Carnaghan H, Johnson H, Eaton S Effectiveness of the antegrade colonic enema stopper at preventing stomal stenosis: long-term follow-up. Eur J Pediatr Surg. 2012; 22:(01)026-028

Church JT, Simha S, Wild LC, Teitelbaum DH, Ehrlich PF. Antegrade continence enemas improve quality of life in patients with medically-refractory encopresis. J Pediatr Surg. 2017; 52:(5)778-782

Curry JI, Osborne A, Malone PSJ. The MACE procedure: experience in the United Kingdom. J Pediatr Surg. 1999; 34:(2)338-340

Grabski DF, Hu Y, Rasmussen SK, McGahren ED, Gander JW. Laparoscopic appendicostomy low-profile balloon button for antegrade enemas in children. J Laparoendosc Adv Surg Tech A. 2018; 28:(3)354-358

Halleran DR, Vilanova-Sanchez A, Rentea RM A comparison of Malone appendicostomy and cecostomy for antegrade access as adjuncts to a bowel management program for patients with functional constipation or fecal incontinence. J Pediatr Surg. 2019; 54:(1)123-128

Hanneman MJG, Sprangers MAG, De Mik EL Quality of life in patients with anorectal malformation or Hirschsprung's disease. Dis Colon Rectum. 2001; 44:(11)1650-1660

Har AF, Rescorla FJ, Croffie JM. Quality of life in pediatric patients with unremitting constipation pre and post Malone Antegrade Continence Enema (MACE) procedure. J Pediatr Surg. 2013; 48:(8)1733-1737

Henrichon S, Hu B, Kurzrock EA. Detailed assessment of stomal incontinence after Malone antegrade continence enema: development of a new grading scale. J Urol. 2012; 187:(2)652-655

Kim J, Beasley SW, Maoate K. Appendicostomy stomas and antegrade colonic irrigation after laparoscopic antegrade continence enema. J Laparoendosc Adv Surg Tech A. 2006; 16:(4)400-403

Koivusalo A, Pakarinen M, Rintala RJ. Are cecal wrap and fixation necessary for antegrade colonic enema appendicostomy?. J Pediatr Surg. 2006a; 41:(2)323-326

Koivusalo A, Pakarinen MP, Rintala RJ. Treatment of a leaking ACE conduit with Deflux injections. Pediatr Surg Int. 2006b; 22:(12)1003-1006

Levitt MA, Soffer SZ, Peña A. Continent appendicostomy in the bowel management of fecally incontinent children. J Pediatr Surg. 1997; 32:(11)1630-1633

Lopez PJ, Ashrafian H, Clarke SA, Johnson H, Kiely EM. Early experience with the antegrade colonic enema stopper to reduce stomal stenosis. J Pediatr Surg. 2007; 42:(3)522-524

Malone PS, Ransley PG, Kiely EM. Preliminary report: the antegrade continence enema. Lancet. 1990; 336:(8725)1217-1218

Nanigian DK, Kurzrock EA. Intermediate-term outcome of the simplified laparoscopic antegrade continence enema procedure: less is better. J Urol. 2008; 179:(1)299-303

Ok J, Kurzrock EA. Objective measurement of quality of life changes after ACE Malone using the FICQOL survey. J Pediatr Urol. 2011; 7:(3)389-393

The PedsQL measurement model for the pediatric quality of life inventory. 2020. (accessed 20 July 2022)

Webb HW, Barraza MA, Crump JM. Laparoscopic appendicostomy for management of fecal incontinence. J Pediatr Surg. 1997; 32:(3)457-458

Antegrade continence enema stoppers: a pilot study on patient preferences

11 August 2022
Volume 31 · Issue 15



Severe constipation can have a major impact on a child's quality of life and that of their families. Forming an antegrade continence enema (ACE) can be a transformational intervention to manage severe symptoms. However, operations can also have unpredictable negative consequences such as stomal stenosis or leaks from the ACE site.


To investigate whether the choice of an ACE stopper can increase patient satisfaction and compliance.


A service evaluation with a standardised questionnaire was completed to assess quality of life and explore factors that have an impact on the preference for which ACE stopper was used.


In total, 17 patients completed the evaluation of all three ACE stopper devices. At least 75% of the children improved their stooling pattern with an overall satisfaction rate of 8.5 out of 10. More patients preferred a flexible stopper but no one device was strongly preferred over the others.


The study shows that an ACE has a positive impact on quality of life. With regards to the choice of ACE stopper, results show that different stoppers suit different individuals, highlighting that there is a place for a choice. This is useful information for healthcare providers who wish to improve compliance and reduce the risk of complications in this patient group.

Forming an antegrade continence enema (ACE) is a long-established way to treat children with difficulty stooling or faecal incontinence that is refractory to medical management, rectal suppositories or enemas. This is seen most commonly in the paediatric surgical patient population with Hirschsprung's disease, anorectal malformations, myelomeningocele, or chronic constipation.

The ACE procedure was first described by Malone et al (1990). Early technique descriptions included caecal imbrication to prevent ACE stoma site leakage (Levitt et al, 1997), but more recent studies concluded that a caecal wrap is not necessary (Curry et al, 1999; Koivusalo et al, 2006a). The introduction of minimally invasive surgery allowed the development of various laparoscopic techniques that demonstrated simplicity (Nanigian et al, 2008) and efficiency (Webb et al, 1997) over the traditional open surgery techniques.

Register now to continue reading

Thank you for visiting British Journal of Nursing and reading some of our peer-reviewed resources for nurses. To read more, please register today. You’ll enjoy the following great benefits:

What's included

  • Limited access to clinical or professional articles

  • Unlimited access to the latest news, blogs and video content