ABSTRACT

The Malone procedure for antegrade continence enema (MACE) is now accepted as an established treatment for intractable fecal incontinence secondary to conditions such as spinal dysraphism and anorectal malformation. The successful use of the MACE is described in numerous reports in thousands of patients with follow-up of 10 years or more, and it has also been demonstrated that a successful MACE significantly improves quality of life. Technical modifications have been introduced over the years and these are illustrated in this chapter. It is no longer recommended to disconnect the appendix from the cecum (as described in the previous edition of this book), and the in-situ appendix is now the norm. If no other procedure is required, a laparoscopic approach (LACE) is recommended. For patients in whom constipation is a major problem, it may be best to site the conduit in the left colon rather than the cecum. A leftsided MACE can be performed colonoscopically, the percutaneous endoscopic colostomy (PEC), inserting a catheter as one would insert a percutaneous gastrostomy tube. This can then be replaced at a later date by a button or conduit,

depending on the patient’s wishes. If the appendix is absent or required for a simultaneous Mitrofanoff procedure, the Yang-Monti conduit is now the procedure of choice. The major ongoing complication associated with the MACE is stomal stenosis, which occurs in approximately 30 percent of patients, and this has led to a number of different techniques to construct the stoma.