Malone antegrade continence enema: Is cecal imbrication essential?

The Malone antegrade continence enema (MACE) procedure is effective in management of fecal incontinence and intractable constipation. Stomal incontinence and stenosis are the most common issues reported, and a recent large study of imbricated MACE procedures reports a surgical revision rate of 17%. The laparoscopic approach is now widely used and precludes imbrication. To date, few studies have reported revision rates in these patients who have undergone non-imbricated MACE creation.

Our goal was to report the long-term outcomes of our non-imbricated patients focusing on complication rates and need for revision.

Records of patients younger than 18 years of age who underwent non-imbricated MACE between January 2000 and March 2016 at our institution were reviewed. Patients with less than 2 years of follow-up or non-compliance with MACE usage were excluded from analysis. Patient age, ambulatory status, surgical technique, stomal site, and complications including stomal leakage, stomal stenosis, and need for revision were evaluated. Stomal leakage was classified based on our previously reported system.

A total of 81 patients met inclusion criteria. Mean age at time of surgery was 8.4 years. Mean and median follow-up were 6.7 and 6.7 years, respectively. Overall revision rate, for stenosis or incontinence, was 16% with a mean time to any revision of 2.1 years (range 28 days to 7.8 years). Four patients required revision for stomal incontinence while others improved spontaneously without intervention. At the last follow-up, stomal leakage was grade 0 in 93.8% of patients, grade 2 in 2.4%, and grade 3a in 3.7% (summary Table). Stomal stenosis was noted in 11 patients, eight of whom required revision.

Our study is limited by its retrospective nature with some component of recall bias. A single surgeon experience is also not representative of others' experiences. However, our results indicate that incontinence improves spontaneously in a majority of patients without need for revision in this non-imbricated cohort.

Our series shows a similar long-term revision rate in line with that reported in the literature. While imbrication is still recommended during open surgery when the anatomy is suitable, equitable success without imbrication supports the laparoscopic approach and a more liberal approach during open surgery if the anatomy does not permit imbrication.