The Malone Antegrade Continence Enema for treating adult constipation and fecal incontinence: a systematic review of the literature

The Malone Antegrade Continence Enema for treating adult constipation and fecal incontinence: a systematic review of the literature | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Malone Antegrade Continence Enema for treating adult constipation and fecal incontinence: a systematic review of the literature Gaetano Gallo, Veronica De Simone, Alex Bruno Bellocchia, Salvatore Sorrenti, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7541297/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 03 Jan, 2026 Read the published version in International Journal of Colorectal Disease → Version 1 posted 8 You are reading this latest preprint version Abstract Purpose : 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. Methods : 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. Results : 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. Conclusions : MACE is a safe and effective option for adults with refractory constipation or FI, especially in those aiming to avoid permanent colostomy. antegrade continence enema fecal incontinence constipation neurogenic bowel dysfunction colostomy Figures Figure 1 Figure 2 Figure 3 Significance statement This systematic review focuses exclusively on the use of the Malone Antegrade Continence Enema (MACE) in adults with refractory constipation and fecal incontinence. Our findings demonstrate that MACE is a viable and generally well-tolerated alternative to permanent colostomy, with a high rate of long-term continuation and symptom improvement. These results support the inclusion of MACE in the therapeutic algorithm for carefully selected adult patients seeking minimally invasive and reversible solutions. Highlights MACE offers a sensible option for adult fecal incontinence or constipation Most frequent complications were minor and stoma-related (39.1%) 75.1% of patients continued MACE at final follow-up Only 9.8% of patients required colostomy conversion 60–83% of patients reported symptom relief and quality of life improvement Introduction Physiological bowel movements require normal colonic transit, intact anorectal sensitivity, adequate expulsive forces, and coordinated pelvic floor function. When any of these mechanisms are impaired, patients may experience constipation or fecal incontinence (FI). Defecatory disorders affect up to one-quarter of the general adult population ( 1 – 3 ), and when present, they can significantly impair quality of life (QOL) ( 4 ). Conservative treatments include dietary modifications, oral laxatives, bulking agents, suppositories, and biofeedback therapy ( 5 ). When these measures fail, surgical interventions may be considered. These include transanal colonic irrigation (TAI), percutaneous tibial nerve stimulation, and sacral neuromodulation ( 5 , 6 ). Colonic resections – ether total or segmental - and stoma formation represent last-resort options ( 7 ), although their outcomes are variable ad often associated with considerable morbidity ( 8 , 9 ). Among surgical options, the Malone-antegrade continence enema (MACE) offers a distinctive approach by enabling antegrade colonic irrigation, which may provide more predictable and complete bowel emptying and improve patient autonomy and quality of life, particularly in those who are refractory to conservative therapies. MACE was introduced as a less invasive and potentially reversible surgical alternative for managing chronic constipation and FI ( 10 ). The principle involves performing antegrade enemas through a conduit into the proximal colon, facilitating mechanical irrigation and stimulating colonic propagating contractions. This dual mechanism enables complete and regular evacuation, helping prevent both constipation and FI ( 11 ). Initially developed for pediatric patients, MACE has since been adapted for use in adults with similar bowel dysfunctions ( 12 ). The technique has evolved over time to include minimally invasive laparoscopic and endoscopic approaches ( 13 , 14 ). Reported outcomes have been encouraging: between 47% and 100% of patients continue irrigation in the medium and long term, while failure rates, defined as conversion to permanent colostomy – range from 0% to 24% ( 10 ). In recent years, evolving techniques have included minimally invasive laparoscopic and endoscopic approaches. Such developments aimed to optimize stoma creation, reduce complications, and expand indications, reflecting a growing interest in tailoring MACE to adult populations and improving long-term functional outcomes. The aim of this study is to perform a systematic review of MACE procedures in adult patients. We present pooled success and failure rates and provide a detailed analysis of complications associated with different MACE techniques. Materials and Methods A review protocol was registered in advance on the International Prospective Register of Systematic Reviews (PROSPERO; registration number: CRD420251025965; https://www.crd.york.ac.uk/PROSPERO/view/CRD420251025965 ). The work has been reported in line with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses), and TITAN (Transparency in the Reporting of Artificial Intelligence) guidelines ( 15 , 16 ). Inclusion criteria comprised all published studies where MACE was performed in the adult population (older than 16 years) for the treatment of constipation and/or FI. Exclusion criteria included pediatric studies, studies where MACE was performed during childhood and adolescence and that report outcomes in adulthood ( 17 , 18 ), studies focusing on outcomes other than constipation or FI. All study types were considered eligible – including retrospective, prospective, observational studies, and clinical trials – with the exception of case reports. Given the expected heterogeneity across study designs and outcome measures, both retrospective and prospective studies were included. Only articles published in English, or those for which a reliable English translation was available, were included. The literature search was conducted using the biomedical databases PubMed, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) from inception to August 2025. The PubMed search strategy combined the following terms: (“antegrade” AND (“continent” OR “continence”) AND “enema”) OR (“antegrade continence enema”), applying filters for “Humans” and “All Adult (16 + years).” The Embase search was performed using an equivalent strategy adapted to Emtree terminology. The CENTRAL database was queried with the term “antegrade continence enema” across titles, abstracts, and full texts. The Current Controlled Trials database ( www.controlled-trials.com ) was also screened to identify ongoing randomized trials. Additionally, the reference lists of relevant articles and prior reviews were screened for further eligible studies. Titles and abstracts were screened for relevance, and full texts of potentially eligible studies were independently reviewed by two authors (GG and GGr) with any disagreements resolved by discussion or consultation with a third author (ABB). Data from eligible studies were extracted and compiled into a centralized database. The methodological quality of the included studies was evaluated using the Newcastle–Ottawa Scale (NOS) for cohort studies ( 19 ). The NOS assigns up to nine points across three domains: Selection (four points: representativeness of the exposed cohort, selection of the non-exposed cohort, ascertainment of exposure, and demonstration that the outcome was not present at baseline), Comparability (two points: adjustment for the most important confounder and for additional confounders), and Outcome (three points: adequacy of outcome assessment, length of follow-up sufficient for outcomes to occur, and adequacy of follow-up of cohorts). Each item was judged as either fulfilled (awarding a star) or not fulfilled. Two authors (GGa and GGr) independently assessed all studies, with disagreements resolved by discussion with the third author (ABB). Based on the total score, studies were categorized as high quality (≥ 7 points), moderate quality (5–6 points), or low quality (< 5 points). The primary outcome of this systematic review was to assess the long-term clinical efficacy of MACE in adult patients, defined in a patient-centered manner as both the sustained use of antegrade colonic irrigation and meaningful improvements in bowel function and QOL. Traditional measures, such as continued MACE use and the need for definitive colostomy, were included as objectively measurable endpoints; however, these may not fully capture the functional and experiential benefits from the patient perspective. Functional outcomes were extracted as reported, acknowledging the use of diverse scoring systems and QoL instruments, which limited the possibility of direct comparison. Secondary outcomes included the safety of the procedure (type and frequency of postoperative complications) and functional outcomes assessed using validated symptom scores and QoL instruments. Where sufficient data were available, descriptive pooled estimates were calculated, while studies with missing or unclear data were excluded from quantitative synthesis. Because all included studies were single-arm series without comparators, and given the heterogeneity expected (follow-up, indications, technique), a formal meta-analysis and associated bias assessments (e.g., funnel plots) were not applicable. Results Seventeen articles were included in the final analysis (Fig. 1 ) ( 12 – 14 , 20 – 33 ). Eleven were retrospective studies ( 12 , 14 , 20 – 26 , 32 , 33 ), and six were prospective (Table 1 ) ( 13 , 27 – 31 ). All but two studies were conducted in European countries ( 23 , 33 ), and all but one were single-centre series (Table 1 ) ( 20 ). According to the NOS, eleven studies were rated as “moderate-to-good” quality (6/9 points), four as moderate (5/9 points), and two as good quality (7/9 points) (Table 2 ). Most studies used validated outcome measures, had sufficient follow-up duration to assess long-term results, and reported complete follow-up data for all patients (Table 2 ). Common limitations included the absence of control groups, small sample sizes, and the resulting inability to perform subgroup analyses (e.g., comparisons between indications - FI vs. constipation - or between surgical techniques) (Table 2 ). Indications for MACE A total of 404 adult patients underwent MACE procedures, with individual series ranging from 3 to 75 patients (Table 1 ). Patients were predominantly female (219/301, 72.8%), except in three studies that showed a male predominance ( 23 , 26 , 33 ). Three studies did not report patient gender (Table 1 ) ( 12 , 20 , 28 ). The most frequent indication for MACE was constipation (183/371, 49.3%; 44.2%-54.4% 95%CI), followed by FI (143/371, 39.6%; 34.6%-44.6% 95%CI) (Table 3 ). Two studies did not clearly report indications and were therefore excluded from the pooled analysis ( 26 , 28 ). The most common underlying causes were neurological disorders (89/345, 25.8%; 21.2%-30.4% 95%CI), followed by previous surgeries (58/345, 16.8%; 12.9%-20.7% 95%CI), idiopathic etiologies (49/345, 14.2%; 10.5%-17.9% 95%CI), and traumatic spinal injuries (40/345, 11.6%; 8.2%-15.0% 95%CI) (Table 3 ). Two studies did not clearly report the causes of constipation or FI (n = 28) ( 28 ), or failed to specify them for all patients (n = 32) ( 32 ), and were likewise excluded from the pooled analysis. Techniques and short-term outcomes Five different surgical techniques were employed across the included studies, all of which reported the number of patients undergoing each technique (Table 3 ). The most commonly used method was the terminal ileal loop (ileal neoappendicostomy; 153/404, 37.9%; 33.2%-42.6% 95%CI), followed by percutaneous endoscopic cecostomy (105/404, 26.0%; 21.7%-30.3% 95%CI) and appendicostomy (100/404, 24.8%; 20.6%-29.0% 95%CI - Table 3 ). The stoma was most frequently created in the right iliac fossa, though occasionally positioned at the umbilicus for cosmetic reasons ( 32 , 33 ). All but one study (Uno et al. ( 23 )) reported postoperative complications (Table 4 ). Clavien–Dindo grade I–II complications (not requiring invasive treatment) were reported in 56.3% (51.4%-61.2% 95%CI) of patients (219/389), while grade III complications occurred in 14.4% (10.9–17.9% 95%CI) of them (56/389). No grade IV or V complications were reported. There was substantial heterogeneity in the types of complications reported (Table 4 , Fig. 2), and only a limited number of studies described technique-specific complications when multiple approaches were used ( 12 , 13 , 20 , 25 , 28 , 29 ). Overall, minor stoma-related complications - including superficial infections, granulation tissue, local pain, abscesses, excoriation, inflammation, and hematomas - were the most frequent, affecting 39.1% (152/389; 34.3%-43.9% 95%CI) of patients. These were followed by fecal leakage (63/389; 16.2%; 12.5%-19.9% 95%CI) and stoma stenosis (44/389; 11.3%; 8.2%-14.4% 95%CI) (Table 4 ). Stoma stenosis was significantly more likely after appendicostomy than ileal neoappendicostomy (9/29, 31.0% vs. 3/60, 5.0%; Odds Ratio = 6.3, 1.6–25.0 95%CI; Fisher’s exact test p = 0.001). No statistically significant differences were found between appendicostomy and cecostomy (9/29, 31.0% vs. 3/24, 12.5%; OR = 2.5, 0.6–10.3 95%CI; Fisher’s exact test p = 0.11), nor between cecostomy and ileal neoappendicostomy (3/24, 12.5% vs. 3/60, 5.0%; OR = 2.5, 0.9–26.5 95%CI; Fisher’s exact test p = 0.228). Long-term success and failure The median follow-up was 28.5 months (range: 1–140 months) (Table 5 , Fig. 3). A majority of patients (283/377; 75.1%, 70.7%-79.5% 95%CI) continued to use colonic irrigations at the end of follow-up (range: 48.4%–100%; Table 5 ). MACE failure, defined as conversion to permanent colostomy, was reported in 9.8% (6.8%-12.8% 95%CI) of patients (37/377). Major causes of failure included stoma-related complications such as stenosis, necrosis, and abscesses ( 25 ). Other causes included progression of the underlying disease ( 27 ), persistence of symptoms ( 29 ), abdominal pain, and reflux or leakage from the stoma ( 21 ). Functional results Since 1998, functional outcomes have been assessed using various symptom-specific and quality-of-life instruments (Table 5 ) ( 21 ). Four studies did not report functional outcomes or did not use validated assessment tools ( 12 , 23 , 28 , 32 ). Constipation severity was evaluated using the Knowles-Eccersley-Scott Symptom (KESS) score ( 34 ) in five studies ( 13 , 20 , 25 , 30 , 34 ), and the Cleveland Clinic Constipation Score (CCCS) ( 35 ) in three studies ( 14 , 27 , 31 ). Fecal incontinence was assessed with the Cleveland Clinic Incontinence Score (CCIS) ( 6 ) in six studies ( 6 , 20 , 22 , 24 , 25 , 35 ), and with the Vaizey Score ( 36 ) in one study ( 14 ). Stomal continence was measured using the Malone Continence Scale ( 37 ) in a single study ( 14 ). QOL was assessed using the Gastrointestinal Quality of Life Index (GIQLI) ( 38 ) in five studies ( 13 , 20 , 24 , 27 , 30 ), the Fecal Incontinence Quality of Life (FIQL) score ( 39 ) in one study ( 25 ), the Short Form (SF) 36 Health Survey ( 40 ) in four studies ( 14 , 22 , 24 , 29 ), and the Nottingham Health Profile ( 41 ) in one study ( 31 ). The Zung self-rating depression scale ( 42 ) and the State Trait Anxiety Inventory ( 43 ) were used to assess anxiety and depression in one study ( 31 ). Satisfactory outcomes, defined as improved function and QOL, were reported in 60–83% of patients (Table 5 ). However, no definitive conclusion could be drawn regarding whether MACE provided superior results for constipation or FI. Some studies suggested better outcomes in constipated patients ( 13 , 14 ), while others favored incontinent patients ( 24 , 29 , 30 ). In the study by Brinas et al. ( 25 ), KESS and CCIS scores did not significantly change postoperatively, though this result may have been influenced by the low number of patients who completed follow-up questionnaires. Discussion Constipation and FI are disorders that significantly impact QOL, affecting approximately 10% of the general adult population ( 1 , 3 ). These conditions may occur individually, although their coexistence is common and clinically variable ( 44 ). Initial management typically involves conservative medical therapies, but more invasive options, including surgery, are required in severe refractory cases. Resective procedures - such as total colectomy with ileorectal anastomosis or segmental colectomy - offer limited long-term functional outcomes and are associated with significant morbidity ( 45 , 46 ). MACE offers an alternative by enabling self-administered antegrade colonic irrigation ( 9 ). In its original form, the procedure involves resecting the appendix—while preserving its arterial supply—and creating a submucosal tunnel in the cecum, where the distal appendix is sutured. The proximal end is externalized at the skin level to form a stoma through which antegrade irrigation is performed using a catheter. When the appendix is unavailable, alternative approaches using the terminal ileum, cecum ( 13 ), or distal colon ( 47 ) have been described. More recently, minimally invasive laparoscopic or percutaneous endoscopic techniques have been developed with comparable results ( 13 , 23 ). Initially introduced for the treatment of FI in pediatric patients ( 9 , 48 , 49 ), MACE was later adopted for constipation as well. Pediatric studies have demonstrated long-term success rates of 78–93% ( 18 , 50 ), while evidence in the adult population remains limited and more heterogeneous. The reality is, however, that many adults with MACE have transitioned from the pediatric population, and therefore the two groups are not always distinct. Nevertheless, our review focused exclusively on a pure adult population, thereby complementing the limited data currently available. In adults, MACE is used to treat constipation, FI or both. Although most published studies are small, single-centre case series ( 50 ), our review indicates that a substantial proportion of adult patients (46.9%-92.9%) continued using irrigations at the end of follow-up, in line with a previous meta-analysis reporting success rates of approximately 74% (range 66–83%) at an average follow-up of 39 months ( 10 , 51 ). From a technical standpoint, appendicostomy should be preferred when the appendix is available, as it is associated with lower rates of stomal stenosis compared to ileal channels. Minimally invasive and percutaneous approaches may be considered in selected patients, but current data suggest a higher risk of pain