title: The Malone antegrade continence enema procedure in the management of patients with spina bifida.
abstract: BACKGROUND
  In patients with spina bifida, traditional bowel management programs such as suppositories, retrograde enemas, and manual disimpaction have been largely unsatisfactory. The Malone antegrade continence enema (ACE) procedure has largely changed our approach to bowel management in this patient group.
  
  
  METHODS
  Over a 3-year period between January 1994 and January 1997, 27 patients with spina bifida underwent the Malone ACE procedure at our institutions. At the time of their ACE procedure, four patients underwent simultaneous continent urinary diversion and three had simultaneous small-bowel bladder augmentation. All the patients were evaluated for 9 months or more after their procedure, and 10 of the patients have been followed for more than 2 years.
  
  
  RESULTS
  Postoperatively, predictable bowel control and continence were achieved in 19 of the 27 patients, but 6 had some rectal soiling requiring a sanitary pad. All patients were out of diapers and none reported stomal leakage. Eighteen of the 27 patients were able to manage independently and 9 required assistance. Two patients had stopped using their ACE stoma despite good technical results. The appendix was used as a catheterizable stoma in 15 of the 27 patients. The appendix was not available in 12 patients, so a tubularized cecal flap was used in 9 and a small-bowel neoappendix was created in 3. Complications included stomal stenosis in 5 patients, cecal-flap necrosis in 1, and stomal granulations in 3.
  
  
  CONCLUSIONS
  We believe that the ACE procedure provides reliable colonic emptying and avoids fecal soiling in the majority of individuals, and we find it widely and enthusiastically accepted by patients with spina bifida.
authors.affiliation: Department of Urology, College of Physicians and Surgeons, Columbia University, New York, NY, USA.
authors.forename: T W
authors.initials: TW
authors.lastname: Hensle
authors.forename: E A
authors.initials: EA
authors.lastname: Reiley
authors.forename: D T
authors.initials: DT
authors.lastname: Chang
mesh_terms: D000293:Adolescent; D000328:Adult; D002408:Catheters, Indwelling; D002431:Cecostomy / Q000379:methods*; D002648:Child; D003131:Combined Modality Therapy; D004733:Enema; D005244:Fecal Impaction / Q000601:surgery*; D005242:Fecal Incontinence / Q000601:surgery*; D005260:Female; D005772:Gastrointestinal Transit / Q000502:physiology; D006801:Humans; D008297:Male; D011183:Postoperative Complications / Q000209:etiology; D016135:Spinal Dysraphism / Q000601:surgery*; D014547:Urinary Diversion