Malone antegrade continence enema (MACE) for fecal incontinence in imperforate anus improves quality of life

Abstract

The MACE procedure has been used in patients with imperforate anus (IA) to improve fecal continence. Our aim was to assess the impact of the MACE on the quality of life (QOL) in children with IA and fecal incontinence. A retrospective review was performed of children with IA that underwent the MACE procedure between 1997 and 2004. Patients and their parents were contacted by telephone survey regarding continence and its psychosocial effects before and after MACE. The same survey was given to the patients' teachers. Responses to 15 questions were compiled and a QOL score calculated and significance evaluated by t-test (P < or = 0.05). IRB approval was obtained. Thirty-two patients were identified with a mean age at operation of 9 years (4-19 years) and mean follow-up of 3.8 years (7 months to 8 years). Four patients had a low malformation, 8 were intermediate, 15 were high, and 5 had a cloacal anomaly. Twenty patients had documented sacral/spinal anomalies, including five with tethered cord. Post-MACE complications included stenosis in 16 (50%), with 11 requiring an operative revision at a mean of 21.7 months (2 months to 6 years), takedown in one at 4 years and volvulus in one at 18 months. Prior to the MACE, 18/25 (72%) had poor QOL scores. Post-MACE QOL results were similar between patients, parents and teachers. Patients' mean QOL score improved from 59.9 to 26.3% (P < 0.001), with parents from 59.7 to 26.4% (P < 0.001). QOL score improved >50% in nine families, 25-50% in ten and <25% in six. All patients and parents interviewed reported an improvement in their QOL following the MACE. This procedure should be offered to children with IA with the expectation of significant improvement in QOL.

Antegrade continence enema (ACE): current practice

“…It has been shown in various studies that ACE improves the quality of life significantly [29][30][31]. Most of these assessments were done with structured questionnaires answered either on the phone or by mail.…”

Quality of life in children and adults with constipation

“…In one group of children with slow transit constipation who were successfully treated with sacral stimulation, improvement in abdominal pain, fecal soiling and QOL occurred after treatment [21]. In addition, the successful use of antegrade enemas in children with anorectal malformations was demonstrated to improve both soiling and QOL [22]. However, similar data do not exist in children with functional constipation.…”

Association of anorectal malformation and intestinal malrotation

“…16 When performed, an appendicostomy is typically not created until later in childhood, typically at a mean of 9 years old. 18,19 This study is a 10-year review of anorectal malformations at a single institution and many of these patients are now reaching the age where an appendicostomy might be appropriate after failure of more conservative bowel management strategies. Therefore, it is not surprising that our appendicostomy and cecostomy rates are much lower than other studies.…”