In situ Malone antegrade continence enema in 127 patients: A 6-year experience

Purpose: The initial description of the Malone antegrade continence enema (MACE) relied on a reversed, tunneled and reimplanted appendix. In 1999 we reported our in situ technique that uses windows developed in the appendiceal mesentery for imbrication. We present our long-term results. Materials and Methods: From 1997 to 2003, 168 patients were identified who had undergone a MACE procedure. An in situ technique was performed in 76 females and 51 males. Average patient age at the time of surgery was 9.6 years (range 2.9 to 28.4). Diagnoses included myelomeningocele in 116 cases, lipomeningocele in 6, spinal cord injury in 2, posterior urethral valves in 1, sacral agenesis in 1 and functional constipation in 1. Results: Cecal plication/imbrication was performed in 100 patients, appendix intussusception and imbrication in 24, and creation of tenia flaps in 3. The abdominal stoma was umbilical in 50 cases, right lower quadrant in 74 and periumbilical in 3. Concomitant genitourinary reconstruction was performed in 87% of patients. Mean followup was 26.9 months (range 0.7 to 68.1). Fecal continence was reported by 91% of the patients. Thirteen stomal revisions (stenosis 10, prolapse 2 and leakage 1) were required in 11 patients. Major complications included a cecal volvulus requiring a right hemicolectomy in 1 patient, small bowel obstruction in 2, and shunt infection and/or malfunction in 2. Four patients have elected to no longer use the MACE for non-technical reasons. Conclusions: The in situ MACE procedure has reliable long-term results for treating fecal incontinence associated with neuropathic bowel.