The Procedure of Antegrade Continence Enema (ACE)

Muntadhar Muhammad Isa

Pe d i a t r i c S u r g e r y D i v i s i o n , D e p a r t m e n t O f S u r g e r y
Faculty Of Medicine, Syiah Kuala University
d r. Z a i n o e l A b i d i n , B a n d a A c e h

Presented in Pertemuan Ilmiah Tahunan XXV PERBANI

Samarinda,13-14 Oct 2017
 Introduction

Target of An0-
Repair Colo-Rectal
Repair organic
anatomical Surgery in
malformations Congenital function
Malformation

• Anomalies at the other end of the spectrum carry a poor or

indeterminate prognosis with regards to bowel control.
• These patients are incontinent of stool => not capable of having
voluntary bowel movements.

[1] Maria Zornoza, et al (2017) Operative Techniques: New surgical technique for creation of a continent appendicostomy: Invaginated appendicostomy, Journal of Pediatric Surgery 52 10671069,
[2] Balgopal E, et al (2013) The Role Of A Colon Resection In Combination With A Malone Appendicostomy As Part Of A Bowel Management Program For The Treatment Of Fecal Incontinence. J Ped Surg (2013) 48, 2296–2300
• The antegrade continence enema (ACE) (-) change
originally described by Malone et al => regular
Bowel
widely accepted as a valuable addition to Movement
↓↓ Disturbance
the therapeutic regimens available for of Childern
treating intractable fecal incontinence Independency
(such as myelomeningocele and anorectal and Privacy =>
malformations). ↑ Quality of
Minimal
Life
• Thousands of patients around the world need’s for
have undergone ACE procedures => parental
assistance
success rates in > 80%.

[1] Maria Zornoza, et al (2017) Operative Techniques: New surgical technique for creation of a continent appendicostomy: Invaginated appendicostomy, Journal of Pediatric Surgery 52 1067–1069,
[2] Balgopal E, et al (2013) The Role Of A Colon Resection In Combination With A Malone Appendicostomy As Part Of A Bowel Management Program For The Treatment Of Fecal Incontinence. J Ped
Surg (2013) 48, 2296–2300
[3] Malone PS, et al (1990) InBrian A. Vander Brink, Mark P. Cain, Martin Kaefer, Kirstan K. Meldrum, RosaliaMisseri, Richard C. Rink (2013) Outcomes following Malone antegrade continence enema
and their surgical revisions, Journal of Pediatric Surgery 48, 2134–2139.
 Functional
Constipation

Anorectal Idiopathic
Anomalies COnstipation

Indications

Hirschsprung’s
Spina Bifida
Disease

etc

[2] Balgopal E, et al (2013) The Role Of A Colon Resection In Combination With A Malone Appendicostomy As Part Of A Bowel Management Program For The Treatment Of Fecal Incontinence. J Ped Surg (2013) 48, 2296–2300
Operation Technique
• The type of MACE was divided into one of three groups based
upon original surgical technique utilized for their creation;
• In situ appendicocecostomy (AC) w/o splitting of the appendix
• ileocecostomy: a transverse retubularized segment of ileum
(Monti) implanted into the tenia of the caecum (IC)
• Caecal flap: a lateral flap of caecum is raised on the right colic
artery, tubularized and buried into a seromuscular tunnel (CF).

[1] Maria Zornoza, et al (2017) Operative Techniques: New surgical technique for creation of a continent appendicostomy: Invaginated appendicostomy, Journal of Pediatric Surgery 52 1067–1069,
[4] Curry JL, et al (1999) The MACE procedure: experience in the united Kingdom. Journalof pediatric surgery 34 : 338–340
[6] Koyle MA, Malone PSJ (2001) The Malone antegrade continence enema (MACE). In: King LR,BelmanAB,Kramer SA, (eds) Clinical pediatric urology, 4th ed. Martin Dunitz, London, Chap 18, pp 529–536
 • Patient is placed supine on the operating table.
• The caecum is mobilized; amputate the tip of the
appendix; stay suture is inserted in the open end to apply
traction.
• A 10–12 Ch catheter is passed via the appendix into the
caecum.
• The stretched mesentery is inspected and fenestrated
between the vessels; caecum wrapped around the
appendix through the mesenteric windows.
• Stay sutures inserted into the caecum alongside the
anterior taenia (under tension whilst a submucosal tunnel
is made).
• The serosa and muscle incised using a to expose the
submucosa.
• Incision includes the base of the appendix reducing
angulation and making catheterization easier.[6]

[4] Curry JL, et al (1999) The MACE procedure: experience in the united Kingdom. Journalof pediatric surgery 34 : 338–340
[6] Koyle MA, Malone PSJ (2001) The Malone antegrade continence enema (MACE). In: King LR,BelmanAB,Kramer SA, (eds) Clinical pediatric urology, 4th ed. Martin Dunitz, London, Chap 18, pp 529–536
 • The appendix is folded along the length of the submucosal tunnel
and the caecum is wrapped around it using an absorbable 4/0
suture.
• The first suture is placed at the base of the appendix picking up
the caecum–appendix–caecum (prevents movement and kinking
and facilitates easy catheterization).
• Further sutures are progressively placed along the length of the
appendix in a similar fashion, bringing the caecal wrap through
the mesenteric windows.
• The entire appendix is wrapped within the caecum until only a
sufficient length is left to bring it out through the abdominal wall
when the stoma is constructed.
• The antemesenteric end of the appendix is spatulated to allow a
V flap of skin to be inlaid during construction of the stoma to
reduce the incidence of stomal stenosis.
• It is important to anchor the caecum to the posterior aspect of
the anterior abdominal wall using absorbable sutures so it is not
hanging on the appendix and at risk of torsion.[6]

