Colorectal Quiz: Episode 43

Published: 2025-01-16

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Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

Philippa Jalus — host
Speaker 2 — host
Jeffrey Avansino — guest
Mark Levitt — guest
Jason Frischer — guest
Hira Ahmad — guest

Chapters

0:00Case Presentation: Recurrent Malone Leakage — 21-year-old male with anorectal malformation without fistula, tethered cord, underwent Malone and Mitrofanoff in 2009. Appendicostomy placed at umbilicus without initial plication. Developed leakage managed first with Deflux, then plication, then re-plication after 30-pound weight loss. After second plication, catheter could not be replaced at 4 weeks.
3:33Appendix Allocation and Plication Technique — Discussion of when to share appendix between Malone and Mitrofanoff versus using alternative conduits. Rules for appendix allocation based on length: short/stumpy for Malone only, 5-7cm insufficient to share (use for Mitrofanoff, create neo-Malone), ≥7cm can be split with 2cm minimum for Malone and 5cm for Mitrofanoff. Universal plication adopted after 50% leakage rate in non-plicated series.
10:00Plication Methods and Anatomic Considerations — Two wrapping techniques described: Nissen-type wrap through mesenteric window versus 180-degree fold-over wrap, choice dictated by mesenteric anatomy. Importance of checking catheter passage during plication and avoiding ileocecal valve obstruction. Contrast studies indicated for patients with poor flush efficacy or nausea to assess terminal ileum reflux.
15:32Complication Management: Stenosis and Prolapse — Stenosis rate 10-20%, mitigated by using 10-French tubes (not 8), leaving in place one month, and catheterizing twice daily rather than leaving indwelling tube. Indwelling tubes associated with increased prolapse from pressure on appendiceal base. IR can dilate stenosed tracts. Case patient developed kink after second plication preventing catheterization despite intraoperative passage.
19:27Access Loss and Rescue Techniques — Techniques for non-visualizable Malone access: Lone Star retractor for umbilical exposure, Foley balloon occlusion with contrast injection to identify micro-tracts, ultrasound-guided needle localization of appendiceal lumen. Appendicitis impossible in patent Malone due to lack of obstruction. Appendix preservation indicated in Crohn's, anorectal malformation, spine abnormalities, absent sacrum, spina bifida. Appendiceal tips sent to pathology; one carcinoid tumor identified in series.

