Early experience with the laparoscopic ace procedure

In 1990 Malone et al. introduced the reversed appendicocaecostomy as a technique to enable an antegrade continence enema (ACE) to be administered. The aim is to achieve colonic emptying and thus prevent soiling in children with faecal incontinence. The procedure has been modified by suturing the opened appendix directly to the skin as a stoma, and can now also be performed laparoscopically.

All children undergoing laparoscopic ACE procedures at Christchurch Hospital, Christchurch, New Zealand and Princess Margaret Hospital, Perth, Australia, were reviewed. Intra-operative and postoperative problems were identified retrospectively and questionnaires were completed by the children's caregivers detailing their experience with managing their children following the ACE procedure.

Thirty children have had a laparoscopic ACE procedure performed since 1994. Two required conversion to an open procedure because of difficulty locating the appendix. Twenty-nine children are currently using the stoma for regular antegrade colonic washouts. Improvement in continence was seen in 27 children, 15 of whom have been completely continent. Stenosis of the stoma occurred in eight children, two of whom required operative revision of the stoma; the others have been managed by daily dilatation, either with the irrigation catheter or a small perspex dilator. More recently, spatulating the appendix tip has reduced the incidence of stenosis. Two children have had troublesome leaks.

The laparoscopic approach to the ACE procedure results in an improved level of continence in this difficult group of children with faecal incontinence. It is a simpler alternative to previously described methods and causes minimal morbidity. Results to date suggest a satisfactory outcome for both the children and their families.