Experience of the MACE procedure at a regional pediatric surgical unit: a 15-year retrospective review.

INTRODUCTION: The Malone antegrade continence enema (MACE) procedure is an established treatment option for children with constipation or fecal incontinence. This study retrospectively analyses the management and outcomes of children who underwent MACE procedures at a regional pediatric surgery unit. PATIENTS AND METHODS: Children who underwent a MACE procedure in our unit between 1998 and 2012 were identified. Demographic and clinical data were obtained from contemporaneous records. Using the continence scale described by Malone, overall outcomes were categorized as full, partial, or failure (full: totally clean or minor rectal leakage on night of washout; partial: clean but significant stoma or rectal leakage, occasional major leak and/or still wearing protection but perceived by child or parent to be an improvement; failure: regular soiling or constipation persisted, no perceived improvement, procedure was abandoned). Data entry and statistical analysis were performed using Excel and SPSS (IBM Corp., Armonk, New York, United States). RESULTS: A total of 40 children (29 male) were identified for inclusion. Underlying diagnoses were idiopathic constipation (16), anorectal anomalies (14) and Hirschprung's disease (10). The MACE procedure was performed laparoscopically in 26 cases and using an open technique in 14 cases. Mean age at the time of surgery was 8.9 years (range, 3-19 years) and mean follow-up time was 6.5 years (range, 1-10 years). Outcomes categorized as full were 62.5% for chronic idiopathic constipation (CIC), 71.4% for anorectal malformation (ARM), and 70% for Hirschsprung disease (HD). Overall success rates (full and partial outcomes combined) were 87.5% for CIC, 92.8% for ARM, 100% for HD, and 92.5% for all diagnoses taken together. Eleven MACE procedures (27.5%) were reversed, in seven (17.5%) due to the return of spontaneous and regular bowel movements and in four (10%) due to stomal problems. CONCLUSION: This study identified a high success rate (combining full and partial outcomes) of 92.5% for MACE procedures within our unit. An encouraging finding is that the procedure was reversed in a significant proportion of patients following the return of normal bowel habits.

Malone antegrade continence enema (MACE) for fecal incontinence in imperforate anus improves quality of life.

The MACE procedure has been used in patients with imperforate anus (IA) to improve fecal continence. Our aim was to assess the impact of the MACE on the quality of life (QOL) in children with IA and fecal incontinence. A retrospective review was performed of children with IA that underwent the MACE procedure between 1997 and 2004. Patients and their parents were contacted by telephone survey regarding continence and its psychosocial effects before and after MACE. The same survey was given to the patients' teachers. Responses to 15 questions were compiled and a QOL score calculated and significance evaluated by t-test (P < or = 0.05). IRB approval was obtained. Thirty-two patients were identified with a mean age at operation of 9 years (4-19 years) and mean follow-up of 3.8 years (7 months to 8 years). Four patients had a low malformation, 8 were intermediate, 15 were high, and 5 had a cloacal anomaly. Twenty patients had documented sacral/spinal anomalies, including five with tethered cord. Post-MACE complications included stenosis in 16 (50%), with 11 requiring an operative revision at a mean of 21.7 months (2 months to 6 years), takedown in one at 4 years and volvulus in one at 18 months. Prior to the MACE, 18/25 (72%) had poor QOL scores. Post-MACE QOL results were similar between patients, parents and teachers. Patients' mean QOL score improved from 59.9 to 26.3% (P < 0.001), with parents from 59.7 to 26.4% (P < 0.001). QOL score improved >50% in nine families, 25-50% in ten and <25% in six. All patients and parents interviewed reported an improvement in their QOL following the MACE. This procedure should be offered to children with IA with the expectation of significant improvement in QOL.

Continence following electrical stimulation and EMG biofeedback in a teenager with imperforate anus.

A teenage boy with repaired high imperforate anus relied on daily enemas for social continence. After treatment with low intensity transcutaneous electrical stimulation and electromyographic biofeedback home programs, he achieved improved fecal continence requiring only one enema per month.