Antegrade Continence Enema (ACE) procedure

What is an ACE?

An ACE procedure is a surgery that creates a channel for a more comfortable way for children to get or self-administer enemas. Sometimes these enemas may also be referred to as flushes.

The surgeon makes a small opening in the child’s belly and creates a small tunnel to connect to the child’s large intestine. After the procedure, you or your child can put an enema into the opening, through the tunnel and into the large intestine. The enema flushes poop through the large intestine in the same way poop naturally leaves the body.

What’s the difference between a MACE and a cecostomy?

The main difference between a MACE procedure and a cecostomy tube is the type of channel that’s used.

MACE procedure

In this surgery, the surgeon uses the appendix to create the channel between the large intestine and the belly opening. The appendix is a small, tube-shaped organ attached to the beginning of the large intestine. A catheter (thin plastic tube) has to be inserted through the opening each time in order to give an enema.

Cecostomy

In this surgery, the surgeon places a small, soft, plastic tube through the small belly opening and into the beginning of the large intestine (the cecum). This tube will remain in place for as long as enemas are needed and the tube will need to be replaced periodically. There are many different types of tubes that can be used including Chait tubes and low-profile buttons.

What are the benefits of the ACE procedure?

The key benefits are the ability for children to receive or give themselves an enema through the belly instead of through the anus:

• Easier enema process: The procedure creates an opening on the belly so that enemas can be given through there instead of through the anus. This makes it easier for older children to give themselves an enema. The process is also easier with younger children, allowing parents to give enemas through the belly rather than the anus.

• More independence and privacy for your child: Older children can take control of their poop schedule by doing their own enemas.

• More natural bowel movements: The ACE procedure allows the enema to start at the beginning of the large intestine. This method mimics the natural flow of poop.

An ACE procedure provides a long-term solution for children who need ongoing enema therapy. Children might need regular enemas for conditions such as:

• Anorectal malformation (imperforate anus)

• Hirschsprung disease

• Neurogenic bowel

• Severe constipation and/or fecal incontinence that other treatments haven’t helped

• Spina bifida and other spinal cord conditions

What are the possible complications from an ACE procedure?

As with any surgical procedure, an ACE procedure carries a few risks. Your child’s care team works carefully to reduce risks and prevent complications.

Risks of these procedures may include:

• Bleeding

• Infection

• Irritated skin around the opening

• Narrowing or blockage in the tunnel

• Tube that slides out of place

• Leakage from the opening

• Soreness at the opening

With a MACE procedure, the opening in the skin can close if it isn’t used regularly. Most children with MACE need enemas once or twice a day, so this risk is rare.

What to expect with ACE procedure

At Children’s Health, your child receives care from nationally ranked surgeons with experience in the latest techniques for ACE procedures. Our surgical program is designated as a Level I Children’s Surgery Center by the American College of Surgeons Children’s Surgery Verification™ Quality Improvement Program. This verification is the highest level of recognition for pediatric hospitals that perform complex surgeries in newborns and children.

Our team provides you with complete instructions to help you prepare for your child’s surgery. In general, here’s what you can expect.

What to expect before ACE procedure

Children must avoid food and liquids for a period of time before surgery, so that the intestines are empty. Your child’s care team will tell you what time your child should stop eating and drinking. Your child may need to take medicines the day before the surgery to clean poop out of the colon. Your surgeon may ask that this be done at home or in the hospital.

If your child takes any medications, we’ll also tell you which ones they should or shouldn’t take on the day of surgery.

What to expect during pediatric MACE and cecostomy

Your child will have general anesthesia (medicine to put them in a sleep-like state) before surgery. They won’t feel pain or remember anything during the procedure.

The MACE procedure includes these steps:

1. The surgeon makes a small opening in the skin of your child’s belly. The opening is usually in the belly button or on the right side.

2. The appendix, which is already attached to the large intestine, is used a channel.

3. The tip of the appendix is opened and it is attached to the belly opening.

4. A one-way valve around the bottom of the appendix is created to allow enema fluid to go in but no poop or fluid to leak out.

5. A catheter (thin, plastic tube) is placed inside the opening and through the appendix to keep it open as the new channel heals. Your child can get enemas through this tube, then we’ll remove the tube after the area heals.

The cecostomy procedure includes these steps:

1. The surgeon makes a small opening in the skin of your child’s belly, usually on the right side.

2. A small, soft, plastic tube is guided through the opening and placed into the beginning of the large intestine.

3. The tube is secured so that a portion of it stays in the large intestine.

4. The part of the tube that is outside the belly sits slightly above the skin. This is where the enema tubing is attached each time your child receives an enema.

We use a minimally invasive approach (laparoscopic surgery) whenever possible. In this technique, our surgeon makes two to three small cuts (incisions) and inserts a tiny camera and instruments through the cuts to do the surgery. Minimally invasive procedures help children recover faster with less risk of problems after surgery.

Some children need to have open surgery. This approach uses one longer incision to access the treatment area.

What to expect after an ACE procedure

To begin their recovery, your child will stay in the hospital for a few days after surgery. During this time:

• Your child will have medication to relieve any pain or discomfort.

• They usually can eat and drink as they normally do.

• We make sure that the opening/tube is working well and has no leaks.

• We teach you and your child how to do enemas and keep the area clean.

Follow-up and home care

Children who have had a MACE procedure will go home with a small tube in the new opening in their belly. They will come back to clinic to have the tube removed once everything has healed. For children who’ve had a cecostomy, the cecostomy tube (sometimes also referred to as a button) will remain in place and will be used to give the enema.

Sometimes children must wait a few days or weeks before using their new method for enemas so that the area can heal. Our care team will tell you when your child can start using the opening for enemas.

The surgeon will tell you when your child can return to their usual activities at home and school as they recover.

What questions should I ask my provider about the ACE procedure?

• Will my child be able to do enemas on their own?

• Who do I contact if we have trouble doing an enema or experience other problems?

• What other treatment options could be right for my child?

• If my child needs other surgical procedures, can they be done at the same time?

• How soon will I be able to see my child after a MACE or cecostomy procedure?