The appendix is a finger-like tube that is located in the lower section of the stomach and is a part of the gastrointestinal tract. It has a reputation for being an organ that has no use and can cause problems, but now it can be put to work!
The Malone Appendicostomy, also known as the Malone Continence Enema (MACE) or Antegrade Continence Enema (ACE), uses the appendix to create a channel from the belly button to the right side of the colon. The goal of this procedure is to give your child an enema through their belly button daily to keep them clean for poop.
This simple, low risk procedure is ideal for patients who are incontinent of poop or severely constipated due to an anorectal malformation (ARM), Hirschsprung disease, severe functional constipation, or spinal cord issues. It can transform the care of patients suffering from these conditions and get them independent and in control of their own bowel function.
The appendix is prepared and moved, usually with keyhole surgery (laparoscopy) so that it can reach the belly button. A one-way valve is created at the bottom of the appendix, to stop poop from leaking through the appendix and out of the belly button. The appendix is then opened on the end and is joined to the belly button, in a way that it is not seen. This will prevent embarrassment if the child does not want anybody to know about their condition.
A catheter tube is left in the belly button for one month while it all heals. During this time, the tube can be used to flush the colon daily to get your child clean and out of diapers. After that month, you will see your provider to remove the tube in the office and be taught how to put a tube into the Malone daily to continue giving the Malone flush to empty the colon and keep your child clean.
For six months after the catheter tube is removed and you are putting a tube into the Malone daily, a stopper is used to stop the hole from closing. This stopper is a soft piece of silicone that is goes into the Malone and is level with the skin, not irritating to the child. There are a few patients that form scars easily and will need to use the stopper for longer. If you think your child might not be able to tolerate daily use of the tube, a device can be left in that is level with the skin and can be connected to an enema set and disconnected at the end of administration of the Malone flush.
The process of giving a flush through the Malone tube is simple and not traumatic for the child. A thin tube is inserted into the Malone and connected to a bag that is preloaded with the liquid required. If your child has a device in his Malone, this device is connected directly to the bag. The solution is run in over 5 – 10 minutes while your child is sitting on the toilet. There is no mess and no need to transfer your child to the toilet after instilling the fluid. In fact, it is important to get them involved, to insert the tube and to even run the fluid. This teaches them to be independent and gives them autonomy and confidence. Once the flush is finished, the tube is removed, or disconnected, from the device, and your child sits on the toilet until they are clean. Our goal is to get this process to about 45 minutes with different formulations of the flush.
The Malone flush is usually made up of water or saline and an added stimulant. The stimulant (glycerin, bisacodyl or senna) causes the colon to contract and force the poop out along with the flush. If the stimulant is too strong, it causes cramping pain, so the ideal solution is strong enough to clean the colon, but not too strong as to cause pain.
The advantages of this procedure over other techniques are that no laxatives need to be taken by mouth, there is nothing inserted into the anus and rectum, there is no mess involved, and the child can gain independence when they develop the coordination and maturity to insert the tube themselves. This usually happens after the age of 6 years. The disadvantages are that it does involve a minor operation, and there are risks and complications that can occur. These are usually minor, but the child will need a full anesthetic and a 2–3-day hospital stay after the procedure. In the right circumstances, the benefits far outweigh the risks and life of the child can be vastly improved.
Dr. Wood completed fellowship training in Cape Town, South Africa. In 2014, he joined the CCPR team at Nationwide Children's Hospital. Many of his surgical cases are for complex problems, such as cloacal malformations, vaginal replacement, and reoperations for ARM and hirschsprung disease.
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