Is The Cecal/Colonic Flap Inferior To The Appendix And The Monti Reconfigured Ileum For The Malone Antegrade Continence Enema?

Abstract

PURPOSE Cecal/colonic flap (CCF) has been suggested as an alternative to the appendix or Monti reconfigured ileum (MRI) for the Malone antegrade continence enema (MACE) procedure in children. The literature regarding its efficiency is scant. We, therefore, analyzed our results of MACE, and compared these 3 alternative techniques, regarding stomal incontinence, and stenosis/obstruction. MATERIAL AND METHODS We conducted a retrospective chart search. All patients who underwent the MACE procedures at our institute were included in our study. RESULTS Seventeen patients with fecal incontinence (11 males, 6 females; mean age 12.8 years) underwent the MACE procedure between 1998 and 2008. Diagnoses included myelodysplasia (8 patients), anorectal malformations (6), sacral agenesis (2), and pelvic trauma (1). The MACE conduits were constructed using the appendix in 5 patients, MRI in 8, and CCF in 4. One patient with an appendix-MACE underwent dilation of a stenosed stoma. In two of the patients with MRI revision was necessary for obstruction/stenosis. No appendix or MRI conduits leaked. All 4 patients with CCF conduits became incontinent 6 to 24 months following surgery. One of these patients also required dilation for stomal stenosis. Attempts to cure incontinence by submucosal injection of dextronomer/hyaluronic acid at the conduit-colon junction failed in 2 patients. Two CCF conduits were successfully replaced by MRI, 1 was replaced by button cecostomy, and 1 is awaiting reconstruction. CONCLUSIONS Our initial results reveal that CCF has failed as a conduit for the MACE procedure because of 100% stomal incontinence. We, therefore, abandoned this procedure, and recommend the appendix or MRI for MACE procedures.