Antegrade Continence Enema (ACE)

What Is an Antegrade Continence Enema (ACE)?

An antegrade continence enema is a different way to give an enema. Enemas can help someone poop if they become constipated or have another problem moving their bowels.

The most common type of enema (EN-eh-muh) puts liquid directly into the rectum, the last part of the large intestine, to help release poop. It's simple to do and does not involve any kind of surgery. But because these start at the end of the large intestine (also called the colon or bowel) rather than the beginning, they work backward from how we move our bowels naturally. Usually, poop (or feces or stool) moves from the start of the large intestine, through the rectum, and out of the body via the anus.

An antegrade (which means "forward moving") continence enema starts at the beginning of the large intestine, so poop moves out of the body more normally.

Why Is an Antegrade Continence Enema Done?

In children, an antegrade continence enema can treat fecal incontinence that happens because of serious health problems. Fecal incontinence is when a child can't control his or her bowels. This doesn't just mean pooping accidents — most kids with fecal incontinence have severe constipation.

In most cases, doctors consider an ACE only when fecal incontinence (FEE-kul in-KAHN-tih-nentz) is severe and hasn't responded to other treatments. Less-invasive treatments work for most kids, such as dietary changes, laxatives, suppositories, and traditional enemas.

An ACE is helpful for kids who need long-term enema therapy. It lets them control their enemas through a tube that passes through the abdominal (belly) wall.

An ACE often works well for a child with:

• very severe constipation that isn't helped by laxatives or other ways to release poop
• a condition that causes severe fecal incontinence, such as:
  • an imperforate anus (when the opening to the anus is missing or blocked)
  • spinal problems, such as spina bifida
  • Hirschsprung disease

What Are the Types of Antegrade Continence Enemas?

The two types of antegrade continence enemas most often used for children are:

• an appendicostomy (also called Malone or MACE Procedure)
• a cecostomy

What Is an Appendicostomy (Malone or MACE Procedure)?

Appendicostomy (ah-pen-di-KOSS-tuh-mee) surgery makes a path from the belly button into the large intestine (colon).

An appendicostomy is often called a "Malone antegrade continence enema (MACE)" or a Malone. In this procedure, a surgeon creates a hole (or ostomy) in the skin of the belly that connects to the appendix and leads to the colon. 

The appendix is a small, finger-like tube attached to the cecum (SEE-kum). The cecum is the first part of the colon. An appendicostomy lets the enema liquid go in here, instead of through the rectum.

What Is a Cecostomy?

For a cecostomy (see-KOSS-tuh-mee), a surgeon creates a hole (ostomy) in the skin of the belly that opens directly into the cecum, the first part of the colon. 

The surgeon places a tube into the hole called a cecostomy tube, C-tube, or Chait tube. The cecostomy tube lets poop be flushed quickly and completely out of the large intestine. The enema fluid goes into a bag, then travels through tubing into the cecostomy. From the cecostomy tube, the fluid passes into the cecum. This encourages a bowel movement (BM).

What Are the Benefits of an ACE?

Parents usually begin helping kids use their ACE at home about 1 week after the cecostomy.

When a child has an ACE:

• A parent, guardian, caregiver, school nurse, or the child can slide a tube into the ACE and then let enema fluid flow into the colon.
• Enema fluid and poop flow from the beginning of the colon to the end and come out of the anus, not the hole in the belly.
• The child sits on the toilet during the enema, so the stool can be flushed normally.

A successful ACE:

• avoids a colostomy (a hole in the belly skin that connects to the colon and requires a bag for poop)
• does not need a bag
• may be hidden in the belly button or capped with a flat cover and hidden under clothing

What Happens Before an ACE?

A team of specialists that includes a pediatric surgeon usually treats children who have trouble pooping or poop accidents. Working with an experienced surgeon is important because slight differences in how the surgery is done can make a big difference in how well the ACE works.

The pediatric surgeon will discuss the risks and benefits of an appendicostomy, cecostomy, and other options. Together, you'll decide which is best is best based on your child's age, activities, and health problems.

You'll sign a consent (permission) form. The surgery team will talk to you about:

• medicines to give your child and when
• when your child should stop eating before the surgery
• how to clear your child's colon before the procedure (bowel prep), if necessary
• the plan for anesthesia during the procedure and pain control after it

On the day of surgery, the preparation (pre-op) team:

• will start an intravenous (IV) line
• may give your child antibiotics through the IV to reduce the risk of infection

What Happens During an Appendicostomy?