or local complications. Important considerations for the clinical implementation of MACE are its cost-effectiveness and adequate patient selection. While formal cost-effectiveness analyses in adults are limited, the procedure may reduce long-term healthcare utilization by decreasing the need for chronic medications, hospitalizations for complications of constipation or FI, and repeated interventions. Patient selection remains crucial. MACE appears to be most beneficial for adults with refractory constipation or FI who have not responded to conservative therapies, including dietary management, laxatives, and transanal irrigation (TAI), and who possess adequate manual dexterity and motivation to perform regular antegrade irrigations. Patients with severe neurogenic bowel dysfunction (e.g., spinal cord injury, spina bifida) may particularly benefit, while outcomes could be less predictable in those with progressive neurological decline where declining mobility is expected. Classic surgical options - such as segmental, subtotal, or total colectomy - achieve success rates of 65–100% but are associated with substantial morbidity, including diarrhea (46%), abdominal pain (41%), de novo incontinence (21%), and small bowel obstruction (15%) ( 52 – 54 ). Similarly, sacral nerve stimulation carries a procedural complication rate leading to reoperation in 13–34% of patients and a device removal rate of 8–23% at a mean follow-up of 31 months, most commonly due to lack of efficacy, infection, lead-related issues, or pain at the implant site and from stimulation ( 55 ). In comparison, MACE represents a less invasive alternative with favorable long-term outcomes. Indeed, MACE is most directly compared with TAI, another non-pharmacological technique aimed at improving bowel function. TAI shares similar indications and mechanisms of action with MACE and has demonstrated sustained efficacy in 60–70% of patients, along with improved QOL in both the short and long term ( 56 – 58 ). Compared to MACE, which showed a 75.1% long-term success rate in our pooled analysis, TAI offers comparable functional outcomes with the advantage of being less invasive and fully reversible. However, MACE and TAI should not be considered mutually exclusive, but rather sequential steps within a therapeutic algorithm tailored to the severity of symptoms, patient compliance, and response to previous treatments. TAI is best suited as a first-line option due to its non-invasive nature and ease of use, particularly in compliant patients with preserved dexterity (e.g., those with low anterior resection syndrome or mild neurogenic bowel dysfunction). MACE, conversely, represents a later-stage intervention for patients who fail or do not tolerate TAI, or for those with anatomical or severe neurological conditions that render TAI ineffective (i.e. selected cases of severe or refractory LARS). More recently, alternative MACE techniques involving the descending colon have been described. Notably, Macedo et al. introduced a method using a catheter placed in the left sigmoid colon to create a stoma for distal colonic irrigation, thereby avoiding the use of the appendix ( 47 ). Although the indications may overlap, left-sided procedures differ significantly from classic MACE and were therefore excluded from our systematic review ( 59 ). Failure of the MACE procedure – traditionally defined as the need for conversion to permanent colostomy – ranged from 0% to 29.0%, with stoma-related complications representing a major contributing factor ( 25 ). Stomal stenosis, often requiring dilatation or surgical revision, occurred six times more frequently following appendicostomy compared to ileal appendicostomy. Local pain, particularly after percutaneous endoscopic approaches ( 13 ), also contributed to failure, potentially due to injury of the ilioinguinal or iliohypogastric nerves or colonic traction from endoscopic fixation. Other reported causes included persistent FI, stoma leakage, and progression of underlying neurological disorders that impeded effective irrigation ( 26 ). It is important to note that while conversion to colostomy or cessation of antegrade irrigation provides an objectively measurable endpoint, this definition may oversimplify clinical reality and fail to fully capture patient-centered success. In some cases, patients may successfully transition to TAI after stoma closure, whereas in others - particularly those with severe motor disability - a permanent colostomy may represent the most appropriate and effective long-term solution. From the patient’s perspective, functional outcomes such as symptom relief and QOL improvement are arguably more relevant than technical continuation of irrigation or avoidance of colostomy. Therefore, definitions of success and failure should integrate both functional improvement and sustained use of MACE, rather than relying solely on procedural endpoints. Most studies reported improvements in bowel function and patient-reported QOL, supporting the view that the benefits of MACE extend beyond technical outcomes. However, interpretation is complicated by heterogeneity in assessment tools, including CCIS ( 35 ), KESS ( 34 ), and various QoL instruments, which limits direct comparisons. This review is limited by the heterogeneity of the included studies (indications, techniques, follow-ups, retrospective and prospective designs) with relatively small sample sizes (3–75 patients per study, 404 patients in total). Only single-arm case series were available, precluding formal meta-analysis, publication bias assessment, or sensitivity analyses. Pooled results should therefore be interpreted as descriptive rather than inferential. Furthermore, functional outcomes were assessed using a wide range of scoring systems and quality-of-life instruments, which complicates direct comparison and pooling of results. In addition, although a formal risk of bias assessment was performed, its results were not homogeneous: most studies showed a moderate to high risk of selection and reporting bias, with only a minority judged as low risk. These limitations must be considered when interpreting the pooled findings, and observed success rates should be viewed as exploratory signals rather than definitive estimates. Future studies should aim to standardize outcome measures using validated scoring systems and QOL instruments to enable meaningful comparison. Comparative studies between MACE and TAI are needed to clarify their relative roles within treatment algorithms. In addition, long-term prospective registries could help identify predictors of success or failure, refine patient selection criteria, and explore cost-effectiveness. Finally, technical innovations - such as less invasive access techniques - should be investigated to reduce complications and improve durability of treatment. Conclusions MACE represents an effective and safe therapeutic option for the medium and long management of severe constipation and FI in adult patients, particularly in those who have not responded to medical therapy and wish to avoid permanent colostomy. Over time, the majority of patients report satisfaction with the procedure, improved QOL, and maintain regular use of irrigations with satisfactory symptom control. However, no definitive conclusions can be drawn regarding the most effective MACE technique. While percutaneous endoscopic cecostomy offers the advantage of minimal invasiveness, it is frequently associated with postoperative pain and higher rates of conversion to colostomy. Conversely, surgical approaches involving the creation of a neo-appendix may provide better long-term outcomes, but they are associated with greater morbidity and a noteworthy risk of stomal stenosis. Declarations Human Ethics and Consent to Participate declarations not applicable. This study is a systematic review of previously published research; no new data involving human participants were collected. Conflict of interest . All authors declare no personal conflict of interest. Funding: none. Author Contribution Authors’ Contributions. GGr & GGa contributed equally. Substantial contributions to the conception and design of the work, acquisition, analysis, and interpretation of data for the work, drafting and revising the work critically for important intellectual content. Final approval of the version to be published. Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy and integrity of any part of the work are appropriately investigated and resolved. ARL, GC, VDS: analysis and interpretation of data for the work, revising the work critically for important intellectual content. Final approval of the version to be published. Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy and integrity of any part of the work are appropriately investigated and resolved. ABB, SS, RS, PS, MT contributed to drafting the work and revised it critically for important intellectual content. Analysis and interpretation of data for the work. Final approval of the version to be published. Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy and integrity of any part of the work are appropriately investigated and resolved. Data Availability Statement. Datasets generated are available upon reasonable request. References Higgins PD, Johanson JF (2004) Epidemiology of constipation in North America: a systematic review. Am J Gastroenterol 99(4):750–759 Perry S, Shaw C, McGrother C, Matthews RJ, Assassa RP, Dallosso H et al (2002) Prevalence of faecal incontinence in adults aged 40 years or more living in the community. 