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Thread: Anyone had a Malone Procedure done?

  1. #1
    Senior Member mk99's Avatar
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    Anyone had a Malone Procedure done?

    I can't find too much info here on it.

    Anyone had this done? I am thinking about different alternatives to speed up bowel programs. On a day-to-day basis, it is by far the worst aspect of my life with SCI.

    I understand the surgery but am curious about any personal experiences. As I strongly believe in an SCI cure and intend to have significant functional recovery in the next few years, how "screwed up" would I be if I did this procedure now?

    thanks

  2. #2
    Down at the bottom of this page of this link tells a little bit about the Malone procedure, there is also some interesting info about Bladder options. http://www.med.wayne.edu/urology/DIS...icbladder.html

    "Life is about how you
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    the challenges you seek...If
    you have no goals, no
    mountains to climb, your
    soul dies".~Liz Fordred

  3. #3
    mike, I have never met a person with spinal cord injury who had a malone procedure and so cannot contribute any personal impressions of the efficacy of the procedure. It was first developed and has mostly been applied to children.

    A review of the literature suggests that the procedure should be reversible. The question is how effective it is for treating rectal incontinence in males. After all, it is a method of being able to introduce fluid and medication to the rectum from above and being able to achieve better rectal evacuation.

    1. Sugarman ID, Malone PS, Terry TR and Koyle MA (1998). "Transversely tubularized ileal segments for the Mitrofanoff or Malone antegrade colonic enema procedures: the Monti principle." Br J Urol 81(2): 253-6. Contact: Department of Paediatric Urology, Southampton General Hospital, UK.
    OBJECTIVE: To assess the use of a transverse tubularized segment(s) of ileum in the Mitrofanoff or Malone antegrade colonic enema (MACE) procedures. PATIENTS AND METHODS: Eleven patients in three centres underwent the formation of a continent conduit to bowel (MACE, eight patients) and/or bladder (Mitrofanoff, four) using either a single segment of transverse tubularized ileum (10 patients) or two segments of ileum anastomosed and tubularized into a single conduit (two). RESULTS: Within a follow-up of 8 weeks to 6 months, all conduits were continent and catheterized easily. One stomal stenosis required a revision procedure. CONCLUSION: This method for forming a continent catheterizing conduit, based on the Mitrofanoff principle, appears to be effective and is recommended in cases where the appendix cannot be used or where a second conduit is required.

    2. Teichman JM, Harris JM, Currie DM and Barber DB (1998). "Malone antegrade continence enema for adults with neurogenic bowel disease." J Urol 160(4): 1278-81. Contact: Department of Rehabilitation Medicine, University of Texas Health Science Center, Audie L. Murphy Veterans' Affairs Medical Center, San Antonio, USA.
    PURPOSE: We describe the outcomes of adults with neurogenic bowel disease who underwent a Malone antegrade continence enema procedure with or without concomitant urinary diversion. MATERIALS AND METHODS: Consecutive adult patients with neurogenic bowel disease who underwent an antegrade continence enema procedure (continent catheterizable appendicocecostomy for fecal impaction) were retrospectively reviewed. RESULTS: Of the 7 patients who underwent an antegrade continence enema synchronous urinary procedure (ileal conduit, augmentation ileocystoplasty with continent catheterizable abdominal stoma or augmentation ileocystoplasty) was also performed in 6. Mean patient age was 32 years and mean followup was 11 months. Of the 7 patients 6 who self-administered antegrade continence enemas regularly were continent of stool per rectum and appendicocecostomy, using the appendicocecostomy as the portal for antegrade enemas. All 6 compliant patients reported decreased toileting time and improved quality of life. Preoperative autonomic dysreflexia resolved postoperatively in 3 patients. All urinary tracts were stable. In 4 patients 5 complications occurred, including antegrade continence enema stomal stenosis requiring appendicocutaneous revision (1), antegrade continence enema stomal stenosis requiring dilation (1), superficial wound infection (1), small bowel obstruction requiring lysis of adhesions (1) and urinary incontinence (1 who underwent continent urinary diversion). CONCLUSIONS: Patients with neurogenic bladder and bowel disease may benefit from antegrade continence enema performed synchronously with a urinary procedure. Antegrade continence enema may be indicated alone for neurogenic bowel. Patient selection is important.