Key claims

6:29The most common complication of Malone procedure is stricture occurring in 17 to 20% of patients — Philippa Jalus
5:37About 60% of the time there is success with using a split appendix for both Malone and Mitrofanoff, but about 40% of the time you cannot make it work — Jason Frischer
9:03If appendix is seven centimeters or greater it can be split, requiring two centimeters minimum for Malone and five centimeters minimum for Mitrofanoff — Jason Frischer
9:46A neo-Malone does just as well as a Malone, so if you can only use the appendix for one channel it should be the Mitrofanoff because an appendix-based Mitrofanoff does much better than a small bowel Monty — Philippa Jalus
8:35In a study of 10 Malones in a row without plicating, five leaked, leading to decision to plicate all appendicostomies — Jason Frischer
7:37Poiseuille's law governs flow of fluid through a tube based on radius to the fourth power and length; longer appendix less likely to leak — Jason Frischer
2:33Deflux is a non-surgical procedure where sterile biodegradable gel is injected into structural wall to act as valve preventing backflow — Philippa Jalus
9:03If short and stumpy appendix, best for Malone and Mitrofanoff should be made from small bowel — Jason Frischer
9:03If appendix is five to seven centimeters, not enough to share and should go for Mitrofanoff, requiring neo-Malone — Jason Frischer
13:21Small bowel volvulus around appendix has occurred in two or three cases — Mark Levitt
16:13Stenosis rate can be minimized by using 10 French tube not 8, leaving it in for a month, and catheterizing twice a day — Jason Frischer
16:54Leaving indwelling tubes increases prolapse rate due to pressure on appendiceal base pushing up mucosa — Jason Frischer
17:45Urologists almost never get stenosis of Mitrofanoff because they catheterize every four hours; catheterizing Malone twice daily has reduced stenosis rate — Jason Frischer
20:55Appendicitis in a Malone is impossible unless the hole closes, because there is no obstruction — Mark Levitt
21:26In South Africa they never take out the appendix as part of laparoscopic appendectomy for other conditions; it is a United States practice — Mark Levitt
22:05One carcinoid tumor (neuroendocrine tumor) was found in appendiceal tip sent to pathology after Malone creation — Mark Levitt
1:35Mitrofanoff is a surgical procedure creating channel from bladder to skin surface allowing patients to urinate via catheter through small opening in lower abdomen — Philippa Jalus
1:35Malone appendicostomy is a surgical procedure creating channel between abdomen and colon to treat fecal incontinence and constipation — Philippa Jalus
6:46For leaking Malone, first check if patient is cleaning themselves out with enemas; if backed up, enemas may not be effective — Jeffrey Avansino
6:46Water-soluble fiber can be tried to thicken stool so content entering right colon is thicker, then flush with enema — Jeffrey Avansino
14:44If patient not doing well with flushes or getting significant nausea, must do contrast study through Malone to check for reflux into terminal ileum — Jeffrey Avansino
21:26Appendix should not be removed in first Crohn's or anorectal malformation patient or child with spine issues, absent sacrum, or spina bifida — Mark Levitt
14:16When doing neo-Malone, try to orient catheter entry into right colon to avoid retrograde catheterization into ileum — Mark Levitt
13:51Visualizing floppy cecum with laparoscope means patient could have volvulus; should check alignment of Treitz before completing case — Philippa Jalus

Cases discussed

0:5421-year-old male with anorectal malformation without fistula, tethered cord (repaired), underwent Malone appendicostomy and Mitrofanoff in 2009. Appendicostomy placed at umbilicus without plication. Mitrofanoff used small bowel, later closed. Presented 2019 with leaking appendicostomy.

Points of disagreement

15:17Whether to pass catheter during each plication stitch versus using bougie
- Mark Levitt: Passes tube after every stitch during plication to ensure it passes in desired direction
- Jeffrey Avansino: Uses 10 French coude catheter as bougie during entire plication, then checks passage at end; usually not one offending stitch if bougie left in throughout
16:47Whether to leave indwelling tube in Malone tract
- Jason Frischer: Concerns about indwelling tubes: cannot get stenosis but increases leakage risk because valve is stented open, and bigger problem is increased prolapse rate from pressure on appendiceal base
- Philippa Jalus: Acknowledges exchange of one problem (stenosis) for another (prolapse) with indwelling tubes

Open questions

Should this 21-year-old patient be reassessed for potential continence independence from enemas given developmental normalcy and time since original surgery?
What is the optimal duration for Malone plug weaning protocol in patients with recurrent catheterization difficulty?
What is the true incidence of small bowel volvulus around Malone appendix and does cecal fixation prevent it?
Should all appendiceal tips be sent to pathology after Malone creation given rare but documented carcinoid findings?

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Written for:

The Twice-Plicated Malone: When Weight Loss Unmasks a Leaking Appendicostomy

The patient case from this episode, retold from presentation to outcome with the decisions made along the way. Written by Kai from the episode transcript and reviewed before publishing.

For the care team · Case narrative · AI-written, human-reviewed

Presentation

A 21-year-old developmentally typical male with anorectal malformation without fistula presented with a leaking Malone appendicostomy 6:29. He had undergone primary repair in 2001, tethered cord release, and in 2009 received both a Malone appendicostomy at the umbilicus and a small bowel Mitrofanoff, which was later closed. The original appendicostomy had been created without plication or an anti-reflux valve. By 2019, the channel was leaking stool around the catheter site 6:46.