[4] Curry JL, et al (1999) The MACE procedure: experience in the united Kingdom. Journalof pediatric surgery 34 : 338–340
[6] Koyle MA, Malone PSJ (2001) The Malone antegrade continence enema (MACE). In: King LR,BelmanAB,Kramer SA, (eds) Clinical pediatric urology, 4th ed. Martin Dunitz, London, Chap 18, pp 529–536
 • The Monti ACE is required when the appendix is absent or
required for a Mitrofanoff conduit or when a left colonic ACE is
constructed.
• A 2-cm segment of ileum is isolated on its vascular pedicle.
Straight noncrushing bowel clamps are applied to either end
of the isolated segment and the bowel divided using a knife.
• An end-to-end ileal anastomosis is performed using
interrupted extra mucosal 4/0 absorbable sutures and the
mesenteric defect is closed.
• The bowel is detubularized by opening it along its
antemesenteric border in the midline using scissors or
diathermy [6].
• The Monti tube is constructed using a single layer of pp,
interrupted extra-mucosal 6/0 monofilament absorbable
sutures over a 12 Ch catheter.

[4] Curry JL, et al (1999) The MACE procedure: experience in the united Kingdom. Journalof pediatric surgery 34 : 338–340
[6] Koyle MA, Malone PSJ (2001) The Malone antegrade continence enema (MACE). In: King LR,BelmanAB,Kramer SA, (eds) Clinical pediatric urology, 4th ed. Martin Dunitz, London, Chap 18, pp 529–536
 • Using this approach it is also possible to test in which part
of the colon the conduit will work best.
• Increasing numbers of conduits are now placed in the distal
descending colon because the time taken to perform the
washout is reduced.
• In practical terms there are now two types of ACE, the
original caecal ACE and the new left colonic ACE.
• For the caecal ACE, many surgeons now advocate simply
amputating the tip of the appendix and bringing the open
end on to the abdominal wall without constructing any
continence mechanism. This is being increasingly
performed laparoscopically.

[4] Curry JL, et al (1999) The MACE procedure: experience in the united Kingdom. Journalof pediatric surgery 34 : 338–340
[6] Koyle MA, Malone PSJ (2001) The Malone antegrade continence enema (MACE). In: King LR,BelmanAB,Kramer SA, (eds) Clinical pediatric urology, 4th ed. Martin Dunitz, London, Chap 18, pp 529–536
 •The recommended technique for creating the continence
mechanism has changed.
•If the appendix is absent, required for a simultaneous Mitrofanoff
procedure or if a left colonic ACE is being constructed, a tabularized
small bowel tube using the Monti procedure is recommended.
•The incision will depend on whether it is a caecal, left colonic or an
ACE performed in combination with a bladder reconstruction.
•The surgeon can choose his or her own preferred approach. It is
recommended that patients receive broad spectrum antibiotic
prophylaxis and undergo a full bowel preparation pre-operatively,
as it is helpful to have the colon empty when the washouts are first
commenced. [4]

[4] Curry JL, et al (1999) The MACE procedure: experience in the united Kingdom. Journalof pediatric surgery 34 : 338–340
[6] Koyle MA, Malone PSJ (2001) The Malone antegrade continence enema (MACE). In: King LR,BelmanAB,Kramer SA, (eds) Clinical pediatric urology, 4th ed. Martin Dunitz, London, Chap 18, pp 529–536
 Figure 2. (A) Depiction of resection of a mega-rectosigmoid combined with a Malone procedure [2] (B) Schematic of
MACE flushing technique [10].

[10] Hinds AC, et al (2004) The New Malone Antegrade Enema Automatic Instillation Device Allows Independeces and Decreases Flush Times. Jurnal of Urology 172:1681-1685
 Figure 1. ACE assessment scheme. Each domain is assessed from left to right [11]

[11] Siddiqui AA, et al (2011) Long-term Follow-up of Patients After Antegrade Continence Enema Procedure. J Pediatr Gastroenterol Nutr; 52(5):1-10
 Figure 4. Charts illustrate representative objective changes after ACE Malone with no significant difference
in time needed for bowel care, almost all BMs in toilet and corresponding decrease in incontinent episodes
per week (P < 0.05 for all except bowel care time).Note: BM: Bowel Movement. [12]

[12] Joon-ha Ok and Kurzrock EA (2011) Objective measurement of quality of life changes after ACE Malone using the FICQOL survey. J Ped Uro 7:389-39
Figure 3. Kaplan Meier curve for relapse-free probability (Mean: 88.4 ± 4.9 months) [11]

[11] Siddiqui AA, et al (2011) Long-term Follow-up of Patients After Antegrade Continence Enema Procedure. J Pediatr Gastroenterol Nutr; 52(5):1-10
Conclusion
• The most common is pain during the washout, which is reported
in up to 60% of patients. This usually settles spontaneously
during the first 3 months but can be helped by reducing the
concentration of the phosphate, reducing the rate of the infusion
or using an antispasmodic prior to the enema (Colofac, Solvary,
UK).
• The commonest operative complication encountered is stomal
stenosis,which occurs in up to 30% of cases with half of these
patients requiring revisional surgery.
• It has also been shown to significantly improve patient’s quality
of life. [4]
Thank You