The Malone Antegrade Continence Enema (MACE) is an approach using a surgically-created entry into the large intestine to irrigate the intestine. The procedure consists of re-implanting the appendix into the cecum and bringing the other end to the abdominal wall, thus forming an appendicostomy (Malone et al. 1990). Consequently, a catheter can be introduced to the patient through the stoma and an enema administered (Christensen et al. 2000). Due to the wash-out effect and perhaps the stimulated colonic peristaltic, the colon and rectum will empty, thus preventing fecal incontinence and constipation (Christensen et al. 2000).

Table 10: The MACE and Enema Continence Catheter

Discussion

In persons with SCI for whom conservative bowel management measures prove ineffective, the MACE eliminates fecal incontinence (Worsoe et al. 2008; Teichman et al. 2003; Christensen et al. 2000; Teichman et al. 1998), reduces time spent on bowel care (Worsoe et al. 2008; Teichman et al. 2003; Teichman et al. 1998), improves quality of life (Teichman et al. 2003; Christensen et al. 2000), resolves autonomic dysreflexia secondary to the neurogenic bowel (Teichman et al. 1998), and successfully treats constipation (Christensen et al. 2000; Teichman et al. 2000). 

Christensen et al. (2000) compared the efficacy of MACE with the Enema Continence Catheter (ECE). The ECE, a specially designed catheter with an inflatable balloon, was originally developed by Shandling & Gilmour (1987) for bowel management in individuals with spina bifida. The catheter is inserted into the rectum and the balloon inflated to hold the catheter in place. When the enema is administered in the bowel, the balloon is deflated, the catheter removed and the bowel contents emptied (Christensen et al. 2000). Christensen et al. (2000) reported successful treatment of fecal incontinence, slow transit or constipation, and obstructed defecation in persons with SCI. The authors recommend that if the ECC fails, the MACE is a suitable alternative to more extensive procedures.

Conclusion

• There is level 4 evidence (from 4 retrospective reviews) (Teichman et al. 1998; Christensen et al. 2000; Teichman et al. 2003, Worsoe et al. 2008) that the Malone Antegrade Continence Enema successfully treats the neurogenic bowel.
• There is level 4 evidence (from 1 retrospective review) (Christensen et al. 2000) that the Enema Continence Catheter can be used to treat the neurogenic bowel.  

• The Malone Antegrade Continence Enema is a safe and effective treatment for severe, chronic gastrointestinal problems in persons with SCI when conservative bowel management options are unsuccessful.