Source: Yardley IE, Pauniaho S, Baillie CT, et al. After the honeymoon comes divorce: long-term use of the antegrade continence enema procedure. J Pediatr Surg.2009;44(5):1274–1277; doi:10.1016/j.jpedsurg.2009.02.030The antegrade continence enema (ACE) procedure involves the construction of an abdominal wall stoma using the appendix as the conduit from the skin level in the right lower quadrant into the cecum; this allows access for antegrade irrigations on a regular and scheduled basis to provide effective colonic washout in patients with refractory chronic constipation. Investigators from Alder Hey Children’s Hospital in Liverpool, England, sought to determine the long-term use of ACE. All children who had an ACE at a single tertiary care center between 1993 and 1997 were surveyed to determine if they were still using the ACE and, if not, why use had been discontinued.Of the 84 eligible patients, 61 could be contacted. The mean age was 22.4 years (15–35 years) with an average follow-up time of 11 years (8–14 years). Their underlying diagnoses included spina bifida (27), anorectal malformation (18), intractable constipation (11), sacral agenesis (2), trauma or tumor (2), and Hirschsprung’s Disease (1). Thirty-six of the 61 patients (59%) were still using their ACE. In those patients continuing to use their ACE, the overall satisfaction score was 4 (on a scale of 1 to 5, with 5 being very satisfied).Among the 25 patients (41%) who reported discontinuing use of their ACE, 14 stated they had done so because the washouts had proven ineffective for prevention of soiling. Five others described significant pain with washouts, stomal stenosis, or difficulty in using the stoma during pregnancy. Two patients stopped using the ACE because of psychological issues, one because of being disturbed at the appearance of the stoma and one secondary to depression. Two additional patients were unable to comply with the washout regimen, rendering the ACE ineffective. There was no association between diagnosis and non-use. Several individuals reported feeling abandoned on becoming adults and losing the support they had in childhood.The authors conclude that patients discontinue use of the ACE for a variety of reasons and suggest that newer refinements of the surgical procedure may lead to its greater long-term successful use. Most concerning, however, is the high level of discontent with the transitional care arrangements on reaching adulthood.Dr Cavett has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.The ACE allows the patient to receive effective colonic irrigation via the right colon, thereby promoting cleanout of the entire colon at one time. The colon can then serve as a large reservoir for stool, permitting absence of soiling during the day. The usual regimen involves a mixture of water and either mineral oil or glycerin in volumes and concentrations necessary to obtain washout results.The principal complication of this procedure is painful catheter insertion as a result of stomal stenosis. Mucus leak can be a problem but this is usually temporary during the first several weeks following the surgery. Several changes in the washout regimen are usually necessary before a steady state is reached.2The operation is not terribly complicated and involves constructing a stoma via the tip of the still-attached appendix. An anti-refluxing wrap of cecal wall around the base of the appendix can usually prevent fecal reflux. Much attention must be paid to construction of the stoma itself, interdigitating skin and opened appendiceal lumen in such a way as to allow easy catheterization, yet it must remain fairly flat and dry of mucus.3This group report denotes two important points for surgeons and pediatricians alike. First, we have a good tool available to us when patients need this level of colon washout which cannot be managed with rectal irrigations, and would benefit from an intervention that offers some degree of social acceptance. Second, we must endeavor to provide seamless care as patients with lifelong problems move into the adult world of health care. These patients require ongoing support and care if maintaining continence is to be effective.