The antegrade continence enema (ACE) procedure is a surgical option to manage severe bowel issues. It provides a predictable way to empty the colon for individuals with chronic constipation or fecal incontinence that has not improved with other treatments. The procedure involves creating a small channel connecting the skin on the abdomen directly to the large intestine. This channel allows for administering a liquid solution that flushes out the colon, prompting a controlled bowel movement.
Candidates for the ACE Procedure
The ACE procedure is considered for adults after less invasive treatments have failed. Candidates include individuals with neurogenic bowel dysfunction, where nerve damage from conditions like spinal cord injuries, multiple sclerosis (MS), or spina bifida affects bowel control. These neurological issues disrupt the coordination required for defecation, leading to severe incontinence or chronic constipation.
Another group of candidates are those with intractable chronic constipation or fecal incontinence not related to nerve damage. These individuals have often exhausted options such as high-fiber diets, laxatives, and physical therapy without achieving relief. The decision to proceed is made when the daily burden of bowel management becomes unsustainable.
Studies show that patients with fecal incontinence may experience a higher success rate with the procedure compared to those with constipation, though it remains an effective option for both. The procedure is a long-term treatment strategy intended to provide a stable and manageable bowel routine for years.
The Surgical Procedure Explained
The ACE channel is created using one of two main surgical techniques. The most common is an appendicostomy, also known as the Malone procedure (MACE). In this operation, the surgeon uses the patient’s appendix, detaching it from the cecum (the beginning of the large intestine) and repositioning it. This creates a conduit from the cecum to a small opening, or stoma, on the abdomen, usually in the right lower quadrant.
If a patient’s appendix has been removed or is unsuitable, surgeons can perform a cecostomy. This technique involves placing a tube or a low-profile button device, such as a Chait catheter, directly through the abdominal wall into the cecum. Unlike an appendicostomy, a cecostomy relies on a medical device to keep the channel open.
Both laparoscopic (minimally invasive) and open surgery approaches can be used for either technique, depending on the patient’s anatomy and surgical history. The goal is to create a discreet, continent stoma that allows controlled access to the colon for flushing. The stoma is designed so that fluid can be put in, but stool does not come out.
Recovery and Establishing a Routine
Following the ACE procedure, a hospital stay is necessary to begin healing. A catheter is temporarily placed through the new stoma to ensure the channel heals correctly and remains open. Pain is managed with medication, and a bladder catheter may be used for a few days. The medical team will wait for signs that the bowel is ready before starting to use the ACE, which may be a few days post-operation.
The initial phase of using the ACE at home involves trial and error to find the most effective flushing regimen. Guided by their healthcare team, patients learn to administer the enema through the stoma while sitting on the toilet. This process begins with determining the correct type and amount of solution, which may be tap water, a saline solution, or a solution with additives.
Patients will experiment with the volume of fluid and the timing of the flush. Most people find that performing the irrigation once a day or every other day is sufficient to keep the bowel empty and prevent accidents. The entire process, from setting up to completing the bowel movement, can take 30 to 60 minutes.
Over the first few weeks, the temporary catheter placed during surgery will remain. After about four weeks, it is removed in the surgeon’s office, and the patient is taught how to insert a catheter for each flush and remove it afterward.
Long-Term Management of an ACE Stoma
Once an effective routine is established, living with an ACE stoma becomes part of daily life. The main responsibility is keeping the stoma site clean and dry to prevent skin irritation, and simple daily hygiene is all that is required. The stoma is discreet, not noticeable under clothing, and does not interfere with most physical activities.
Even with good care, some long-term issues can arise. The most common complication is stoma stenosis, a narrowing of the opening that can make inserting the catheter difficult. Regular catheterization, even on non-flush days, helps prevent stenosis, which is a frequent reason for follow-up surgery.
Other potential issues include leakage of stool or mucus from the stoma, skin infections, or the development of granulation tissue. Granulation tissue is a pink, bumpy tissue that can form around the stoma and may bleed or cause discomfort but is managed with simple treatments. Most complications are minor, but they require vigilance and communication with a healthcare provider.