The Macedo-Malone antegrade continence enema procedure: early experience.

PURPOSE: The successful treatment of fecal incontinence can dramatically improve the quality of life of affected children. The introduction of the Malone antegrade continence enema provides the opportunity to manage previously resistant cases. However, using the to create this catheterizable channel is not always possible, and the duration of these antegrade enemas is a source of concern for the patients. We describe a new approach to create left continent colonic access to shorten the duration of these enemas, and report the experience gained from the first 9 cases managed at our institution. MATERIALS AND METHODS: During a 5-year period 9 patients underwent a Macedo-Malone antegrade continence enema at our institution. Incontinence was associated with myelomeningocele in 7 patients and anorectal malformation in 2. The antegrade continence enema procedure is begun by isolating a 2 cm flap in a tenia on the left colon (spleen flexure). A 12Fr silicone Foley catheter is placed on the mucosal surface of the flap to allow tubularization of the plate with interrupted polyglycolic acid 3-zero transverse sutures, creating an efferent tubular conduit. Antegrade colonic washouts were started 2 weeks after surgery with saline solution or tap water in all patients. RESULTS: Followup of our 9 cases ranged from 8 to 33 months (average 20.7). Enema volume varied from 250 to 800 ml, with administration taking from 45 to 60 minutes, and colonic evacuation occurred within 30 to 60 minutes of enema administration. Of the 9 patients 8 were completely continent and 1 was partially continent. Four patients experienced difficulty with catheterization initially because of stenosis of the stomal track. The affected stomas were dilated, which was successful in 1 case. Three patients subsequently required stomal revision. CONCLUSIONS: The Macedo-Malone procedure is a relatively straightforward operative approach providing an effective washout technique that is acceptable to parents and children.

Management of bowel dysfunction in children with spinal cord disease or injury by means of the enema continence catheter.

Because bowel dysfunction in children with spinal cord impairment is a common and disabling problem that does not have adequate treatment, we evaluated the enema continence catheter developed in Toronto, Canada. Thirty-one children and their families were taught to administer a 20 ml/kg saline enema through this device. The children's bowel functions were evaluated 18 and 20 months after the start of the program. Six of the children dropped out of the study in the first 2 weeks and nine dropped out after between 18 and 30 months. For those remaining in the study, the proportion of continent stools rose from 28% to 94% (p less than 0.01); constipated stools dropped from 55% to 15% (p less than 0.01). Satisfaction with the bowel program increased, and five children were able to switch from diapers to lined underwear. No adverse effects were reported, and the amount of time required for toileting did not increase. Although compliance with the regimen was difficult for some families and its use carries potential risks, we believe that it can provide significant improvement in the bowel care of selected persons with spinal cord impairment.

Acuidade do enema opaco pela técnica de Neuhauser no diagnóstico de doença de Hirschsprung / Accuracy of barium enema with Neuhauser's technique in the diagnosis of Hirschsprung's disease

Avaliamos retrospectivamente 14 pacientes de grupos etários variados, com quadro clínico de constipaçäo intestinal e que foram submetidos, no período de 1976 a 1989, a biópsia retal para confirmaçäo do diagnóstico de doença de Hirschsprung. Fizemos a correlaçäo entre enema opaco pela técnica de Neuhauser, manometria anorretal e biópsia retal. Concluimos que a doença é mais comum no sexo masculino; a localizaçäo do segmento agangliônico é mais frequente no reto e no sigmóide; a maioria das crianças com doença de Hirschsprung inicia com sintomas logo após o nascimento; o enema opaco pela técnica de Neuhauser apresenta acurácia de cerca de 80 p/cento no diagnóstico da doença de Hirschsprung, o que näo é suficiente para ser usado como método único na avaliaçäo da criança obstipada; a manometria anorretal, associada ao enema opaco pela técnica de Neuhauser, obtiveram acurácia de 100 p/cento quando houve concordância entre os métodos