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The Malone antegrade continence enema adapting a transanal irrigation system in patients with neurogenic bowel dysfunction



Patients with severe neurogenic bowel dysfunction (NBD) may undergo the Malone antegrade continence enema (MACE) surgery to perform antegrade bowel irrigation (ABI). The standard approach may be prevented by a previous appendectomy or complicated by appendicular stenoses and/or stomal leakages. We present the experience by our tertiary referral center for NBD, adopting a modified surgical technique, based on a neoappendix with the terminal ileum to preserve the natural anti-reflux mechanism of the ileocecal valve and avoid stool leakage, and a largely available transanal irrigation (TAI) system to catheterize the neoappendix and perform ABI.

Case presentation

Three individuals with NBD successfully underwent our modified MACE program. Case 1 had cauda equina syndrome. He underwent surgery at 40. Case 2 was a man who suffered from spinal cord dysfunction due to acute disseminated encephalomyelitis, functionally T12 AIS B, at 57. Case 3 was a man with traumatic L1 AIS B paraplegia. At 60 he underwent surgery after 29 years since the injury. He needed a surgical revision due to a postoperative subcutaneous infection. After 121, 84 and 14 months from surgery, the three individuals performed ABI every 2 days, presented functional stomas, had no fecal incontinence, and reported an NBD score of 6, compared to 40, 33 and 35 pre-operatively.


To our knowledge, this is the first report of MACE combining a tapered terminal ileum conduit and an adapted TAI system. Our approach proved to be a safe and effective strategy for severe NBD avoiding a colostomy.

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Fig. 1: Description of our modified Malone antegrade continence enema procedure.
Fig. 2: Description of the method to evaluate and set a safe and effective antegrade bowel irrigation (ABI).

Data availability

The data collected and analyzed during the current study are available from the corresponding author upon reasonable request.


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We thank our physiotherapist, Tatiana Bianconi, and the staff by our Neurourology Service for their help in managing patients and finding medical records.


The authors received no funding support to undertake this study.

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Authors and Affiliations



MS supervised the study. MS and GS contributed to study conceptualization, literature search, data analysis and interpretation. MS and GS wrote the original draft. LR, AS, FS and SC were responsible for collecting data and creating figures. EM contributed to evaluating study methods and revising the paper. OC contributed to project planning, review of data analysis, data interpretation, and paper revision.

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Correspondence to Michele Spinelli.

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Spinelli, M., Sampogna, G., Rizzato, L. et al. The Malone antegrade continence enema adapting a transanal irrigation system in patients with neurogenic bowel dysfunction. Spinal Cord Ser Cases 7, 34 (2021).

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