The Decision Point

The initial management came from urology, who attempted Deflux injection — a biodegradable gel meant to create a valve effect at the appendiceal base 2:33. When this failed, the surgical team faced a choice: revise the tract with formal plication, attempt further injections, or accept chronic leakage managed with barrier products and frequent dressing changes.

Before operating, the team confirmed the patient was performing enemas correctly and was not impacted — backed-up stool can overwhelm any continence mechanism 6:46. They tried thickening the effluent with water-soluble fiber to reduce the liquid load entering the right colon 6:46. Neither maneuver controlled the leakage.

The decision was made to plicate the appendix. The rationale rested on Poiseuille's law: flow through a tube depends on radius to the fourth power and length 7:37. A longer, narrower channel resists retrograde flow. One of the discussants described abandoning the strategy of selective plication after five of ten consecutive unplicated Malones leaked 8:35. The team now plicates all appendicostomies.

What They Did

At the first operation, the appendix was plicated and the leakage resolved. One year later, after the patient lost 30 pounds, leakage recurred. The team returned to the operating room and re-plicated the appendix. This time, leakage stopped — but at four weeks post-op, the catheter could not be reinserted. Interventional radiology successfully placed a tube through what proved to be a 5-centimeter tract. At the second operation, the exposed appendix had been 3 to 4 centimeters; most of it was wrapped, leaving approximately one centimeter brought to the umbilicus. The tube passed intraoperatively after plication but would not pass afterward, suggesting a kink in the tract [case1].

What Happened

The patient now has a non-leaking but difficult-to-catheterize Malone. The IR-placed tube maintains access. The team is considering a third operation to address the kinked tract, with options including leaving an indwelling tube or using a Malone plug with gradual weaning [case1]. The indwelling-tube strategy carries its own risk: prolonged stenting increases prolapse rates by exerting pressure on the appendiceal base and pushing up mucosa 16:54. The alternative — frequent catheterization without an indwelling tube — reduces stenosis, a lesson borrowed from urology, where Mitrofanoff stenosis is rare because patients catheterize every four hours 17:45. Catheterizing a Malone twice daily has reduced stenosis rates in the discussants' practice 16:13.

What the Case Changes

This case illustrates three transferable judgments. First, plication is not optional. The physics of the appendiceal lumen — its radius and length — govern continence, but biology is variable enough that selective plication fails too often 8:35. Second, weight loss can unmask a marginal repair. Thirty pounds of abdominal wall change likely altered the geometry of the tract, converting a continent channel into a leaking one. Third, over-plication creates its own problem. A twice-plicated appendix with most of its length buried may be continent but unkinkable, forcing a choice between chronic stenting with prolapse risk or repeated dilation.

The discussants also noted that had this patient presented today rather than in 2009, the first question would have been whether he had any potential for volitional continence 6:29. A 21-year-old with an anorectal malformation, repaired tethered cord, and flush-dependence may benefit more from optimized medical management or a different reconstructive approach than from serial revisions of a failing appendicostomy. The Malone is a tool, not a solution, and its morbidity — 17 to 20% stricture rate 6:29, plus leakage, prolapse, and loss of access — accumulates with each revision.

If the appendix had been longer than seven centimeters, it could have been split, with two centimeters for the Malone and five for the Mitrofanoff 9:03. If it had been five to seven centimeters, the entire appendix should have gone to the Mitrofanoff, which performs better with appendiceal tissue than with small bowel, and a neo-Malone should have been fashioned from cecal flap 9:03. A neo-Malone performs as well as an appendix-based Malone, so the appendix should be allocated where it makes the most difference 9:46. In this case, the appendix went to the Malone and small bowel to the Mitrofanoff — a choice that worked until it didn't.

Takeaways from this story

Plicate all Malones — selective plication based on appendix length failed in 50% of cases in one series.
Weight loss can unmask marginal continence by altering tract geometry; consider this in patients with late leakage.
Catheterizing a Malone twice daily reduces stenosis, mirroring urology's success with frequent Mitrofanoff catheterization.
Indwelling tubes prevent stenosis but increase prolapse rates by exerting pressure on the appendiceal base.
Allocate appendix ≥7cm by splitting (2cm Malone, 5cm Mitrofanoff); if 5-7cm, use entire appendix for Mitrofanoff and create neo-Malone.

