MACEs, Malones, and Chait Cecostomies
Many patients require enemas every day in order to remain clean and have a good quality of life. For those patients who will require enemas for a long time (many years, or possibly for life), the Malone operation is a way to make the process easier. In giving a routine enema, a tube is placed into the person’s anus and the liquid is run in that way. For Malone patients, a very tiny tube is placed into a special opening in the belly – often hidden inside the belly button, or sometimes hidden down low below where the underwear sits, and the enema is given through this tube. Because the tube goes directly into the belly, the person may give themselves the enema, and can do so while sitting on a toilet. This allows people to be independent. The Malone procedure is just another way to administer an enema and therefore, before performing the operation, we prefer to make sure the patient is already clean with a successful bowel management regimen.
A pediatric urologist in the United Kingdom, named Malone, developed this procedure. It is often referred to as the Malone Antegrade Continent Enema procedure, or MACE. It is also refered to as a Malone Appendicostomy, which means an opening is made between the appendix and the skin. That opening is what's used to give the enemas.
The operation consists of connecting the appendix to the belly skin, and creating a valve mechanism that allows the small tube used for the enema to be passed into the opening, through the appendix, but avoids leakage of stool back up through the opening. The operation involves a small incision and sometimes can be done with the help of laparoscopy to minimize the size of that incision. It takes approximately two hours to complete, for patients who still have their appendix. If for some reason the appendix has been removed we can still do the operation, but it takes about 2 hours longer as we need to create a new ‘appendix’ out of a part of the colon.
At the conclusion of the operation a small tube is left through the opening of the Malone, and is used for the enemas. About 6 weeks following surgery that tube is removed (although some patients prefer we leave it in for them) and the patient and parents are taught how to pass a very fine tube through the Malone once a day for the enema administration. Once the tube is out, since the opening is most often hidden in the belly button, no one except for the patient, family, and doctor know it is there. The child can participate in all activities including swimming.
With an appendicostomy the enema formula remains the same as it was when the enema was given through the bottom. The only thing that changes is the route of administration. Some families note that the enema runs through more efficiently when it is administered through the Malone site, and there is a great deal of satisfaction with this procedure as it gives the child significantly more independence with their bowel management regimen.
ALTERNATIVES TO THE MALONE: CHAIT CECOSTOMY
The alternatives to the Malone procedure are to continue enemas directly through the bottom, or to have a cecostomy button placed. A cecostomy button is a small device placed directly into the colon by an interventional radiologist. This procedure was popularized at Toronto Hospital for Sick Children by Peter Chait, an interventional radiologist. The procedure is very quick - takes less than 30 minutes to perform, and does not require surgically opening the abdomen. While many patients are satisfied with their cecostomies, there can be problems. The tube is placed directly through the skin into the colon - no valve mechanism is created and therefore it is possible for stool to leak around the tube. Recent reports have shown that the complication rates of Chaits versus Malones are fairly similar.
The biggest challenge I see with cecostomy tubes are that as long as the patient requires enemas, the tube must remain there. With a Malone you can be tube-free except at enema time. Malones have their other little issues (like narrowing - which is the most common issue, leak (rare) and infection (extremely rare)) but in my opinion a Malone leads to better quality of life than having a Chait button indefinitely. For those who prefer the ease of the button with the advantages of a Malone we have the ideal procedure - we use the Chait button through all of our Malones during the initial 6 weeks after surgery. We can then just leave the tube indefinitely and you can have the ease of simply connecting to the button to give the enema, and the leak-resistant nature of the Malone to keep things clean and neat.