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Br J Surg 103(4):322–327 FitzHarris GP, Garcia-Aguilar J, Parker SC, Bullard KM, Madoff RD, Goldberg SM et al (2003) Quality of life after subtotal colectomy for slow-transit constipation: both quality and quantity count. Dis Colon Rectum 46(4):433–440 McCoy JA, Beck DE (2012) Surgical management of colonic inertia. Clin Colon Rectal Surg 25(1):20–23 Knowles CH, Grossi U, Chapman M, Mason J, group, NCw (2017) Pelvic floor S. Surgery for constipation: systematic review and practice recommendations: Results I: Colonic resection. Colorectal Dis. ;19 Suppl 3:17–36 Pilkington SA, Emmett C, Knowles CH, Mason J, Yiannakou Y, group NCw et al (2017) Surgery for constipation: systematic review and practice recommendations: Results V: Sacral Nerve Stimulation. Colorectal Dis 19(Suppl 3):92–100 Ji Y, Ji JE, Kim B, Han SW, Lee YS, Kim SW et al (2024) Long-term outcome of transanal irrigation for individuals with spina bifida: a 12-year experience study. Tech Coloproctol 28(1):159 Falletto E, Martellucci J, Rossitti P, Bondurri A, Zaffaroni G, Ascanelli S et al (2023) Transanal irrigation in functional bowel disorders and LARS: short-term results from an Italian national study. Tech Coloproctol 27(6):481–490 Martellucci J, Falletto E, Ascanelli S, Bondurri A, Borin S, Bottini C et al (2024) Consensus-driven protocol for transanal irrigation in patients with low anterior resection syndrome and functional constipation. Tech Coloproctol 28(1):153 Ellison JS, Haraway AN, Park JM (2013) The distal left Malone antegrade continence enema–is it better? J Urol 190(4 Suppl):1529–1533 Tables Tables 1 to 5 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table15.docx Cite Share Download PDF Status: Published Journal Publication published 03 Jan, 2026 Read the published version in International Journal of Colorectal Disease → Version 1 posted Editorial decision: Accepted 23 Oct, 2025 Reviews received at journal 16 Sep, 2025 Reviewers agreed at journal 15 Sep, 2025 Reviewers agreed at journal 15 Sep, 2025 Reviewers invited by journal 13 Sep, 2025 Editor assigned by journal 12 Sep, 2025 Submission checks completed at journal 11 Sep, 2025 First submitted to journal 10 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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02:46:50","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":201033,"visible":true,"origin":"","legend":"\u003cp\u003eBar chart showing complications pooled frequencies (%) in decrescent order.\u003c/p\u003e","description":"","filename":"Fig.2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7541297/v1/6f780fa93d23c2b6bd5a629c.jpg"},{"id":91937182,"identity":"565014b5-505b-42a4-9712-a7b7bc7555f5","added_by":"auto","created_at":"2025-09-23 02:54:50","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":232348,"visible":true,"origin":"","legend":"\u003cp\u003eBar chart showing success rates and failure rates (definite colostomy) for individual studies.\u003c/p\u003e","description":"","filename":"Fig.3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7541297/v1/f3e85651814773bf1b90845f.jpg"},{"id":99546151,"identity":"bf39ae31-ee14-4262-b953-58ec88445c6c","added_by":"auto","created_at":"2026-01-05 16:10:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1152213,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7541297/v1/47bd2a8e-efd7-4b82-b93e-05983ef4fb8a.pdf"},{"id":91935948,"identity":"485ec712-a1d3-455a-9bf9-57755c26059c","added_by":"auto","created_at":"2025-09-23 02:46:50","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":227673,"visible":true,"origin":"","legend":"","description":"","filename":"Table15.docx","url":"https://assets-eu.researchsquare.com/files/rs-7541297/v1/3afcfb19df41217fb2d6d0d3.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Malone Antegrade Continence Enema for treating adult constipation and fecal incontinence: a systematic review of the literature","fulltext":[{"header":"Significance statement","content":"\u003cp\u003e\u003cem\u003eThis systematic review focuses exclusively on the use of the Malone Antegrade Continence Enema (MACE) in adults with refractory constipation and fecal incontinence. Our findings demonstrate that MACE is a viable and generally well-tolerated alternative to permanent colostomy, with a high rate of long-term continuation and symptom improvement. These results support the inclusion of MACE in the therapeutic algorithm for carefully selected adult patients seeking minimally invasive and reversible solutions.\u003c/em\u003e\u003c/p\u003e"},{"header":"Highlights","content":"\u003cul\u003e\n \u003cli\u003eMACE offers a sensible option for adult fecal incontinence or constipation\u003c/li\u003e\n \u003cli\u003eMost frequent complications were minor and stoma-related (39.1%)\u003c/li\u003e\n \u003cli\u003e75.1% of patients continued MACE at final follow-up\u003c/li\u003e\n \u003cli\u003eOnly 9.8% of patients required colostomy conversion\u003c/li\u003e\n \u003cli\u003e60–83% of patients reported symptom relief and quality of life improvement\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Introduction","content":"\u003cp\u003ePhysiological bowel movements require normal colonic transit, intact anorectal sensitivity, adequate expulsive forces, and coordinated pelvic floor function. When any of these mechanisms are impaired, patients may experience constipation or fecal incontinence (FI). Defecatory disorders affect up to one-quarter of the general adult population (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), and when present, they can significantly impair quality of life (QOL) (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Conservative treatments include dietary modifications, oral laxatives, bulking agents, suppositories, and biofeedback therapy (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). When these measures fail, surgical interventions may be considered. These include transanal colonic irrigation (TAI), percutaneous tibial nerve stimulation, and sacral neuromodulation (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Colonic resections \u0026ndash; ether total or segmental - and stoma formation represent last-resort options (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), although their outcomes are variable ad often associated with considerable morbidity (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Among surgical options, the Malone-antegrade continence enema (MACE) offers a distinctive approach by enabling antegrade colonic irrigation, which may provide more predictable and complete bowel emptying and improve patient autonomy and quality of life, particularly in those who are refractory to conservative therapies.\u003c/p\u003e\u003cp\u003eMACE was introduced as a less invasive and potentially reversible surgical alternative for managing chronic constipation and FI (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). The principle involves performing antegrade enemas through a conduit into the proximal colon, facilitating mechanical irrigation and stimulating colonic propagating contractions. This dual mechanism enables complete and regular evacuation, helping prevent both constipation and FI (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Initially developed for pediatric patients, MACE has since been adapted for use in adults with similar bowel dysfunctions (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The technique has evolved over time to include minimally invasive laparoscopic and endoscopic approaches (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Reported outcomes have been encouraging: between 47% and 100% of patients continue irrigation in the medium and long term, while failure rates, defined as conversion to permanent colostomy \u0026ndash; range from 0% to 24% (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). In recent years, evolving techniques have included minimally invasive laparoscopic and endoscopic approaches. Such developments aimed to optimize stoma creation, reduce complications, and expand indications, reflecting a growing interest in tailoring MACE to adult populations and improving long-term functional outcomes.\u003c/p\u003e\u003cp\u003eThe aim of this study is to perform a systematic review of MACE procedures in adult patients. We present pooled success and failure rates and provide a detailed analysis of complications associated with different MACE techniques.