Most appendicostomies are done using two or three small cuts and a tiny camera (laparoscopy). The surgeon typically:

• creates a valve at the base of the appendix to prevent leakage
• opens the end of the appendix and attaches it to the skin
• checks for leakage
• places a tube in the appendicostomy to keep it open

If your child's appendix was removed or isn't long enough, the surgeon will make a tube from a piece of your child's colon.

The surgeon usually removes the tube about 2 weeks after the surgery and replaces it with a stopper.

What Happens During a Cecostomy?

Doctors usually use one or more of these minimally invasive techniques to create a cecostomy:

• laparoscopy, which means using a tiny camera and 2–3 small cuts in the belly
• interventional radiology, in which the doctor uses X-ray and other images for guidance
• endoscopy, which uses a camera passed through the anus and the colon into the cecum

Steps for creating a cecostomy include:

• bringing the cecum close to the skin of the child's belly
• making a hole through the skin into the cecum
• placing a capped tube into the cecostomy

The capped tube:

• keeps the cecostomy open
• prevents leakage from the cecum
• provides a convenient channel for enemas

Can I Stay With My Child During the Procedure?

No. You may stay in the preparation (pre-op) area until the team moves your child to the operating room. You'll move to a waiting area during the surgery, then join your child in the recovery area after it's done.

How Long Does ACE Surgery Take?

Cecostomy surgery usually takes less than an hour. Appendicostomy surgery usually takes about 2 hours. 

What Happens After the Procedure?

Your child will stay in the hospital for 2–3 days. During this time: 

• Your child will start eating regular food.
• The care team tests the ACE.
• An experienced continence nurse will teach you and your child how to use the ACE.

Doctors suggest replacing the cecostomy tube every 12–15 months.

What Are the Risks From ACE Surgery?

Any surgery can cause unexpected bleeding or infection. Rarely, these problems may be life-threatening. Fixing some problems may mean doing another surgery. 

Risks with an appendicostomy can include:

• ongoing problems pooping (constipation) or poop accidents (incontinence)
• narrowed or blocked appendicostomy passage (stricture)
• leakage of poop, poop-stained liquid, clear mucus, or gas. This can happen when a child has diarrhea from a viral infection.
• leakage of small amounts of poop-stained liquid from the child's anus between enemas
• visible appendix lining at the appendicostomy opening (mucosal prolapse)

Risks with a cecostomy can include:

• ongoing constipation or poop accidents
• leakage of poop, poop-stained liquid, or gas around the cecostomy
• leakage of poop-stained liquid from the child's anus between enemas
• red, bumpy tissue that forms around the opening

How Can Parents Help?

The best ways to help your child are:

• Follow the care team's instructions.
• Ask about any home care instructions that are not clear. 
• Know that it will take time for your child to get used to the ACE. You also might need to try a few different types and quantities of enema liquid to find what works best for your child.

After the surgeon removes the tube from your child's appendicostomy:

• Pass a tube through the appendicostomy daily to keep it open.
• Stay on the lookout for problems.

After the doctor says to begin using the cecostomy:

• Check and clean the cecostomy daily.
• Discuss any problems you have using the cecostomy with the care team. 

What Else Should I Know?

Fecal incontinence, no matter the cause, is upsetting for kids. It affects their quality of life and can be embarrassing, especially if a child has poop accidents. This can make kids feel isolated and alone, and lead to depression, behavior problems, and trouble at school. Soiling also can make kids an easy target for bullies.

An ACE can help end fecal incontinence. But because kids who have one don't poop the way other kids do, emotional issues can still happen. Help your child focus on the benefits of the ACE, such as:

• An ACE can minimize or even prevent poop accidents.
• Kids sit on the toilet during the irrigation.
• Kids who wore diapers may no longer need to.
• Because you can time the enemas, kids don't have to worry about using them away from home.
• An ACE can make it easier for kids to go to after-school activities and even sleepovers.
• The button or stopper is not noticeable under clothes. Kids also can wear colorful buttons to make these look less like medical devices.

When Should I Call the Doctor?

Call your child's surgery team if:

• Your child has chills or a fever higher than 101°F (38.3°C).
• You notice a problem with the appendicostomy:
  • You can't insert the tube.
  • The area around the opening is redder or more tender than when the surgeon last saw it.
  • It's leaking poop or dark liquid.
• You notice a problem with the cecostomy:
  • The area around the opening is redder or more tender than when the doctor last saw it.
  • Poop or dark liquid leaks around the cecostomy.

Looking Ahead

Taking care of your child's ACE can feel like a challenge. But you don't have to go it alone. Your child's care team has answers and can connect you with resources. 

You also can find support online at:

• United Ostomy Associations of America
• GIKids
• American Pediatric Surgical Association