Malone Appendicostomy: Decision Trees, Physics, and Failure Modes

The episode's teaching points arranged as a structured lesson, building from the basics up to the finer points. Written by Kai from the episode transcript and reviewed before publishing.

For trainees · Teaching arc · AI-written, human-reviewed

Appendix Allocation When Two Channels Are Needed

The first decision when a patient needs both urinary and fecal continence channels is whether the appendix can serve both. The allocation follows a length-based algorithm: if the appendix is short and stumpy, use it for the Malone and construct the Mitrofanoff from small bowel 9:03. If it measures five to seven centimeters, it cannot be shared and should go to the Mitrofanoff, requiring a neo-Malone from cecal or colonic flap 9:03. At seven centimeters or greater, the appendix can be split, but only if you can guarantee two centimeters minimum for the Malone and five centimeters for the Mitrofanoff 9:03. The priority reflects outcomes: a neo-Malone performs as well as an appendiceal Malone, but an appendiceal Mitrofanoff substantially outperforms a small bowel Monty 9:46. About 60% of the time a split appendix works; 40% of the time it does not 5:37.

Why Plication Became Standard

Poiseuille's law governs fluid flow through a tube based on radius to the fourth power and length 7:37. A longer appendix provides inherent resistance to reflux, which historically led surgeons to leave long appendices unplicated. However, when one group performed ten consecutive Malones without plication, five leaked 8:35. That experience shifted practice toward universal plication regardless of appendiceal length. The law still matters for understanding *why* some unplicated channels work—but the failure rate is too high to rely on length alone.

Stenosis Prevention Through Catheterization Frequency

Urologists rarely encounter Mitrofanoff stenosis because their patients catheterize every four hours 17:45. Applying this principle to Malone management—catheterizing twice daily rather than leaving an indwelling tube—reduces stenosis rates 17:45. Use a 10-French tube, not 8-French, and leave it in place for one month initially 16:13. The tradeoff matters: leaving an indwelling tube makes stenosis physically impossible, but increases prolapse rate due to pressure on the appendiceal base pushing mucosa upward 16:54. You are choosing between complications, not eliminating them.

Diagnosing Reflux Into Terminal Ileum

When a patient is not cleaning out effectively with enemas or develops significant nausea, perform a contrast study through the Malone to assess for reflux into the terminal ileum 14:44. A competent ileocecal valve protects against this, but you cannot assume competence. When constructing a neo-Malone, orient the catheter entry to direct flow into the right colon rather than retrograde toward the ileum 14:16. This is deliberate surgical planning, not hoping for favorable anatomy.

Rescue Techniques for Lost Access

When a Malone tract becomes non-catheterizable, approaches exist beyond interventional radiology dilation. One technique uses a retractor with pins placed in the umbilicus to achieve exposure sufficient to visualize a tiny hole. Another approach occludes the umbilicus with a Foley balloon and injects contrast to pressurize the system and identify micro-tracts. Ultrasound guidance can localize the appendiceal lumen, similar to techniques for finding the appendix in appendicitis cases. Blind puncture risks entering the sidewall of the thin appendix rather than the lumen.

Appendix Preservation in At-Risk Populations

Do not remove the appendix during laparoscopic procedures in patients with Crohn's disease, anorectal malformation, spine abnormalities, absent sacrum, or spina bifida 21:26. These populations may require a Malone or Mitrofanoff in the future, and preserving the appendix maintains reconstructive options. Routine appendectomy during laparoscopy for other indications is United States practice, not universal—it is not performed in South Africa 21:26. One carcinoid tumor was identified in an appendiceal tip sent to pathology after Malone creation 22:05, supporting the practice of sending the tissue even when the indication is not appendicitis.

