The Malone antegrade continence enema for treating adult constipation and fecal incontinence: a systematic review of the literature

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 a permanent colostomy.