ACE is widely recognized for its use in severe constipation. In 1990, Malone et al. reported the ACE procedure by inverting the appendix and using it as a catheter introduction route [1]. Since then, the Malone procedure has been widely used and modified for treating severe constipation. In 1997, Monti et al. reported a method by which a conduit could be formed from the ileum as a method of urinary diversion, in those cases where the appendix could not be used [4]. In 2002, MM was also applied to the descending or sigmoid colon by creating and anastomosing the conduit [2].
In spina bifida, the efficacy rate of ACE is reported to be 84% [5], and patient satisfaction is reported to be 89%-98% [6]. Currently, transanal irrigation systems are spreading. The ACE procedure, which includes MM, might be applied in cases where the transanal irrigation system is not effective. The advantages of MM are the more precise flow of the enema solution into the colon and the ability to perform enemas on the oral side of the colon that cannot be reached with a transanal irrigation system depending on the construction position. Furthermore, for patients with lower limb paralysis, such as this case, MM could keep the management simpler because of fewer items. For constipation with a neurological cause, the etiology is often in the rectosigmoid region, and ACE to the descending or sigmoid colon is said to be physiologically suitable [7], and requires less time and amount of injection for a single enema. Therefore, we think the MM should be indicated in cases without the appendix because the original Malone procedure is less invasive; however, it is better to construct a MM procedure in the descending colon or sigmoid colon if the appendix cannot be used.
The ACE procedure using a balloon-button gastrostomy tube is a simple and safe method of construction. However, granulation and stool leakage around the gastrostomy tube have been reported as the main complications [8, 9]. This ACE procedure is constructed by directly suturing to the colon and skin as in a gastrostomy; therefore, stool leakage is likely to occur. Complications can be minimized by using the appropriate size of gastrostomy tube in each patient [9]. In this case, the ACE procedure using a balloon-button gastrostomy tube was initially constructed in anticipation of simple surgical technique and management. However, stool leakage increased and dermatitis developed, despite changing the gastrostomy tube to one with appropriate size and shaft length and using a stoma pouch. Although there have been no reports on long-term follow-up of cases using gastrostomy tubes, it is thought that stool leakage and dermatitis would be a late complication in such cases.
Intestinal ischemia is a concern for MM; however, avoiding tension and preserving at least two or more feeding vessels when creating an intestinal tube is an effective preventative measure [10]. MM makes it easy to insert the stent tube, and stool leakage is unlikely to occur because of the distance between the colon and the skin [11]. Reconstruction of the ACE procedure by MM not only eliminates stool leakage, but also simplifies management and improves the patient's QOL.