The Impossibility of Appendicitis in a Patent Malone

Appendicitis cannot occur in a functioning Malone because there is no obstruction 20:55. The pathophysiology requires a closed lumen. If the Malone tract closes, then appendicitis becomes theoretically possible, but the patent channel itself prevents it. This is worth explaining to families and to consulting services who may not understand why a patient with right lower quadrant pain and a Malone does not have appendicitis.

Takeaways from this story

Appendix ≥7cm can be split (2cm for Malone, 5cm for Mitrofanoff); shorter appendix goes to Mitrofanoff since neo-Malone equals appendiceal Malone
Catheterizing Malone twice daily (like urologists do with Mitrofanoff q4h) reduces stenosis; indwelling tubes prevent stenosis but increase prolapse
Universal plication became standard after 5 of 10 unplicated Malones leaked, despite Poiseuille's law suggesting long appendices resist reflux
Contrast study through Malone is mandatory when enemas fail or patient develops nausea—check for reflux into terminal ileum
Preserve appendix in Crohn's, ARM, spina bifida, absent sacrum patients—they may need future Malone or Mitrofanoff reconstruction

Plication Technique and Indwelling Tubes: Two Unresolved Questions in Malone Management

The points where the speakers disagreed, with each position presented side by side. Written by Kai from the episode transcript and reviewed before publishing.

For specialists · Points of disagreement · AI-written, human-reviewed

The Plication Technique Question

When plicating an appendicostomy to create a continence valve, surgeons face a technical choice: how do you confirm the catheter will pass correctly through the narrowed lumen you're creating? One discussant passes a tube after every single stitch during the plication to ensure it passes in the desired direction 6:29. The rationale is straightforward — each throw changes the geometry, and you want to know immediately if you've compromised the tract 6:29.

Another discussant uses a 10 French coudé catheter as a bougie during the entire plication, leaving it in place while throwing and tying all the sutures, then checks passage at the end 5:37. The reasoning: if the bougie remains in place throughout, it's usually not one offending stitch that causes the problem — the whole tract is being shaped around a known diameter 5:37. Both acknowledge that what works on the operating table may not predict how the tissue will lie when intracorporeal 6:29.

Neither approach has been shown superior 6:29 5:37. The disagreement reflects different mental models of the problem: is stenosis usually focal (suggesting the check-each-stitch approach) or diffuse (favouring the continuous bougie method)? The discussants did not propose what evidence would resolve this.

The Indwelling Tube Question

The second disagreement concerns whether to leave an indwelling tube in the Malone tract after creation. The stenosis rate for Malone procedures runs 17 to 20% 6:29, and one approach to reducing this is to leave a G-tube device (now available in 10 French) stenting the channel for months 16:13. The logic is mechanical: you cannot develop stenosis across a stented tract — it is physically impossible 16:54.

But one discussant raises two concerns about this strategy 16:54. First, stenting the tract open means the valve you created is no longer functioning — you have a tube across it, increasing leakage risk 16:54. Second, and more problematic in his experience, leaving tubes in increases the prolapse rate, likely from pressure on the appendiceal base pushing up mucosa 16:54. Another discussant acknowledges this explicitly: you are exchanging one problem (stenosis) for another (prolapse) 17:45.

The counterargument comes from urologic experience 17:45. Urologists almost never see stenosis of a Mitrofanoff because their patients catheterize every four hours 17:45. Applying this principle to Malone management — catheterizing the tract twice daily rather than leaving an indwelling tube — has reduced the stenosis rate 17:45. This suggests frequent catheterization achieves the anti-stenosis benefit without the continuous stenting that promotes prolapse 17:45.

The discussants agree on the mechanism: frequent passage of a catheter prevents stenosis 17:45. They disagree on whether continuous stenting is worth the trade-off 16:54 17:45. The stenosis rate can be minimized by using a 10 French tube rather than 8, leaving it in for a month, and catheterizing twice daily 16:13. But whether this minimizes the rate enough to justify accepting the prolapse risk remains unresolved 16:54 17:45.