    3. Clark T, Pope JCt, Adams C, Wells N and Brock JW, 3rd (2002). "Factors that influence outcomes of the Mitrofanoff and Malone antegrade continence enema reconstructive procedures in children." J Urol 168(4 Pt 1): 1537-40; discussion 1540. Contact: Division of Pediatric Urology, Vanderbilt Children's Hospital, Nashville, Tennessee, USA.
    PURPOSE: Surgical techniques that provide adequate urinary and fecal continence in children with neurogenic bladder and bowel dysfunction are becoming increasingly used. We reviewed our experience and discuss factors that influence outcome. MATERIALS AND METHODS: Between 1994 and 2000, 65 stomal procedures were performed in 47 patients. For the urinary continent catheterizable channel we used appendix in 60% of cases, a continent bladder tube in 20%, a Yang-Monti tube in 16% and ureter in 4%. For the antegrade continence enema continent catheterizable channel we used appendix in 85% of cases, a Yang-Monti tube in 5% and a cecal tube in 10%. In the 19 patients who underwent simultaneous Mitrofanoff and antegrade continence enema procedures the urinary continent catheterizable channel was appendix in 21%, a Yang-Monti tube in 32% and continent vesicostomy in 47%. Patients were divided into 2 groups based on compliance status. In addition, percentile body weight for age was evaluated. RESULTS: Stomal continence was achieved in 63 of the 65 cases (97%). Of the patients who underwent the antegrade continence enema procedure 95% achieved continence via the rectum. Except for ureter stenosis rates according to continent catheterizable channel type did not differ greatly, namely 19% for appendix, 11% for the Yang-Monti tube, 22% for the bladder tube, 50% for ureter and 0% for the cecal tube. Infectious complications developed in 16 patients and 4 had stones. The rates of infection (p = 0.004), stomal stenosis (p = 0.001) and revision (p = 0.004) were statistically lower in the compliant group and the stone formation rate showed a trend favoring the compliant group (p = 0.11). No significant difference was noted for incontinence. Percentile weight predicted a higher rate of stomal stenosis with the highest rate of stomal stenosis overall in the greater than 100th percentile group. CONCLUSIONS: The Mitrofanoff and antegrade continence enema procedures are reliable and effective. Proper patient selection and surgical technique with a tension-free anastomosis are essential. The choice of tissue for constructing the continent catheterizable channel is not as important as patient compliance, age and possibly body habitus. This report reinforces the importance of careful screening, and rigorous preoperative and postoperative teaching to achieve overall patient success.

    4. Teichman JM, Rogenes VJ and Barber DB (1997). "The malone antegrade continence enema combined with urinary diversion in adult neurogenic patients: early results." Urology 49(6): 963-7. Contact: Department of Rehabilitation Medicine, University of Texas Health Science Center, San Antonio 78284-7845, USA.
    OBJECTIVES: Patients with neurogenic voiding dysfunction often have coexisting neurogenic bowel problems. Impaired bowel evacuation is a cause of major morbidity and impaired lifestyle for these patients. The Malone antegrade continence enema (ACE) performed synchronously with a urinary continence procedure has been successful in pediatric patients. We report early experience combining the ACE with a urinary continence procedure in adult neurogenic patients. METHODS: Adult patients with neurogenic voiding dysfunction and impaired bowel evacuation refractory to conservative management underwent a urinary continence procedure synchronously with an ACE. RESULTS: Two patients have undergone the procedure. One patient chose a continent catheterizable supravesical bladder augmentation, whereas the other patient chose an ileal conduit. Both patients had a separate appendiceal stoma for their ACE. Both patients are continent of stool at their appendiceal stoma and per rectum. Both patients have stabilized their urinary tracts. Complications were minimal. CONCLUSIONS: The ACE may benefit adult patients with impaired bowel evacuation and may be combined with a urinary continence procedure. Further study of the ACE is warranted.

    5. Teichman JM, Rogenes VJ and Barber DB (1997). "The utility of the Malone antegrade continence enema for urologists." Tech Urol 3(1): 30-3. Contact: Department of Rehabilitation Medicine, Spinal Cord Injury Service University of Texas Health Science Center, San Antonio 78284-7845, USA.
    Urologists often manage patients with neurogenic voiding dysfunction. These patients often have neuropathic bowel dysfunction. The malone antegrade continence enema (ACE) performed synchronously with a urinary continence procedure has been successful in pediatric patients. We report preliminary experience combining the ACE with a urinary continence procedure in two adult neurogenic patients. The ACE procedure is technically easy. Both patients had a separate urinary stoma and an appendicocecostomy for their ACE. Both patients are continent of stool at their appendicocecostomy and per rectum. Both patients have stabilized their urinary tracts. Complications were minimal. The ACE may benefit adult patients with impaired bowel evacuation and may be combined with a urinary continence procedure. Urologists can easily perform the ACE.

