MACE or caecostomy button for idiopathic constipation in children: a comparison of complications and outcomes

Abstract

The Malone antegrade enema (MACE) and the caecostomy button (CB) are two methods of achieving colonic lavage in constipated children with faecal soiling. We reviewed our experience with the MACE and CB, aiming to compare results, complications, and outcomes. Between June 1998 and August 2002, 37 children (15 boys) underwent MACE and 12 children (9 boys) underwent CB for idiopathic constipation that had failed conventional treatment. Rectal biopsy was ganglionic in all cases. Mean age at surgery was 9.9 years for the MACE patients and 9.8 years for the CB patients. All children are under continuous review, and mean follow-up is 18 months. Statistical analysis of proportions used Fisher's exact test. Soiling stopped completely in 30 children with MACE and in 9 with CB. Occasional soiling is still present in two children with a CB and in one with MACE. One child with a CB had resumed regular bowel activity, and the CB was removed. MACE failed in 5 (14%) patients because of ineffective colonic lavage, and in one patient (3%) the appendix was replaced by a CB because of perforation of the appendicostomy. CB failed in one patient (8%) because of faecal leak around the button; the child was subsequently converted to MACE (P = >0.5). Complications requiring operative intervention were seen in 9 (24%) of the 37 patients who underwent MACE and none of the 12 patients who underwent CB (P = 0.09). The main complication requiring surgical intervention was stoma stenosis (11%). Complications not requiring operative intervention were seen in 7 (19%) patients after MACE and 11 (92%) of the 12 patients who underwent CB (P < 0.001). The MACE and CB procedures are reliable and effective with high success rates. The MACE has a higher incidence of complications requiring operative intervention. Conversely, complications not requiring operative intervention are more frequent with CB. CB is a safe and effective alternative to MACE in children with faecal soiling.

Antegrade continence enema (ACE): current practice

“…Other authors preferred to use the left side of abdomen as stoma [12][13][14]. While most (over 75%) of the authors used the appendix to make the stoma, others used retubularised ileum, open caecal button, caecostomy tube and retubularised colon (descending, transverse and sigmoid) [14][15][16][17][18][19]. The recent trend is towards minimally invasive procedures.…”

Traitement actuel de la constipation de l’enfant

“…La manométrie colique est utilisée à titre de facteur prédictif du succès d'une caecostomie chez les enfants présentant des troubles de la défécation. Les effets indésirables d'une appendicostomie chez l'enfant sont une sténose de l'ouverture cutanée (11%), un cathétérisme douloureux ou difficile (5%) et une perforation iatrogène de l'appendicostomie [46] . Un déplacement des tubes (26%), une fuite autour du bouton de caecostomie (42%) et la formation d'un tissu de granulation (68%) sont des complications connues de l'utilisation des dispositifs de caecostomie [43] .…”

Tratamiento actual del estreñimiento infantil

“…La manometría colóni-ca se utiliza como factor de pronóstico del éxito de la cecostomía en niños con trastornos de la defecación. Los efectos secundarios potenciales en niños tratados con apendicostomía son la estenosis de la abertura cutánea (11%), el cateterismo doloroso o difícil (5%) y la perforación yatrógena de la apendicostomía [46] . Con los dispositivos de cecostomía, las complicaciones conocidas son el desalojamiento de las sondas (26%), el derrame de lí-quidos en torno al botón de cecostomía (42%) y el tejido de granulación (68%) [43] .…”