What They Agree On

Both technical questions exist within a shared framework 6:29 5:37 8:35 16:13. All discussants plicate appendicostomies — the era of relying on appendiceal length alone ended after a study of 10 consecutive unplicated Malones showed five leaked 8:35. All use 10 French tubes rather than 8 16:13. All recognize that the goal is a continent valve that remains catheterizable, and that achieving both simultaneously is harder than achieving either alone 6:29 16:54.

They also agree that patient factors matter more than technique details 5:37 9:03 9:46 9:03 9:03. The quality of the appendix determines whether it can be split for both Malone and Mitrofanoff (successful about 60% of the time 5:37), and the length determines the allocation: seven centimeters or greater can be split (requiring two centimeters minimum for Malone and five centimeters minimum for Mitrofanoff 9:03), five to seven centimeters should go to the Mitrofanoff with a neo-Malone created 9:03, and short stumpy appendices are best for Malone with a small bowel Mitrofanoff 9:03. These allocation rules reflect the evidence that a neo-Malone performs as well as an appendiceal Malone, but an appendix-based Mitrofanoff performs much better than a small bowel Monty 9:46.

What Would Resolve It

The discussants did not specify what evidence would settle either question. For the plication technique, a video review comparing catheter passage at one year between the two methods would be straightforward 6:29 5:37. For the indwelling tube question, the relevant outcome is the balance of stenosis, leakage, and prolapse rates 16:54 17:45 — but the optimal follow-up duration and the acceptable trade-off between complications are both unclear. The prolapse observation is recent enough that it may not appear in older series favouring indwelling tubes 16:54.

Takeaways from this story

Checking catheter passage after every plication stitch versus using a continuous bougie remain both defensible; neither has proven superior
Indwelling tubes prevent stenosis but increase prolapse rate from pressure on appendiceal base; twice-daily catheterization may achieve stenosis reduction without this trade-off
All appendicostomies should be plicated after study showed 50% leak rate in 10 consecutive unplicated cases
Appendix allocation follows length rules: ≥7cm can split (2cm Malone, 5cm Mitrofanoff), 5-7cm goes to Mitrofanoff with neo-Malone, <5cm goes to Malone with small bowel Mitrofanoff

Topic overview

A technical discussion of Malone appendicostomy procedures for fecal management, centered on a 21-year-old male with anorectal malformation and tethered cord who developed recurrent leakage after initial appendicostomy placement. The panel addresses surgical technique variations including plication methods, appendix-sharing strategies when both Malone and Mitrofanoff channels are needed, and troubleshooting common complications: leakage (17-20% incidence), stenosis (17-20%), prolapse, and loss of catheterizable access. Key technical principles include universal plication to prevent reflux, minimum channel lengths (2cm for Malone, 5cm for Mitrofanoff when splitting appendix), and catheterization frequency to maintain tract patency.

Key takeaways

Universal plication prevents leakage: 50% leak rate without plication vs. reduced rates with routine plication of all appendicostomies. (8:35)
Appendix ≥7cm can be split (2cm Malone, 5cm Mitrofanoff); 5-7cm use for Mitrofanoff only; <5cm requires neo-Malone from small bowel. (9:03)
Stenosis minimized by 10Fr tube (not 8Fr), leaving in 1 month, and catheterizing twice daily—mimicking urologists' q4h Mitrofanoff care. (16:13)
Leaking Malone workup: confirm enema compliance, trial water-soluble fiber to thicken stool, then contrast study to rule out ileal reflux. (6:46)
Preserve appendix in Crohn's, anorectal malformation, and spine/sacral anomaly patients—future Malone or Mitrofanoff may be needed. (21:26)

Keywords

anorectal malformation anus without fistula tethered cord fecal incontinence constipation Down syndrome Crohn's disease spina bifida carcinoid tumor neuroendocrine tumor appendicitis colonic dysmotility functional constipation Malone appendicostomy Mitrofanoff procedure

