SC RS 25 500

4 M 5 MMC SC RS 37 250

5 M 10 ARM – RS 11 700

6 F 9 MMC SC RS 19 500

7 F 6 MMC SC RS 4 500

8 F 19 MMC SC RS 31 1000

9 M 3 MMC SC RS 30 600

10 F 7 CA – RS 25 900

11 F 5 MMC IC RI 3 500

12 F 4 MMC SC RS 35 600

13 F 8 MMC IC RI 16 1000

14 M 7 HS SC RS 24 500

15 M 26 SL SC RS 25 250

16 M 4 MMC IC RI 20 700

17 M 11 MMC SC RS 7 1500

18 F 4 MMC SC RS 26 500

19 M 34 MMC SC RS 15 1500

MMC indicates meningomyelocele; SC, sigmoidocystoplasty; IC, ileocystoplas

lipoma; CA, cloacal anomaly; HS, Hinman syndrome; ARM, anorectal malforma Left colonic antegrade continence enema stoma function checkup at lastb Retubularized ileum was closed and changed to retubularized sigmoid co

vascular arcades, and the remaining bowel was anasto-

mosed in an end-to-end fashion (hand-sewn). A previously

made ring of bowel segments was opened along the

antimesenteric border using a Bovie coagulator (detubula-

rization) with the rectangular bowel flap plate wrapped

lengthwise around a 16F Foley catheter. The detubularized

bowel was retubularized with multiple interrupted absorb-

able sutures under the guidance of a 16F Foley catheter.

One end of the retubularized bowel was anastomosed to

the sigmoid colon and the other was exteriorized as a

cutaneous stoma into the umbilicus and anastomosed to an

umbilical stab incision. Witzel-type anti-refluxing sero-

muscular reinforcement was performed with several

sutures in the sigmoid colon. Antimesenteric border of a

20- to 30-cm segment of the ileum (for ileocystoplasty) or

sigmoid colon (sigmoidocystoplasty) was detubularized

with electrical cutting after meticulous povidone-iodine

irrigation. By sweeping with dry gauze, the mucosal layer

of the bowel segment was removed. This bowel segment

was taken down onto the bladder mucosa, then anasto-

mosed with bladder muscle from posterior to anterior using

absorbable interrupted sutures (Fig. 1) An ACE test via

Foley catheter was performed 10 to 12 days after the

operation with 50 to 100 mL of normal saline. The ACE

volume and interval were adjusted until proper bowel

movement was observed.

The treatment outcomes of colonic ACE procedures were

evaluated in terms of ACE volume, interval, and transit time

ure

Duration

(min)

Interval

(d)

Soilinga Regurgitationa Stenosisa Paina

30 0.3 + + � �15 2 � � � +/�30 2 � � � �20 2 � � + �30 3 � � � �30 1 � � � �30 1 +/� � � �20 3 � � � �60 2 � � + �15 2 � � � �15 3 +/� � � +

20 2 +/� � � �30 1 � � � �30 2 � � � �30 1 � � � �20 3 � � � +/�30 1 � � � �30 1 � � � +/�60 2 + + � �

ty; RS, retubularized sigmoid colon; RI, retubularized ileum; SL, spinal

ation.

follow-up.

lon because of stomal obstruction.

S.M. Kim et al.1752

(time from enema fluid administration to bowel move-

ments). The degree of social continence and complications

after LACE procedure were also evaluated.

2. Results

2.1. Demographic data of the patients

The male-to-female ratio was 11:8, with a mean age of 10

years (range, 3-34 years). Diagnoses were of meningomye-

locele in 15 (78.9%) patients, anorectal malformation in 2

(10.5%) patients, Hinman syndrome in 1 patient, and spinal

lipoma in 1 patient. Sigmoidocystoplasty was performed by

Fig. 1 Segments of ileum (A) or sigmoid colon (B) with a length 2.5 to

the remaining bowel was anastomosed in an end-to-end fashion (hand-se

the antimesenteric border using a Bovie coagulator (detubularization) wit

Foley catheter. The detubularized bowel was retubularized with multiple

catheter (C). One end of the retubularized bowel was anastomosed to th

stoma into the umbilicus and anastomosed to an umbilical stab inci

performed with several sutures in the serosa of sigmoid colon. Ileocy

simultaneously as a bladder augmentation procedure.

a urologist concomitantly with LACE in 13 (68.4%)

patients, followed by ileocystoplasty in 4 (21.1%) of these

patients. Operations other than LACE were not performed in

2 (10.5%) patients.

2.2. Volume, transit time, and interval of LACE

After a period of adjustment, all 19 patients were able to

perform LACE regularly without any problems with an

average of once every 2 days (range, 0.3-3 days). These

patients received regular follow-up care every 2 or 3 months

after the LACE procedure. The median total follow-up

period was 23 months (range, 3-37 months), the median

LACE volume requirement was 600 mL (range, 250-1500

3.0 cm were made with care to preserve their vascular arcades, and

wn). A previously made ring of bowel segments was opened along

h the rectangular bowel flap plate wrapped lengthwise around a 16F

interrupted absorbable sutures under the guidance of a 16F Foley

e sigmoid colon and the other end was exteriorized as a cutaneous

sion. Witzel-type anti-refluxing seromuscular reinforcement was

stoplasty (D) or sigmoidocystoplasty (E) was usually performed

Left colonic antegrade continence enema 1753

mL), and the median LACE transit time was 30 minutes

(range, 15-60 minutes).