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eA review protocol was registered in advance on the International Prospective Register of Systematic Reviews (PROSPERO; registration number: CRD420251025965; \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.crd.york.ac.uk/PROSPERO/view/CRD420251025965\u003c/span\u003e\u003cspan address=\"https://www.crd.york.ac.uk/PROSPERO/view/CRD420251025965\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). The work has been reported in line with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses), and TITAN (Transparency in the Reporting of Artificial Intelligence) guidelines (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eInclusion criteria comprised all published studies where MACE was performed in the adult population (older than 16 years) for the treatment of constipation and/or FI. Exclusion criteria included pediatric studies, studies where MACE was performed during childhood and adolescence and that report outcomes in adulthood (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), studies focusing on outcomes other than constipation or FI. All study types were considered eligible \u0026ndash; including retrospective, prospective, observational studies, and clinical trials \u0026ndash; with the exception of case reports. Given the expected heterogeneity across study designs and outcome measures, both retrospective and prospective studies were included. Only articles published in English, or those for which a reliable English translation was available, were included.\u003c/p\u003e\u003cp\u003eThe literature search was conducted using the biomedical databases PubMed, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) from inception to August 2025. The PubMed search strategy combined the following terms: (\u0026ldquo;antegrade\u0026rdquo; AND (\u0026ldquo;continent\u0026rdquo; OR \u0026ldquo;continence\u0026rdquo;) AND \u0026ldquo;enema\u0026rdquo;) OR (\u0026ldquo;antegrade continence enema\u0026rdquo;), applying filters for \u0026ldquo;Humans\u0026rdquo; and \u0026ldquo;All Adult (16\u0026thinsp;+\u0026thinsp;years).\u0026rdquo; The Embase search was performed using an equivalent strategy adapted to Emtree terminology. The CENTRAL database was queried with the term \u0026ldquo;antegrade continence enema\u0026rdquo; across titles, abstracts, and full texts. The Current Controlled Trials database (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e\u003ca href=\"https://www.crd.york.ac.uk/PROSPERO/view/CRD420251025965\" target=\"_blank\"\u003ewww.controlled-trials.com\u003c/a\u003e\u003c/span\u003e\u003cspan address=\"http://www.controlled-trials.com\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e) was also screened to identify ongoing randomized trials. Additionally, the reference lists of relevant articles and prior reviews were screened for further eligible studies.\u003c/p\u003e\u003cp\u003eTitles and abstracts were screened for relevance, and full texts of potentially eligible studies were independently reviewed by two authors (GG and GGr) with any disagreements resolved by discussion or consultation with a third author (ABB). Data from eligible studies were extracted and compiled into a centralized database. The methodological quality of the included studies was evaluated using the Newcastle\u0026ndash;Ottawa Scale (NOS) for cohort studies (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). The NOS assigns up to nine points across three domains: Selection (four points: representativeness of the exposed cohort, selection of the non-exposed cohort, ascertainment of exposure, and demonstration that the outcome was not present at baseline), Comparability (two points: adjustment for the most important confounder and for additional confounders), and Outcome (three points: adequacy of outcome assessment, length of follow-up sufficient for outcomes to occur, and adequacy of follow-up of cohorts). Each item was judged as either fulfilled (awarding a star) or not fulfilled. Two authors (GGa and GGr) independently assessed all studies, with disagreements resolved by discussion with the third author (ABB). Based on the total score, studies were categorized as high quality (\u0026ge;\u0026thinsp;7 points), moderate quality (5\u0026ndash;6 points), or low quality (\u0026lt;\u0026thinsp;5 points).\u003c/p\u003e\u003cp\u003eThe primary outcome of this systematic review was to assess the long-term clinical efficacy of MACE in adult patients, defined in a patient-centered manner as both the sustained use of antegrade colonic irrigation and meaningful improvements in bowel function and QOL. Traditional measures, such as continued MACE use and the need for definitive colostomy, were included as objectively measurable endpoints; however, these may not fully capture the functional and experiential benefits from the patient perspective. Functional outcomes were extracted as reported, acknowledging the use of diverse scoring systems and QoL instruments, which limited the possibility of direct comparison. Secondary outcomes included the safety of the procedure (type and frequency of postoperative complications) and functional outcomes assessed using validated symptom scores and QoL instruments. Where sufficient data were available, descriptive pooled estimates were calculated, while studies with missing or unclear data were excluded from quantitative synthesis. Because all included studies were single-arm series without comparators, and given the heterogeneity expected (follow-up, indications, technique), a formal meta-analysis and associated bias assessments (e.g., funnel plots) were not applicable.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eSeventeen articles were included in the final analysis (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) (\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan additionalcitationids=\"CR21 CR22 CR23 CR24 CR25 CR26 CR27 CR28 CR29 CR30 CR31 CR32\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Eleven were retrospective studies (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan additionalcitationids=\"CR21 CR22 CR23 CR24 CR25\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e), and six were prospective (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e1\u003c/span\u003e) (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan additionalcitationids=\"CR28 CR29 CR30\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). All but two studies were conducted in European countries (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e), and all but one were single-centre series (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e1\u003c/span\u003e) (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). According to the NOS, eleven studies were rated as \u0026ldquo;moderate-to-good\u0026rdquo; quality (6/9 points), four as moderate (5/9 points), and two as good quality (7/9 points) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Most studies used validated outcome measures, had sufficient follow-up duration to assess long-term results, and reported complete follow-up data for all patients (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Common limitations included the absence of control groups, small sample sizes, and the resulting inability to perform subgroup analyses (e.g., comparisons between indications - FI vs. constipation - or between surgical techniques) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\n\u003ch3\u003eIndications for MACE\u003c/h3\u003e\n\u003cp\u003eA total of 404 adult patients underwent MACE procedures, with individual series ranging from 3 to 75 patients (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Patients were predominantly female (219/301, 72.8%), except in three studies that showed a male predominance (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Three studies did not report patient gender (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e1\u003c/span\u003e) (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe most frequent indication for MACE was constipation (183/371, 49.3%; 44.2%-54.4% 95%CI), followed by FI (143/371, 39.6%; 34.6%-44.6% 95%CI) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Two studies did not clearly report indications and were therefore excluded from the pooled analysis (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). The most common underlying causes were neurological disorders (89/345, 25.8%; 21.2%-30.4% 95%CI), followed by previous surgeries (58/345, 16.8%; 12.9%-20.7% 95%CI), idiopathic etiologies (49/345, 14.2%; 10.5%-17.9% 95%CI), and traumatic spinal injuries (40/345, 11.6%; 8.2%-15.0% 95%CI) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Two studies did not clearly report the causes of constipation or FI (n\u0026thinsp;=\u0026thinsp;28) (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e), or failed to specify them for all patients (n\u0026thinsp;=\u0026thinsp;32) (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e), and were likewise excluded from the pooled analysis.\u003c/p\u003e\n\u003ch3\u003eTechniques and short-term outcomes\u003c/h3\u003e\n\u003cp\u003eFive different surgical techniques were employed across the included studies, all of which reported the number of patients undergoing each technique (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The most commonly used method was the terminal ileal loop (ileal neoappendicostomy; 153/404, 37.9%; 33.2%-42.6% 95%CI), followed by percutaneous endoscopic cecostomy (105/404, 26.0%; 21.7%-30.3% 95%CI) and appendicostomy (100/404, 24.8%; 20.6%-29.0% 95%CI - Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The stoma was most frequently created in the right iliac fossa, though occasionally positioned at the umbilicus for cosmetic reasons (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAll but one study (Uno et al. (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)) reported postoperative complications (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Clavien\u0026ndash;Dindo grade I\u0026ndash;II complications (not requiring invasive treatment) were reported in 56.3% (51.4%-61.2% 95%CI) of patients (219/389), while grade III complications occurred in 14.4% (10.9\u0026ndash;17.9% 95%CI) of them (56/389). No grade IV or V complications were reported. There was substantial heterogeneity in the types of complications reported (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e4\u003c/span\u003e, Fig.