Left Antegrade Continent Enema (LACE): review of the literature

Abstract

Purpose: LACE is gradually becoming more established for the treatment of constipation. The purpose of this study was to review the current status of LACE procedure in paediatric practice.

Materials and methods: A systematic database search was performed. Patients who underwent a LACE procedure between 2002 and May 2007 were reviewed retrospectively. The data was analysed with respect to indications for operation, operative techniques, outcome, and complications. The outcomes were compared with those of right-sided antegrade colonic enema (RACE) procedures, published in the same period.

Results: Nine studies describing 93 patients were identified. The underlying diagnoses were spina bifida (70 %), anorectal malformation (10 %), idiopathic constipation (10 %), Hirschsprung's disease (4 %) and other (6 %). The mean age at operation was 10 years. The various operative procedures used included retubularisation of the sigmoid colon (31 %), retubularisation of the splenic flexure (28 %), left Monti from the descending colon (15 %), and retubularisation of the ileum (3 %). Minimally invasive techniques were used in 23 % of cases. Mean volume of enema used was 414 ml. The mean transit time for enema was 31 minutes. Social continence was achieved in 94 % (complete in 72 %; partial in 22 %) cases. Stomal stenosis was seen in 14 % of cases, of which 9 % required revision of the stoma and 5 % responded to dilatation. Sixteen studies describing 583 patients were found for RACE. Indications for operation were similar to those for LACE. Open procedures were done in 86 % of cases, and laparoscopic assisted procedures in 14 % of cases. Mean age at operation was 10 years. Mean volume of enema used 618 ml. Median evacuation time was 53 minutes. Continence was achieved in 94 % of cases. Stomal stenosis occurred in 26 %.

Conclusion: The results of LACE procedures are encouraging, especially in light of the lower amount of enema fluid required, the quicker enema transit time and fewer complications. Overall outcome (continence) is comparable to that of RACE.