2.3. Function of LACE

Social continence without fecal soilage between ACE

was achieved in 14 (73.7%) patients; 5 (26.3%) patients

complained of some fecal soilage between ACE. Regurgi-

tation of fecal material through the umbilical ACE stoma

was not reported at all in 17 (89.5%) patients, whereas

2 others (10.5%) complained of some regurgitation of fecal

material through the umbilical ACE stoma. Stoma stenosis

developed in 2 (10.5%) patients and required surgical

revision (ambulatory surgery). Other patients with minimal

stenosis required just stoma dilatation with a Hegar dilator

or Foley ballooning. Although 15 (78.9%) patients did not

present abdominal pain during LACE, 1 (5.3%) patient

experienced significant abdominal pain and 3 (15.8%)

patients experienced tolerable pain only upon introduction

of the catheter at the umbilical ACE stoma.

2.4. Complications of LACE procedurerequiring rehospitalization

Six (31%) patients required rehospitalization because

of post-LACE complications. Most complications were

stoma problems.

3. Discussion

Patients with dilated ascending and transverse colons, as

well as those with neurogenic bowels, often require

excessive fluid installation and require more ACE transit

time than other patients [7]. Considering this, LACE is more

physiologically sound than right colonic antegrade conti-

nence enema (RACE) because the enema is less likely to

impair water absorption, which occurs predominantly in the

ascending colon. What is more, delivery of enemas into the

descending colon targets the stool where it is hardest,

benefits from gravity, and results in timely and effective

bowel evacuation. Our experience with LACE suggests that

it is not only comparable to RACE, but also quite

satisfactory for children and their caregivers.

The most important parameter of success of the ACE

procedure is bfecal continence.Q Unfortunately, anatomically

and physiologically, these patients remain without conti-

nence (or the ability to control bladder or bowel function).

Therefore, success of the ACE procedure should be judged

by social continence (having soilage-free interval between

ACE). Social continence was achieved in 14 (73.7%) of

19 patients, and the bowel habits of children with fecal

incontinence of various causes changed completely into

normally adjusted, timely, and predictable ones. These

children developed clean perinea without use of a bag or

nappy between ACE. The remaining 3 (15.8%) patients

experienced some fecal soiling once or twice per month, but

it should be noted that 2 of them received LACE procedure

just 3 and 4 months ago, and are still likely to adapt to the

new circumstances. Two (10.5%) patients have experienced

a bplightQ with the LACE stoma because of frequent soiling

between ACE. In this author’s opinion, both patients should

be reeducated about the possibility of achieving fecal

continence with changes in their ACE regimen. One patient

had foregone further treatment after just 2 corrective

operations after LACE. The other patient, a 34-year-old

man, generally remains at home and believes that he can

endure fecal soiling without further treatment by self-

administration of anal enema. In addition to fecal soiling,

stoma stenosis or obstruction can be major problems after

ACE operations [11,12]. Stoma stenosis is frequently

reported after ACE procedure. In our study, mild stenosis

was corrected by repeated Hegar dilator or Foley balloon-

ing. However, 2 patients required stoma revision because of

severe stoma stenosis, which were managed by revision of

stoma opening in the umbilicus (V-Y plastic revision) on an

ambulatory basis. On the other hand, stoma obstruction was

quite problematic, which required laparotomy for closure

and recreation of retubularized bowels. For correction of

stoma obstruction, 2 patients required laparotomy, which

showed stricture in retubularized bowel suggestive of

previous ischemia because of inadequate blood supply or

excessive tension. Bernard et al emphasized 3 factors for

reducing the risk of stoma stenosis or obstruction. (1) There

must be adequate mobilization of the colon to avoid tension;

(2) the tubularized segment of colon must have blood

supply from at least 2 blood vessels to avoid ischemia; and

(3) the LACE stoma must remain intubated for 30 days to

facilitate healing [7].

In our study there are 3 points that should be considered.

First this is retrospective study for 19 patients who received

LACE procedure. We no longer perform the original

Malone’s ACE procedure (RACE) since 2001 (before that

time, we performed 4 cases of RACEprocedure), sowe do not

have any prospective data that can confirm the superiority of

LACE procedure. We have information about the treatment

outcomes of RACE procedure from other reported series

[6,13,14]. Secondly, in this study, postoperative follow-up

period was longer than any other reported series [8,9], but still

relatively short with a median of 23 months. Longer follow-

up period is required. Thirdly, although 73.4% of patients

achieved social continence and became soilage-free between

ACE, as much as 31% of the patients required reoperation

mainly because of stoma problem. However, our result is

comparable to any other reported series in terms of short-term

complications. We believe that these early complications, if

timely corrected, cannot become long-lasting sequelae.

Moreover, outcome of patients who received reoperation

(eg, stoma stenosis) is quite favorable. It is simple and usually

performed in ambulatory surgery. After we started to perform

LACE procedure in 2001, we modified the original LACE

procedure such as opening of stoma at the umbilicus (wide

mucocutaneous anastomosis and partial closure of skin layer)

S.M. Kim et al.1754

and formation of Witzel-type anti-reflux check valve by

several sutures at serosal layer of colon. These technical

modifications helped to decrease the incidence of stoma

problem such as stenosis or regurgitation. In all 6 patients

except 1, the outcome of reoperation was excellent with well-

functioning umbilical LACE stoma. Long-term complica-

tions also should be assessed cautiously. We highly recom-

mend the LACE procedure for patients with intractable

constipation or incontinence after conventional medical

management fails, especially for patients with neurogenic

bowels. Further research should be conducted with respect to

refinement of techniques to reduce the incidence of compli-

cations including partial incontinence and stoma problems.

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