Appendicostomy (MACE Procedure)

Introduction

An appendicostomy, also known as the Malone Antegrade Continence Enema (MACE) procedure, is a surgical operation designed to manage chronic constipation and fecal incontinence, particularly in individuals with neurological disorders such as spina bifida. By facilitating regular bowel movements, the appendicostomy significantly improves the quality of life for patients and can be a crucial part of their daily care routine.

The Concept Behind Appendicostomy

The MACE procedure was first described by Dr. Paul Malone in 1990 and has since gained widespread acceptance. The procedure involves creating a conduit for enema fluid to be introduced directly into the colon, thereby promoting regular and controlled bowel movements. This is achieved by utilizing the patient’s appendix or a portion of the small intestine to create a stoma, or opening, on the abdominal wall.

Surgical Procedure

Preoperative Preparation

Prior to surgery, patients undergo a thorough medical evaluation to assess their suitability for the procedure. This includes a review of their medical history, physical examination, and various diagnostic tests such as imaging studies and motility tests. Preoperative counseling is also provided to ensure patients and their families understand the procedure, its benefits, and potential risks.

Operative Steps

The MACE procedure typically involves the following steps:

• Anesthesia: The patient is administered general anesthesia to ensure they are unconscious and pain-free during the surgery.
• Incision: A small incision is made in the lower right abdomen to access the appendix.
• Mobilization of the Appendix: The appendix is carefully isolated from surrounding tissues while preserving its blood supply.
• Creation of the Conduit: The appendix is then brought to the surface of the abdominal wall, forming a stoma. If the appendix is unavailable or unsuitable, a segment of the small intestine (usually the ileum) may be used instead.
• Stoma Formation: The stoma is meticulously fashioned to ensure it is of appropriate size and shape for the catheter used in administering enemas. The stoma is secured to the abdominal wall to prevent retraction.
• Closure: The incision is closed in layers, and a dressing is applied to protect the surgical site.

Postoperative Care

Postoperative care is crucial for the success of the appendicostomy. Patients are closely monitored in the hospital for any signs of complications such as infection, bleeding, or stoma-related issues. Pain management and wound care are provided, and patients are gradually introduced to a regular bowel regimen using the stoma. Education on stoma care, enema administration, and recognizing signs of complications is provided to patients and their caregivers.

Benefits of the MACE Procedure

The appendicostomy offers several benefits, including:

• Improved Bowel Control: Regular and controlled bowel movements reduce the risk of accidents and associated embarrassment.
• Enhanced Quality of Life: Patients can participate in social, educational, and recreational activities with greater confidence.
• Reduced Dependency on Medications: The need for laxatives and other medications may decrease significantly.
• Minimized Risk of Complications: Complications such as bowel impaction and chronic constipation are less likely with regular bowel management.

Potential Risks and Complications

As with any surgical procedure, the MACE procedure carries potential risks and complications, including:

• Infection: Surgical site infections can occur, requiring prompt medical attention.
• Bleeding: Bleeding may occur during or after surgery, necessitating intervention.
• Stoma-Related Issues: Problems such as stoma retraction, stenosis (narrowing), or prolapse (protrusion) may arise.
• Bowel Obstruction: There is a risk of bowel obstruction due to adhesions or other factors.
• Anesthesia Risks: Complications related to anesthesia can occur, although they are rare.

Nursing Care of Patient with Appendicostomy (MACE Procedure)

This procedure involves creating a stoma from the appendix, which allows for direct access to the colon to facilitate antegrade enemas. Proper nursing care is essential to ensure successful outcomes and minimize complications.

Minimized Risk of Complications

Regular bowel management through the MACE procedure significantly reduces the risk of complications such as bowel impaction and chronic constipation. By maintaining consistent bowel evacuations, patients experience improved quality of life and fewer gastrointestinal issues.

Potential Risks and Complications

As with any surgical procedure, the MACE procedure carries potential risks and complications, including:

• Infection: Surgical site infections can occur, requiring prompt medical attention.
• Bleeding: Bleeding may occur during or after surgery, necessitating intervention.
• Stoma-Related Issues: Problems such as stoma retraction, stenosis (narrowing), or prolapse (protrusion) may arise.
• Bowel Obstruction: There is a risk of bowel obstruction due to adhesions or other factors.
• Anesthesia Risks: Complications related to anesthesia can occur, although they are rare.

Long-Term Management

Successful long-term management of an appendicostomy requires diligent care and monitoring. Patients and their caregivers must adhere to a regular bowel regimen, maintain stoma hygiene, and be vigilant for any signs of complications. Follow-up appointments with healthcare providers are essential to assess stoma function, adjust the bowel regimen as needed, and address any concerns.

