title: Perforation of Malone antegrade continence enema: diagnosis and management.
abstract: OBJECTIVE
  Severe bowel dysfunction often accompanies neurogenic bladder, and Malone antegrade continence enema (MACE) procedures can lead to improvement in the quality of life of these patients. However, complications such as catheter false passage with subsequent intraperitoneal instillation of irrigation can lead to significant morbidity. We present our experience with the diagnosis and management of this condition.
  
  
  METHODS
  The records of all patients undergoing MACE procedures at pediatric institutions from 1989 to 2002 were retrospectively reviewed. The records of patients diagnosed with a perforation were assessed for presentation, initial imaging studies, management and outcomes.
  
  
  RESULTS
  Of 187 consecutive patients treated with MACE procedures we identified 6 females and 1 male (3.7%). Mean patient age at initial surgery was 11.3 years. Of the 7 patients presented within 3 months of the initial surgery, 6 presented with abdominal pain after irrigation and 4 reported traumatic catheterization. Six patients had extravasation of contrast material on imaging studies. Two patients presented with peritonitis and underwent immediate laparotomy. In 5 patients endoscopy was performed with catheter placement which was then maintained for 6 weeks. After a mean followup of 4.7 years 4 patients have complete continence, 2 have a MACE button in place and 1 has mild fecal leakage.
  
  
  CONCLUSIONS
  MACE procedures have a low incidence of conduit false passage and perforation. Prompt diagnosis and early intervention are crucial to management. Endoscopic evaluation with catheter placement can be helpful in preserving continence and decreasing morbidity.
authors.affiliation: Division of Pediatric Urology, Cincinnati Children's Hospital, Cincinnati, Ohio 45229, USA. bob.defoor@cchmc.org
authors.forename: William
authors.initials: W
authors.lastname: Defoor
authors.forename: Eugene
authors.initials: E
authors.lastname: Minevich
authors.forename: Pramod
authors.initials: P
authors.lastname: Reddy
authors.forename: Albaha
authors.initials: A
authors.lastname: Barqawi
authors.forename: David
authors.initials: D
authors.lastname: Kitchens
authors.forename: Curtis
authors.initials: C
authors.lastname: Sheldon
authors.forename: Martin
authors.initials: M
authors.lastname: Koyle
mesh_terms: D002648:Child; D003106:Colon / Q000601:surgery*; D003248:Constipation / Q000209:etiology / Q000601:surgery*; D013505:Digestive System Surgical Procedures / Q000379:methods*; D004733:Enema / Q000379:methods*; D004868:Equipment Failure; D005242:Fecal Incontinence / Q000209:etiology / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D011788:Quality of Life; D012189:Retrospective Studies; D001750:Urinary Bladder, Neurogenic / Q000601:surgery*