\u0026nbsp;2), and only a limited number of studies described technique-specific complications when multiple approaches were used (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Overall, minor stoma-related complications - including superficial infections, granulation tissue, local pain, abscesses, excoriation, inflammation, and hematomas - were the most frequent, affecting 39.1% (152/389; 34.3%-43.9% 95%CI) of patients. These were followed by fecal leakage (63/389; 16.2%; 12.5%-19.9% 95%CI) and stoma stenosis (44/389; 11.3%; 8.2%-14.4% 95%CI) (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Stoma stenosis was significantly more likely after appendicostomy than ileal neoappendicostomy (9/29, 31.0% vs. 3/60, 5.0%; Odds Ratio\u0026thinsp;=\u0026thinsp;6.3, 1.6\u0026ndash;25.0 95%CI; Fisher\u0026rsquo;s exact test \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001). No statistically significant differences were found between appendicostomy and cecostomy (9/29, 31.0% vs. 3/24, 12.5%; OR\u0026thinsp;=\u0026thinsp;2.5, 0.6\u0026ndash;10.3 95%CI; Fisher\u0026rsquo;s exact test \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.11), nor between cecostomy and ileal neoappendicostomy (3/24, 12.5% vs. 3/60, 5.0%; OR\u0026thinsp;=\u0026thinsp;2.5, 0.9\u0026ndash;26.5 95%CI; Fisher\u0026rsquo;s exact test \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.228).\u003c/p\u003e\n\u003ch3\u003eLong-term success and failure\u003c/h3\u003e\n\u003cp\u003eThe median follow-up was 28.5 months (range: 1\u0026ndash;140 months) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e5\u003c/span\u003e, Fig.\u0026nbsp;3). A majority of patients (283/377; 75.1%, 70.7%-79.5% 95%CI) continued to use colonic irrigations at the end of follow-up (range: 48.4%\u0026ndash;100%; Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e5\u003c/span\u003e). MACE failure, defined as conversion to permanent colostomy, was reported in 9.8% (6.8%-12.8% 95%CI) of patients (37/377). Major causes of failure included stoma-related complications such as stenosis, necrosis, and abscesses (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Other causes included progression of the underlying disease (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e), persistence of symptoms (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), abdominal pain, and reflux or leakage from the stoma (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eFunctional results\u003c/h3\u003e\n\u003cp\u003eSince 1998, functional outcomes have been assessed using various symptom-specific and quality-of-life instruments (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e5\u003c/span\u003e) (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Four studies did not report functional outcomes or did not use validated assessment tools (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Constipation severity was evaluated using the Knowles-Eccersley-Scott Symptom (KESS) score (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e) in five studies (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e), and the Cleveland Clinic Constipation Score (CCCS) (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) in three studies (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Fecal incontinence was assessed with the Cleveland Clinic Incontinence Score (CCIS) (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) in six studies (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e), and with the Vaizey Score (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e) in one study (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Stomal continence was measured using the Malone Continence Scale (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) in a single study (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). QOL was assessed using the Gastrointestinal Quality of Life Index (GIQLI) (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e) in five studies (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e), the Fecal Incontinence Quality of Life (FIQL) score (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e) in one study (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e), the Short Form (SF) 36 Health Survey (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e) in four studies (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), and the Nottingham Health Profile (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e) in one study (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). The Zung self-rating depression scale (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e) and the State Trait Anxiety Inventory (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e) were used to assess anxiety and depression in one study (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSatisfactory outcomes, defined as improved function and QOL, were reported in 60\u0026ndash;83% of patients (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e5\u003c/span\u003e). However, no definitive conclusion could be drawn regarding whether MACE provided superior results for constipation or FI. Some studies suggested better outcomes in constipated patients (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), while others favored incontinent patients (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). In the study by Brinas et al. (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e), KESS and CCIS scores did not significantly change postoperatively, though this result may have been influenced by the low number of patients who completed follow-up questionnaires.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eConstipation and FI are disorders that significantly impact QOL, affecting approximately 10% of the general adult population (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). These conditions may occur individually, although their coexistence is common and clinically variable (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). Initial management typically involves conservative medical therapies, but more invasive options, including surgery, are required in severe refractory cases. Resective procedures - such as total colectomy with ileorectal anastomosis or segmental colectomy - offer limited long-term functional outcomes and are associated with significant morbidity (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eMACE offers an alternative by enabling self-administered antegrade colonic irrigation (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). In its original form, the procedure involves resecting the appendix\u0026mdash;while preserving its arterial supply\u0026mdash;and creating a submucosal tunnel in the cecum, where the distal appendix is sutured. The proximal end is externalized at the skin level to form a stoma through which antegrade irrigation is performed using a catheter. When the appendix is unavailable, alternative approaches using the terminal ileum, cecum (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), or distal colon (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e) have been described. More recently, minimally invasive laparoscopic or percutaneous endoscopic techniques have been developed with comparable results (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Initially introduced for the treatment of FI in pediatric patients (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e), MACE was later adopted for constipation as well. Pediatric studies have demonstrated long-term success rates of 78\u0026ndash;93% (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e), while evidence in the adult population remains limited and more heterogeneous. The reality is, however, that many adults with MACE have transitioned from the pediatric population, and therefore the two groups are not always distinct. Nevertheless, our review focused exclusively on a pure adult population, thereby complementing the limited data currently available.\u003c/p\u003e\u003cp\u003eIn adults, MACE is used to treat constipation, FI or both. Although most published studies are small, single-centre case series (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e), our review indicates that a substantial proportion of adult patients (46.9%-92.9%) continued using irrigations at the end of follow-up, in line with a previous meta-analysis reporting success rates of approximately 74% (range 66\u0026ndash;83%) at an average follow-up of 39 months (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e). From a technical standpoint, appendicostomy should be preferred when the appendix is available, as it is associated with lower rates of stomal stenosis compared to ileal channels. Minimally invasive and percutaneous approaches may be considered in selected patients, but current data suggest a higher risk of pain or local complications.