With an appendicostomy, as described by Malone, patients who require daily enemas are able to deliver them via the appendix to the colon. This proceeds in an antegrade manner and for this reason is named an antegrade continence enma (ACE).

This is aimed at children who suffer from severe constipation or fecal incontinence and are participating in a bowel management program.

Understandably, a Malone procedure is not a cure for bowel incontinence or constipation. If the bowel continence cannot be controlled through enemas and all other medical or dietary means, and the patient remains with severe constipation or fecal incontinence, the appendix may be formed as a route to deliver enemas rather than from the rectum. Also, as patients can be trained and catheterize the appendix on their own, it helps them gain independence from third parties administering the enemas. This also gives them greater control over their care and ultimately improves their quality of life.

THE OPERATION

A channel is created between the skin and the colon using the appendix. By doing so a catheter can be placed through this in order to deliver enemas to empty contents from the colon in an antegrade direction (from the cecum to the rectum).

The appendix is ​​used to create this canal. It’s tip opens and is joined to the surface of the skin, usually in the navel or in the lower right quadrant of the abdomen. A valve mechanism is created at its base, to prevent the outflow of intestinal contents from the appendix.

If the appendix has already been removed or used in another procedure (e.g. Mitrofanoff), a section of the small intestine may be used instead to create this canal (Yang-Monti). Another technique, uses part of the colon in the area of ​​the cecum to create a “neo-appendix” that then may be used as a channel.

POSTOPERATIVE COURSE AND CARE

When the patient begins eating according to the surgeon’s instructions, a first enema will be given through the catheter that has been placed intraoperatively through the navel and ends in the cecum. This can be given, once or twice a day, depending on the individual needs of each patient. Once the patient’s condition allows and if they and/or family are competent with the use of the catheter for enemas, they may be discharged. The catheter will remain in place for 1 month after the operation and will be removed by the treating surgeon. Next, instructions and training will be given for catheterisation at home.

BENEFITS AND POTENTIAL COMPLICATIONS

The main benefit is the replacement of unpleasant enemas via the rectum, with a more tolerable alternative. A further aim of the operation is the independence of the patient at the appropriate age with relevant training to be able to catheterize the appendicostomy on their own and administer the enema.

The operation has a very good aesthetic result, especially when the appendicostomy is done through the umbilicus, may improve the patient’s confidence for socializing, and ultimately his quality of life.

Another advantage of the method is also the ease of its reversal. It is not a major operation nor  involves transection of the bowel, such as a colostomy. Reversal was simple based on a recent study of patients who stopped using their appendicostomy following ARM surgery after developing spontaneous and regular bowel movements after years.

The success rates of the operation in the literature are over 80% and its complications (stenosis, leakage, prolapse, granuloma, difficulty of catheterization) are manageable.