The MACE Procedure: Experience in the United Kingdom

By J.I. Curry, A. Osborne, and P.S.J. Malone

Southampton, England

Background/Purpose: The Malone Antegrade Continence enema (MACE) procedure has become commonplace in the treatment of patients with faecal incontinence and constipa- tion. To ascertain its place in paediatric practice, the authors surveyed members of the British Association of Paediatric Surgeons (BAPS) to see if they have performed a MACE and continue to do so. The authors also assessed their indica- tions, success rate, and complications.

Methods: Members were asked to give the diagnosis of the patients submitted for surgery before September 1996, the procedure used to construct the MACE, the rate of failure, and complications encountered.

Results: A total of 300 MACE were reported, and the mean follow-up was 2.4 years. The diagnosis of 273 patients was known: spina bifida, 108; anorectal anomaly, 90; Hirsch-

sprung’s disease, 22; constipation, 23; other, 30. The most popular procedure was appendix disconnection and reimplan- tation. The overall success rate for all diagnoses was 79%. The main complication was stoma1 stenosis, 30%.

Conc/usions: These figures confirm that MACE is a useful operation. Improved patient selection, improvement in tech- niques, and increasing knowledge regarding continued man- agement should lead to improving results across the country. J Pediatr Surg 34:338-340. Copyright o 1999 by W.B. Saun- ders Company.

INDEX WORDS: Faecal incontinence, Malone antegrade co- Ionic enema, stoma1 stenosis, spina bifida, Hirschsprung’s disease.

T HE MALONE ANTEGRADE continence enema (MACE)l has become an established treatment for

children and adults who suffer from faecal incontinence and constipation. 2-6 Its acceptance as such has been based on individual units reporting good results without it having been subjected to a controlled, randomised study. In view of this, and with current emphasis on practising evidence-based medicine, we have conducted a survey of United Kingdom members of the British Association of Paediatric Surgeons (BAPS) to ascertain their experience with this procedure. Our aim was to find out the current status of this operation in terms of its prevalence and indications as well as its success rate and complications.

MATERIALS AND METHODS

A proforma was circulated to all current United Kingdom members of BAPS asking for details regarding the number of MACE procedures that they or their unit had performed up to the end of September 1996. The proformas were unmarked for anonymity. We asked for basic details including the diagnosis of the children and their age, sex, the procedure used. the success rate, and complications encountered.

From the Department of Paediatric Urology, Southampton General Hospital, Southampton, England.

Presented at the 45th Annual International Congress of the British Association of Paediatric Surgeons, Bristol, England, July 21-24, 1998.

Address reprint requests to J.I. Curry, 4 Victoria Crescent, High St, Dover, Kent, CT16 lDU, England.

Copyright 0 1999 by WB. Saunders Company 0022-3468/99/3402-0024$03.00/O

RESULTS

One hundred two proformas were sent, and 58 were returned. Thirty-three replies were from BAPS members who had never performed a MACE. Twenty-three replies were received that reflected individuals’ practice as well as units’ combined experience. We included our previ- ously reported figures as well as reported figures from one other UK centre.7

In total, we were aware of 300 MACE procedures that were performed. We had details relating to 273 of these procedures. The mean age was 12.3 years (range, 7.5 to 29.9) and the mean follow-up was 2.4 years (range, 0.3 to 6). The diagnoses are shown in Table 1. The type of procedure performed was known in 232 patients and is shown in Table 2.

The success rate was based on criteria that we had specified previously8: full, totally clean or minor rectal leakage on the night of the washout; partial, clean but significant stoma1 or rectal leakage, occasional major leak, still wearing protection but perceived by the child or parent to be an improvement; and Failure, regular soiling or constipation persisted, there was no perceived improve- ment, and the procedure was abandoned usually to a colostomy. The overall success rate, including full and partial success, is 79%. The reported success rates with respect to diagnosis are shown in Table 3.

The main complications were stoma1 stenosis in 30%, stoma1 leakage in 7%, adhesion obstruction in 2%, a gangrenous channel in 2%, and other complications,

338 Journal of Pediatric Surgery, Vol34, No 2 (February), 1999: pp 338-340

THE MACE PROCEDURE 339

Table 1. Diagnoses Table 3. Success Rate Based on Diagnosis

Spina bifida 108

Anorectal anomaly 90

Constipation 23

Hirschsprung’s disease 22

Other 30

Diagnosis Full (%I Partial (%I Failure (%I Unknown

Spina bifida 63 21 16 27

Anorectal anomaly 72 17 11 3

Hirschpsrung’s disease 82 9 9 0

Constipation 52 IO 38 1

Other 44 25 31 14

which included phosphate toxicity, granulation tissue around the stoma, button falling out, and one in whom a catheter was introduced into the subserosa of the channel.

children with little in the way of self motivation who undergo a MACE have a higher chance of doing poorly.4*g

DISCUSSION

An original surgical technique or the new application of a previously tried and trusted principle are the hallmarks of advance in surgical science. Any new therapy, however, has to be shown to be safe and effective. The MACE procedure has come to be accepted as an effective treatment for children and adults with faecal incontinence and constipation, but this is the first paper to document this fact nationally.

Its main application in the United Kingdom is in those children with neuropathic sphincter abnormalities or with anorectal abnormalities. This fits with the principle that these patients should have relatively normal colonic function, and their distal rectal and anal incompetence can be compensated for if the colon is kept evacuated. We have reported previously that patients with conditions in which there is dysfunction of colonic motility may do poorly9 and should be properly evaluated before surgery. In this series, nearly 40% of those children operated on for constipation did not respond to treatment. Units and individuals have adopted the message that very young

The main complication continues to be problems related to the stoma, usually in the form of stenosis. Newer reported techniques for stoma creationlO and relatively frequent cathaterisation should reduce this problem. It had been thought that if no antireflux mechanism was created, then there would be stoma1 leakage. Of the 17 stomas that leaked, only three were fashioned without an antireflux procedure (17%), and this suggests that such a procedure may not be necessary. It remains impossible to predict who these will be. Those now involved in creating a MACE using buttons and minimal access techniques 11,12 do not appear to have problems with stoma1 leakage. Adhesive obstruction continues to be a concern in terms of its potential for life-threatening illness. Although this is an accepted complication of any gastrointestinal surgery, those who advocate a minimally invasive approach in performing MACE may eventually take ascendancy in terms of the technique used.

Table 2. Type of Procedure

Appendix disconnection and reimplantation 89

Appendix with no antireflux procedure 58

Tubularised caecal flap 25 Button 19

lleal tube 7

Tubularised colonicflap 2

Other 32

Our knowledge of the MACE procedure is still in its infancy, and these figures represent the first 5 or 6 years of our experience with this novel idea. Many new exciting modifications to the original technique have been put forward, such as the method of creating a cathaterisable channel using small bowel,13 creating the MACE using minimally invasive techniques,“J2 and using smaller volume stimulant laxatives that would require the child to be tied to the lavatory for a far shorter period. The evidence does support this procedure as effective and safe, but we should still continue to accrue more long-term outcome data and also strive to improve on the present state of affairs with prospective standardi- sation for the benefit of our children.

REFERENCES

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340 CURRY, OSBORNE, AND MALONE

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13. Monti PR, Lara RC, Dutra MA: et al: New techniques for construction of efferent conduits based on the Mitrofanoff principle. Urology 49:112-115, 1997