    6. Hutson JM, Chow CW and Borg J (1996). "Intractable constipation with a decrease in substance P-immunoreactive fibres: is it a variant of intestinal neuronal dysplasia?" J Pediatr Surg 31(4): 580-3. Contact: F. Douglas Stephens Surgical Research Unit, Royal Children's Hospital, Melbourne, Australia.
    After Hirschsprung's disease was ruled out for 25 children who had severe chronic constipation, the authors studied the distribution of immunoreactivity for substance P (SP) and vasoactive intestinal peptide (VIP) in the intestinal wall, using immunofluorescence. SP and VIP immunoreactivity identify excitatory and inhibitory nerve fibres, respectively. Full-thickness rectal biopsy specimens were unsatisfactory, so seromuscular biopsies of the caecum, transverse colon, and sigmoid colon were obtained (by laparoscopy and laparotomy; n = 10 patients). SP-immunoreactive fibres were markedly reduced in seven, with concomitant reduction of VIP-immunoreactive fibres in four. In two other patients, there was no obvious reduction in SP- or VIP-immunoreactive fibres. In a patient who subsequently was found to have multiple endocrine neoplasia type 2b, the myenteric plexus was markedly hyperplastic, with an increase in nerve cells and nerve fibres. VIP-immunoreactive fibres were increased, but SP-immunoreactive fibres were markedly decreased. Surgical options included proximal stoma, Malone operation, and subtotal colectomy with preservation of the rectum. Three children with subtotal colectomy have had improvement over short-term follow-up. The combination of seromuscular laparoscopic biopsies and immunofluorescence demonstration of neuropeptides may identify new variants of intestinal neuronal dysplasia than can be treated successfully with surgery.

    7. Yamamoto T, Kubo H and Honzumi M (1996). "Fecal incontinence successfully managed by antegrade continence enema in children: a report of two cases." Surg Today 26(12): 1024-8. Contact: Second Department of Surgery, Mie University School of Medicine, Tsu, Japan.
    Two children with intractable fecal incontinence after correction of high anorectal malformations were successfully managed by the daily administration of a glycerin enema into the cecum via an appendicocecostomy or tubularized cecostomy, according to the method of Malone's antegrade continence enema (ACE). Fluoroscopic defecography performed during this procedure in each patient disclosed that the glycerin enema promptly evoked cecal peristalsis, which was transmitted to the distal colon and rectum, and squeezed out almost all the fecal matter, evacuating it from the anus. However, two enemas within a short interval were required to achieve a complete washout of feces. Although this report describes only two patients, our experience confirmed that the ACE was very effective and that adding the word "continence" to antegrade enema was justifiable. Moreover, fluoroscopic defecography was proven to play a significant role in determining the appropriate regimens of this technique to achieve complete washout of the feces.

    8. Malone PS, Kiely EM and Spitz L (1990). "Diffuse cavernous haemangioma of the rectum in childhood." Br J Surg 77(3): 338-9. Contact: Department of Paediatric Surgery, Hospital for Sick Children, London, UK.

  4. #4
    Senior Member mk99's Avatar
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    Thanks Curtis & Dr. Young.

    For me it's not about incontinence but just to speed up the whole nasty thing altogether. I really like the idea of squirting something in the belly button and things pop out... 10-25 minutes a day is a lot better than 2 hours, shit covered gloves everywhere, bleeding hemmoroids, etc, etc.

    If I'm understanding the procedure correctly, I'm not sure it even would need to be reversed once a "cure" is applied. Once regular bowel function is restored, can you not just stop using the solution and crap like a normal human being again?

    It seems like a potentially better solution than a colostomy... that's something I'm not keen on at all.

  5. #5
    Senior Member KLD's Avatar
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    I have had a couple of patients have this procedure. It is more often called an ACE procedure, and we have discussed it here in the past. It can be done as a reversable procedure, and appears to have no long-term side effects in reducing bowel function in people with spina bifida. It has only recently been used in people with SCI and most studies are English. It is easier and probably aestheticlaly preferable to a colostomy as no pouch is needed, and two of my patients who have low tetraplegic injuries are able to do the procedure themselves.

  6. #6
    Senior Member mk99's Avatar
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    KLD thank you very much for the info.

    Do you know how the bowel program itself changed for these two quads who had the procedure done? ie: how long bowel program now takes, is there still much digital stim necessary, etc, etc.

  7. #7
    Senior Member KLD's Avatar
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    I just ran into one of these guys yesterday and asked him about his program (no dig stim is needed...stool is liquid after the flush, so it just runs out). He says in the 18 months he has had his he has had one bowel accident. He is very happy with it. The other guy who has one has told me the same thing.

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    I have had this for the past 2 years. The surgery is the easy part. I am looking for others who have had success. I have been dealing with getting the quantities and liquid rights. Either it works really well or I am leaking because it didn't finish and doesn't want to finish. I had irregular bowels before my SCI so ...

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    Can you email me the people's names so I can ask questions or can you email them my email? xenarolls@yahoo.com
    Originally posted by KLD:

    I just ran into one of these guys yesterday and asked him about his program (no dig stim is needed...stool is liquid after the flush, so it just runs out). He says in the 18 months he has had his he has had one bowel accident. He is very happy with it. The other guy who has one has told me the same thing.

  10. #10
    I would have to ask them to contact you...I could not give you their contact information. Since then (over two years ago) one of these people has had his converted to a regular colostomy.

    The ACE and Malone are essentially the same procedure. We have several threads about this procedure going on this forum right now.

    (KLD)

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