Bowel Regimen

A consistent and effective bowel regimen is critical for preventing constipation and ensuring the success of the MACE procedure. This typically involves:

• Performing antegrade enemas as prescribed by the healthcare provider.
• Monitoring stool consistency and frequency.
• Adjusting the volume and type of enema solution based on individual patient needs.
• Ensuring adequate hydration and dietary fiber intake.

Stoma Care

Proper stoma care is vital to prevent complications and ensure the longevity of the appendicostomy. Key aspects of stoma care include:

• Cleaning the stoma site daily with mild soap and water.
• Inspecting the stoma for signs of infection, irritation, or retraction.
• Using appropriate stoma appliances and ensuring a secure fit.
• Reporting any changes in stoma appearance or function to the healthcare provider.

Monitoring for Complications

Patients and caregivers must be vigilant for any signs of complications, including:

• Increased pain or discomfort around the stoma site.
• Unexplained fever or signs of infection.
• Changes in stool output, such as diarrhea or constipation.
• Signs of bowel obstruction, such as abdominal distension or vomiting.

Early detection and prompt intervention are crucial for managing complications effectively.

Patient Education

Education plays a pivotal role in the successful management of an appendicostomy. Nurses should provide comprehensive teaching to patients and caregivers on the following topics:

• Proper technique for performing antegrade enemas.
• Stoma care and hygiene practices.
• Recognizing and responding to signs of complications.
• Maintaining a consistent bowel regimen and dietary considerations.

Empowering patients with knowledge and skills promotes independence and confidence in managing their condition.

Psychosocial Support

Living with an appendicostomy can be challenging, and patients may experience emotional and psychological stress. Nurses should offer psychosocial support by:

• Encouraging open communication and addressing any concerns or fears.
• Providing resources for support groups or counseling services.
• Promoting a positive outlook and reinforcing the benefits of the procedure.

Holistic care that addresses both physical and emotional well-being is essential for optimal patient outcomes.

The Malone Flush

• Once your child is eating a regular diet without any issues, they will get their first flush through the Malone tube. This will be done by the Wound/Ostomy Team. They will teach you how to do the flush so that you know how to do it at home.
• Some children need a flush once a day while others may need it twice a day during the first month after surgery. This depends on how the Malone was made and what works best for your child.
• If your child only gets one flush per day, they will need a patency flush (10 mL saline) 8 to 10 hours after their main flush. This flush keeps the Malone tube from getting clogged with stool.

Cleaning and Caring for the Malone

• Clean the Malone site around the tube every day. Wash the site with soap and water, rinse and pat dry. You will get education about this while you are in the hospital. Continue to clean the Malone site at home every day until the follow-up visit.
• It is normal for the Malone site to have drainage. Cleaning the site daily helps decrease the risk of irritation and infection. Use a Q-tip to clean dried drainage around the tube or in the belly button. If you cannot remove all the dried drainage, try again the next day. Put a warm, soapy washcloth or no-rinse foam cleanser over the site and let it sit. This may soften the dried drainage so it can come off easier.
• If the tape holding the Malone tube on the belly becomes loose, you may put on more tape or replace it. Be VERY careful when removing tape so you do not pull the Malone tube or stitches. To do this, hold down on the Malone tube while taking off the tape.
• Your child may have white strips, called Steri-Strips™ across their surgical sites. The strips will fall off on their own in 7 to 14 days.
• Your health care team will tell you when it is okay for your child to shower, swim and take tub baths after surgery.
• Your health care team will tell you when your child can return to sports or other activities after surgery.

REFERENCES

1. Diaz S, Bittar K, Mendez MD. Constipation. https://www.ncbi.nlm.nih.gov/books/NBK513291/). [Updated 2023 Jan 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. 
2. Nationwide Children ’s Hospital, Appendicostomy (Malone or MACE)  revised 2020, https://www.nationwidechildrens.org/family-resources-education/health-wellness-and-safety-resources/helping-hands/appendicostomy
3. Grabski DF, Hu Y, Rasmussen SK, McGahren ED, Gander JW. Laparoscopic Appendicostomy Low-Profile Balloon Button for Antegrade Enemas in Children. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7364318/). J Laparoendosc Adv Surg Tech A. 2018 Mar;28(3):354-358.
4. Hooker E, Martin B, Gee O, Jester I. Antegrade continence enema stoppers: a pilot study on patient preferences. https://pubmed.ncbi.nlm.nih.gov/35980916/). Br J Nurs. 2022 Aug 11;31(15):770-774.
5. Spinelli M, Sampogna G, Rizzato L, Spinelli A, Sammartano F, Cimbanassi S, et al. The Malone antegrade continence enema adapting a transanal irrigation system in patients with neurogenic bowel dysfunction. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8065210/). Spinal Cord Ser Cases. 2021 Apr 23;7(1):34.

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