The antegrade continence enema procedure and total anorectal reconstruction

Abstract

Patients may present with anal incontinence (AI) following repair of a congenital anorectal anomaly years previously, or require total anorectal reconstruction (TAR) following radical rectal extirpation, most commonly for rectal cancer. Others may require removal of their colostomy following sphincter excision for Fournier's gangrene, or in cases of severe perineal trauma. Most of the data pertaining to antegrade continence enema (the ACE or Malone procedure) comes from the pediatric literature in the management of children with AI, but also with supervening chronic constipation, where the quality of life and compliance with this technique appears superior to retrograde colonic washouts. Total anorectal reconstruction requires an anatomical or physical supplement to the performance of a perineal colostomy, which may include an extrinsic muscle interposition (which may or may not be 'dynamized'), construction of a neorectal reservoir, implantation of an incremental artificial bowel sphincter or creation of a terminal, smooth-muscle neosphincter. The advantages and disadvantages of these techniques and their outcome are presented here.

Keywords: anal incontinence; antegrade continence enema; malone procedure; total anorectal reconstruction.

Figure 1.

V–Y ACE procedure. The skin flap is sutured to the wall of either the appendix or a fashioned ileal conduit, with formation of a skin tunnel which covers the stoma. (Reprinted with permission from Christensen P, Laurberg S. The Malone procedure and its variants. In Reconstructive Surgery of the Rectum, Anus and Perineum AP Zbar, RD Madoff and SD Wexner Eds. Springer 2013:273–282).

Figure 2.

An ileocolic anastomosis is fashioned from the proximal ileum and the ascending colon with production of a small-caliber orifice for the stoma preserving the ileo-cecal valve. (Reprinted with permission from Christensen P, Laurberg S. The Malone procedure and its variants. In Reconstructive Surgery of the Rectum, Anus and Perineum AP Zbar, RD Madoff and SD Wexner Eds. Springer 2013:273–282).