Comments on ?Application of the Malone antegrade continence enema (MACE) principle in degenerative leiomyopathy?

Abstract

Sir, In the paper, ‘‘Application of the Malone antegrade continence enema (MACE) principle in degenerative leiomyopathy’’ by Chitnis et al. [6], authors have shown that some modification of MACE is possible. The old standard MACE [1, 2] uses the caecum-ascending colon as the site for the stoma; however, certain problems are encountered while using this site and therefore a number of patients have abandoned the use of MACE [3]. In the absence of dysmotility, the right colon usually has very little fecal residue in a child who has been treated with suitable laxatives; and is almost never dilated like the mega-sigmoid and mega-rectum. The right colon, which has more absorptive potential, can lead to the absorption of electrolytes and water. The intestinal transit study often shows the delay in the lower part of the descending and sigmoid colons, except perhaps in the case of slow-transit constipation. In one-third of the population an incompetent ileocaecal valve may cause enema fluid in the MACE to regurgitate into the terminal ileum, causing the need for a large amount of enema fluid. This larger volume of fluid may cause abdominal pain [4]. The duration of MACE technique varies from 1 to 4 h and is associated with substantial morbidity. All these points suggest that while using the classical site MACE, there is an associated ‘‘dead space’’ in the caecum, in the ascending colon-hepatic flexure, in the transverse colon-splenic flexure and in the upper part of descending colon. This dead, water-absorbing space can be avoided by selecting the lowermost part of the descending colon or the uppermost part of the sigmoid colon as the site for MACE; after excluding any problems of dysmotility in the right colon by doing barium and transit studies. This site, in the left lower colonic region, is more effective and advantageous. Unlike the Shandling continent catheter technique [5], a patient can receive the antegrade enema through this site while sitting on the toilet seat. Unlike the Shandling continent catheter regime this would be more effective, and this can report good results. This technique needs smaller volumes of fluid, takes shorter duration to act and is less likely to cause late leakage problems. Since fecal impaction is difficult to treat by the usual MACE technique; a modified MACE, using inflated Foley’s balloon catheter is more effective in the treatment of fecal impaction, which, if desired, may be preceded by the use of oil or liquid paraffin instillation. Some of the points that need to be emphasized about this technique are: 1. The site for the stoma to be selected by barium enema and transit study.