Enterprise AI Analysis: The Malone antegrade continence enema for treating adult constipation and fecal incontinence: a systematic review of the literature
Unlocking Efficacy: AI-Powered Insights into MACE for Adult Bowel Dysfunction
Authors: Gaetano Gallo, Veronica De Simone, Alex Bruno Bellocchia, Salvatore Sorrenti, Alberto Realis Luc, Giuseppe Clerico, Roberto Sorge, Pierpaolo Sileri, Mario Trompetto, Gianpiero Gravante
Publication: International Journal of Colorectal Disease (2026) 41:4
Abstract: The Malone antegrade continence enema (MACE) offers a minimally invasive and potentially reversible option for managing chronic constipation and fecal incontinence (FI). This systematic review evaluates its efficacy, safety, and long-term outcomes in adults. A comprehensive search was conducted across PubMed, EMBASE, and CENTRAL databases up to April 2025 to identify studies on MACE in adults. Study quality was assessed using the Newcastle-Ottawa scale. The primary outcome was the proportion of patients continuing MACE at follow-up (treatment success); failure was defined as conversion to definitive colostomy. Seventeen studies with 404 patients were included. Study quality was rated moderate to good. The most common indications were neurological disorders (25.8%), prior surgeries (16.8%), idiopathic constipation (14.2%), and traumatic spinal injuries (11.6%). Techniques included terminal ileal loop (37.9%), percutaneous endoscopic cecostomy (26.0%), and appendicostomy (24.8%). Minor stoma-related complications were most frequent (39.1%), followed by fecal leakage (16.2%) and stoma stenosis (11.3%). Median follow-up was 28.5 months. At final follow-up, 75.1% of patients continued using MACE, while 9.8% required colostomy. Satisfactory outcomes were reported by 60%-83% of patients, with improvements in symptoms and quality of life.
Executive Impact Summary
This analysis reveals that MACE is a valuable therapeutic option for adults with refractory constipation and fecal incontinence, offering significant improvements in patient quality of life and sustained treatment adherence, with relatively low rates of major complications or permanent colostomy conversion.
404
Patients Included
75.1%
MACE Continuation Rate
9.8%
Colostomy Conversion
28.5 months
Median Follow-up
39.1%
Minor Stoma Complications
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Overview of MACE Efficacy and Safety
The systematic review confirms Malone Antegrade Continence Enema (MACE) as a safe and effective therapeutic option for adults dealing with refractory constipation and fecal incontinence. It represents a minimally invasive, potentially reversible alternative to permanent colostomy, particularly for patients who have not responded to conservative treatments.
Key findings highlight that a significant majority of patients (75.1%) continued using MACE at the final follow-up, with only a small proportion (9.8%) requiring conversion to a permanent colostomy. This high continuation rate, coupled with reported improvements in symptoms and quality of life (60%-83% satisfaction), underscores MACE's long-term viability.
While minor stoma-related complications were the most frequent (39.1%), major complications leading to treatment failure were less common. The review also identifies diverse indications for MACE, with neurological disorders, prior surgeries, and idiopathic constipation being the most prevalent underlying causes. Different surgical techniques exist, with terminal ileal loop, percutaneous endoscopic cecostomy, and appendicostomy being the most common approaches.
Key Insights into MACE Outcomes
MACE Long-term Adherence
75.1% of patients continued MACE at final follow-up, highlighting long-term treatment adherence.| Complication | Appendicostomy (APP) | Ileal Neoappendicostomy (IIAPP) | Percutaneous Endoscopic Cecostomy (PEC) |
|---|---|---|---|
| Stoma Stenosis | 31.0% | 5.0% | 12.5% |
| Fecal Leakage/Reflux | 17.2% | 6.7% | 7.8% |
| Superficial Infection | 6.9% | 16.7% | 16.7% |
| Granulation Tissue | NA | 42.2% | 42.2% |
| Wound Pain | NA | 47.8% | 16.7% |
MACE Decision Pathway
Refractory Constipation/FI
→
MACE Procedure
→
Bowel Emptying & QOL Improvement
→
Long-Term Use & Autonomy
→
Avoid Permanent Colostomy
Patient Profile & Outcome
MACE proves most beneficial for adults with refractory constipation or FI who have not responded to conservative therapies, demonstrating significant improvements in bowel function and quality of life. The ideal candidate possesses adequate manual dexterity and motivation to perform regular antegrade irrigations.
For example, patients with severe neurogenic bowel dysfunction (e.g., spinal cord injury, spina bifida) particularly benefit from MACE, as it provides a predictable and effective method for bowel management, substantially improving their autonomy and daily quality of life.
The procedure helps avoid the significant morbidity and permanent nature associated with traditional surgical options like total colectomy or a permanent colostomy, offering a less invasive and reversible solution.
Methodology Overview
This systematic review conducted a comprehensive search across PubMed, EMBASE, and CENTRAL databases up to April 2025. The aim was to identify all studies on MACE in adults (older than 16 years) for the treatment of constipation and/or fecal incontinence.
Inclusion criteria focused on studies where MACE was performed in adults for the specified indications, while excluding pediatric studies, case reports, and studies not focused on constipation or FI outcomes. All study types (retrospective, prospective, observational, clinical trials) published in English were considered.
Study quality was assessed using the Newcastle-Ottawa Scale (NOS), with most studies rated as moderate to good quality. Data extraction involved compiling details on patient demographics, indications, surgical techniques, complications, and functional outcomes. The primary outcome was the proportion of patients continuing MACE (treatment success), with failure defined as conversion to a definitive colostomy.
Due to significant heterogeneity across study designs, follow-up durations, indications, and techniques, a formal meta-analysis was not performed. Instead, descriptive pooled estimates were calculated where sufficient data were available. Functional outcomes, assessed using diverse scoring systems and QOL instruments, were reported as described in the individual studies.
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