\u003c/p\u003e\u003cp\u003eImportant considerations for the clinical implementation of MACE are its cost-effectiveness and adequate patient selection. While formal cost-effectiveness analyses in adults are limited, the procedure may reduce long-term healthcare utilization by decreasing the need for chronic medications, hospitalizations for complications of constipation or FI, and repeated interventions. Patient selection remains crucial. MACE appears to be most beneficial for adults with refractory constipation or FI who have not responded to conservative therapies, including dietary management, laxatives, and transanal irrigation (TAI), and who possess adequate manual dexterity and motivation to perform regular antegrade irrigations. Patients with severe neurogenic bowel dysfunction (e.g., spinal cord injury, spina bifida) may particularly benefit, while outcomes could be less predictable in those with progressive neurological decline where declining mobility is expected. Classic surgical options - such as segmental, subtotal, or total colectomy - achieve success rates of 65\u0026ndash;100% but are associated with substantial morbidity, including diarrhea (46%), abdominal pain (41%), de novo incontinence (21%), and small bowel obstruction (15%) (\u003cspan additionalcitationids=\"CR53\" citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e). Similarly, sacral nerve stimulation carries a procedural complication rate leading to reoperation in 13\u0026ndash;34% of patients and a device removal rate of 8\u0026ndash;23% at a mean follow-up of 31 months, most commonly due to lack of efficacy, infection, lead-related issues, or pain at the implant site and from stimulation (\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e). In comparison, MACE represents a less invasive alternative with favorable long-term outcomes.\u003c/p\u003e\u003cp\u003eIndeed, MACE is most directly compared with TAI, another non-pharmacological technique aimed at improving bowel function. TAI shares similar indications and mechanisms of action with MACE and has demonstrated sustained efficacy in 60\u0026ndash;70% of patients, along with improved QOL in both the short and long term (\u003cspan additionalcitationids=\"CR57\" citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e). Compared to MACE, which showed a 75.1% long-term success rate in our pooled analysis, TAI offers comparable functional outcomes with the advantage of being less invasive and fully reversible. However, MACE and TAI should not be considered mutually exclusive, but rather sequential steps within a therapeutic algorithm tailored to the severity of symptoms, patient compliance, and response to previous treatments. TAI is best suited as a first-line option due to its non-invasive nature and ease of use, particularly in compliant patients with preserved dexterity (e.g., those with low anterior resection syndrome or mild neurogenic bowel dysfunction). MACE, conversely, represents a later-stage intervention for patients who fail or do not tolerate TAI, or for those with anatomical or severe neurological conditions that render TAI ineffective (i.e. selected cases of severe or refractory LARS). More recently, alternative MACE techniques involving the descending colon have been described. Notably, Macedo et al. introduced a method using a catheter placed in the left sigmoid colon to create a stoma for distal colonic irrigation, thereby avoiding the use of the appendix (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). Although the indications may overlap, left-sided procedures differ significantly from classic MACE and were therefore excluded from our systematic review (\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eFailure of the MACE procedure \u0026ndash; traditionally defined as the need for conversion to permanent colostomy \u0026ndash; ranged from 0% to 29.0%, with stoma-related complications representing a major contributing factor (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Stomal stenosis, often requiring dilatation or surgical revision, occurred six times more frequently following appendicostomy compared to ileal appendicostomy. Local pain, particularly after percutaneous endoscopic approaches (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), also contributed to failure, potentially due to injury of the ilioinguinal or iliohypogastric nerves or colonic traction from endoscopic fixation. Other reported causes included persistent FI, stoma leakage, and progression of underlying neurological disorders that impeded effective irrigation (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). It is important to note that while conversion to colostomy or cessation of antegrade irrigation provides an objectively measurable endpoint, this definition may oversimplify clinical reality and fail to fully capture patient-centered success. In some cases, patients may successfully transition to TAI after stoma closure, whereas in others - particularly those with severe motor disability - a permanent colostomy may represent the most appropriate and effective long-term solution. From the patient\u0026rsquo;s perspective, functional outcomes such as symptom relief and QOL improvement are arguably more relevant than technical continuation of irrigation or avoidance of colostomy. Therefore, definitions of success and failure should integrate both functional improvement and sustained use of MACE, rather than relying solely on procedural endpoints. Most studies reported improvements in bowel function and patient-reported QOL, supporting the view that the benefits of MACE extend beyond technical outcomes. However, interpretation is complicated by heterogeneity in assessment tools, including CCIS (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e), KESS (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e), and various QoL instruments, which limits direct comparisons.\u003c/p\u003e\u003cp\u003e This review is limited by the heterogeneity of the included studies (indications, techniques, follow-ups, retrospective and prospective designs) with relatively small sample sizes (3\u0026ndash;75 patients per study, 404 patients in total). Only single-arm case series were available, precluding formal meta-analysis, publication bias assessment, or sensitivity analyses. Pooled results should therefore be interpreted as descriptive rather than inferential. Furthermore, functional outcomes were assessed using a wide range of scoring systems and quality-of-life instruments, which complicates direct comparison and pooling of results. In addition, although a formal risk of bias assessment was performed, its results were not homogeneous: most studies showed a moderate to high risk of selection and reporting bias, with only a minority judged as low risk. These limitations must be considered when interpreting the pooled findings, and observed success rates should be viewed as exploratory signals rather than definitive estimates. Future studies should aim to standardize outcome measures using validated scoring systems and QOL instruments to enable meaningful comparison. Comparative studies between MACE and TAI are needed to clarify their relative roles within treatment algorithms. In addition, long-term prospective registries could help identify predictors of success or failure, refine patient selection criteria, and explore cost-effectiveness. Finally, technical innovations - such as less invasive access techniques - should be investigated to reduce complications and improve durability of treatment.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eMACE represents an effective and safe therapeutic option for the medium and long management of severe constipation and FI in adult patients, particularly in those who have not responded to medical therapy and wish to avoid permanent colostomy. Over time, the majority of patients report satisfaction with the procedure, improved QOL, and maintain regular use of irrigations with satisfactory symptom control. However, no definitive conclusions can be drawn regarding the most effective MACE technique. While percutaneous endoscopic cecostomy offers the advantage of minimal invasiveness, it is frequently associated with postoperative pain and higher rates of conversion to colostomy. Conversely, surgical approaches involving the creation of a neo-appendix may provide better long-term outcomes, but they are associated with greater morbidity and a noteworthy risk of stomal stenosis.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eHuman Ethics and Consent to Participate declarations\u003c/h2\u003e\u003cp\u003enot applicable. This study is a systematic review of previously published research; no new data involving human participants were collected.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003e\u003cb\u003eConflict of interest\u003c/b\u003e.\u003c/h2\u003e\u003cp\u003eAll authors declare no personal conflict of interest.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e\u003cp\u003enone.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAuthors\u0026rsquo; Contributions. GGr \u0026amp; GGa contributed equally. Substantial contributions to the conception and design of the work, acquisition, analysis, and interpretation of data for the work, drafting and revising the work critically for important intellectual content. Final approval of the version to be published. Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy and integrity of any part of the work are appropriately investigated and resolved. ARL, GC, VDS: analysis and interpretation of data for the work, revising the work critically for important intellectual content. Final approval of the version to be published. Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy and integrity of any part of the work are appropriately investigated and resolved. ABB, SS, RS, PS, MT contributed to drafting the work and revised it critically for important intellectual content. Analysis and interpretation of data for the work. Final approval of the version to be published. Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy and integrity of any part of the work are appropriately investigated and resolved.\u003c/p\u003e\u003ch2\u003eData Availability Statement.\u003c/h2\u003e\u003cp\u003eDatasets generated are available upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHiggins PD, Johanson JF (2004) Epidemiology of constipation in North America: a systematic review. Am J Gastroenterol 99(4):750\u0026ndash;759\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePerry S, Shaw C, McGrother C, Matthews RJ, Assassa RP, Dallosso H et al (2002) Prevalence of faecal incontinence in adults aged 40 years or more living in the community. 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Dis Colon Rectum 50(7):1023\u0026ndash;1031\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePortier G, Ghouti L, Kirzin S, Chauffour M, Lazorthes F (2006) Malone antegrade colonic irrigation: ileal neoappendicostomy is the preferred procedure in adults. Int J Colorectal Dis 21(5):458\u0026ndash;460\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLefevre JH, Parc Y, Giraudo G, Bell S, Parc R, Tiret E (2006) Outcome of antegrade continence enema procedures for faecal incontinence in adults. Br J Surg 93(10):1265\u0026ndash;1269\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMeurette G, Lehur PA, Coron E, Regenet N (2010) Long-term results of Malone's procedure with antegrade irrigation for severe chronic constipation. 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Gut 44(1):77\u0026ndash;80\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHenrichon S, Hu B, Kurzrock EA (2012) Detailed assessment of stomal incontinence after Malone antegrade continence enema: development of a new grading scale. J Urol 187(2):652\u0026ndash;655\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEypasch E, Williams JI, Wood-Dauphinee S, Ure BM, Schm\u0026uuml;lling C, Neugebauer E et al (1995) Gastrointestinal Quality of Life Index: development, validation and application of a new instrument. Br J Surg 82(2):216\u0026ndash;222\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRockwood TH, Church JM, Fleshman JW, Kane RL, Mavrantonis C, Thorson AG et al (2000) Fecal Incontinence Quality of Life Scale: quality of life instrument for patients with fecal incontinence. Dis Colon Rectum 43(1):9\u0026ndash;16 discussion \u0026ndash;\u0026thinsp;7\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWare JE Jr., Sherbourne CD (1992) The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care 30(6):473\u0026ndash;483\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHunt SM, McEwen J, McKenna SP (1985) Measuring health status: a new tool for clinicians and epidemiologists. J R Coll Gen Pract 35(273):185\u0026ndash;188\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZung WW (1965) A Self-Rating Depression Scale. Arch Gen Psychiatry 12:63\u0026ndash;70\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSpielberger CD, Gorsuch RL, Lushene R, Vagg PR, Jacobs GA (1983) Manual for the State-Trait Anxiety Inventory. Consulting Psychologists, Palo Alto\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVollebregt PF, Wiklendt L, Dinning PG, Knowles CH, Scott SM (2020) Coexistent faecal incontinence and constipation: A cross-sectional study of 4027 adults undergoing specialist assessment. EClinicalMedicine 27:100572\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGor RA, Katorski JR, Elliott SP (2016) Medical and surgical management of neurogenic bowel. Curr Opin Urol 26(4):369\u0026ndash;375\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKnowles CH, Scott M, Lunniss PJ (1999) Outcome of colectomy for slow transit constipation. Ann Surg 230(5):627\u0026ndash;638\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMacedo Junior A, Garrone G, Ottoni SL, de Mattos RM, Leal da Cruz M (2022) The Macedo-Malone antegrade colonic enema: A minimal invasive technique that precludes appendix use. 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Colorectal Dis. ;19 Suppl 3:17\u0026ndash;36\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePilkington SA, Emmett C, Knowles CH, Mason J, Yiannakou Y, group NCw et al (2017) Surgery for constipation: systematic review and practice recommendations: Results V: Sacral Nerve Stimulation. Colorectal Dis 19(Suppl 3):92\u0026ndash;100\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJi Y, Ji JE, Kim B, Han SW, Lee YS, Kim SW et al (2024) Long-term outcome of transanal irrigation for individuals with spina bifida: a 12-year experience study. Tech Coloproctol 28(1):159\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFalletto E, Martellucci J, Rossitti P, Bondurri A, Zaffaroni G, Ascanelli S et al (2023) Transanal irrigation in functional bowel disorders and LARS: short-term results from an Italian national study. Tech Coloproctol 27(6):481\u0026ndash;490\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMartellucci J, Falletto E, Ascanelli S, Bondurri A, Borin S, Bottini C et al (2024) Consensus-driven protocol for transanal irrigation in patients with low anterior resection syndrome and functional constipation. Tech Coloproctol 28(1):153\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEllison JS, Haraway AN, Park JM (2013) The distal left Malone antegrade continence enema\u0026ndash;is it better? J Urol 190(4 Suppl):1529\u0026ndash;1533\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 5 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-colorectal-disease","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijcd","sideBox":"Learn more about [International Journal of Colorectal Disease](http://link.springer.com/journal/384)","snPcode":"384","submissionUrl":"https://submission.nature.com/new-submission/384/3","title":"International Journal of Colorectal Disease","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"antegrade continence enema, fecal incontinence, constipation, neurogenic bowel dysfunction, colostomy","lastPublishedDoi":"10.21203/rs.3.rs-7541297/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7541297/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose\u003c/strong\u003e: 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.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: 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.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: 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.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: MACE is a safe and effective option for adults with refractory constipation or FI, especially in those aiming to avoid permanent colostomy.\u003c/p\u003e","manuscriptTitle":"The Malone Antegrade Continence Enema for treating adult constipation and fecal incontinence: a systematic review of the literature","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-23 02:46:44","doi":"10.21203/rs.3.rs-7541297/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Accepted","date":"2025-10-23T13:20:09+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-16T11:11:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"180997732454905271128564053467523535765","date":"2025-09-15T07:34:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"153768636553133180305014396188541118","date":"2025-09-15T07:17:31+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-13T05:13:28+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-12T08:21:08+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-11T05:41:55+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Journal of Colorectal Disease","date":"2025-09-10T10:54:59+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-colorectal-disease","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijcd","sideBox":"Learn more about [International Journal of Colorectal Disease](http://link.springer.com/journal/384)","snPcode":"384","submissionUrl":"https://submission.nature.com/new-submission/384/3","title":"International Journal of Colorectal Disease","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"f4a7e2c4-b1f4-442f-bfc5-ff08b75d2682","owner":[],"postedDate":"September 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-05T16:08:39+00:00","versionOfRecord":{"articleIdentity":"rs-7541297","link":"https://doi.org/10.1007/s00384-025-05022-5","journal":{"identity":"international-journal-of-colorectal-disease","isVorOnly":false,"title":"International Journal of Colorectal Disease"},"publishedOn":"2026-01-03 15:58:34","publishedOnDateReadable":"January 3rd, 2026"},"versionCreatedAt":"2025-09-23 02:46:44","video":"","vorDoi":"10.1007/s00384-025-05022-5","vorDoiUrl":"https://doi.org/10.1007/s00384-025-05022-5","workflowStages":[]},"version":"v1","identity":"rs-7541297","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7541297","identity":"rs-7541297","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}