Hashtags

#ColorectalSurgery #MaloneProcedure #PediatricSurgery #BowelManagement

Transcript

Click "Show Transcript" to view the full text (20823 characters)

Welcome to another episode of the Colorectal Quiz. I am Philippa Jalus, Colorectal Research Fellow at Children's National Hospital, and today we'll be discussing the Malone procedure. Make sure you download the sticker and app to follow along with images and other related cases. Welcome back everyone to another episode of the Colorectal Quizzes. You may have thought we were hibernating, but no, we were just working. But we're back with some special guests and very excited to hear a nice case. I'm so excited to hear today's cases. We are joined as always by Dr. Jason Frischer and Mark Leavitt. Today, our guests are Dr. Jeffrey Avanzino from Seattle Children's Hospital and his fellow Dr. Hira Ahmad. Let's dive right in. So today we're going to talk a little bit about Malone appendicostomies and some of the challenges that they present to us. And so I'll start off with a case of a 21-year-old male who had a history of anus without fistula. He does not have a history Down syndrome. He's developmentally typical. He had a repair back in 2001. He also has a history of a tethered cord that was repaired. And he subsequently underwent a Malone appendicostomy as well as Mitrofinov in 2009. For our listeners, a Mitrofinov procedure or appendicovisicostomy is a surgical procedure that creates a channel from the bladder to the skin surface, allowing the patients to urinate via catheter through a small opening in their lower abdomen. Whereas a Malone appendicostomy is a surgical procedure that creates a channel between the abdomen and colon to treat fecal incontinence and constipation. These patients, Mitrofinov utilized a small bowel and was later closed prior to presenting to Dr. Avanzino's office in 2019 when his appendicostomy started leaking. He had been managed by urology up until that point. And this appendicostomy, just for orientation sake, was placed in the embolicus. And so this was leaking and urology at the time was actually doing deflux on these appendicostomies. And the original appendicostomy that was placed actually did not have a plication or a valve to prevent reflux. The flux is a non-surgical procedure where a sterile biodegradable gel is injected into the structural wall, allowing fluid to flow in, but acting as a valve to prevent black flow. So despite their initial efforts, the patient came back and one of my partners took the patient and did a plication, which actually took care of the leakage. And however, a year later, the patient came back after a weight loss of 30 pounds and was leaking again. So we took the patient back and replicated the appendix. And now the leakage has gone away. But when we took the catheter out at four weeks, we couldn't replace it. And so now the patient had to go back to IR, which they're able to place a five centimeter channel length AMT button or replace a tube, excuse me, into the appendicostomy. If I can just interject for one second. So this is the, this is the Malone saga. I'm just curious. This patient is now 21. And I would venture to say that your management of this patient has changed very dramatically had he presented today. Can you elaborate Dr. Levitt? It's very important to know the type of malformation, the quality of the sacrum, and the quality of the spine and give the patient's family some estimate of the likelihood that they will or not be continent. And I think in a 21 year old who underwent a Malone, well, they went underwent a Malone in 2009. So that's 10 years ago. I probably would take a moment to say, Hey, does this patient have any potential for continence? I see. So you'd want to know if the Malone is really needed before you try to fix a leaky one. So do you have any insight into, into that? Is this a Malone for life patient or is this a patient with some potential? Yeah. I mean, this, this particular patient, they are flush dependent. Again, this patient had a tethered cord and is reliant upon enemas to stay clean. It's good to potentially reassess if they can be independent of enemas. Let's step back to this patient's original procedure. 10 years ago, urology did both the ACE and the Mitrofenov. Nowadays and at your institutions, this would be done as a joint case or at minimum plan together. There might be some sharing of, of the plan and potentially sharing of tissue. So you had mentioned that the, um, um, the Monty was made by, from small bowel. It's important to recognize that some appendixes, and we did handle this topic also on another podcast are shareable and some can go from Malone and some can go for the Mitrofenov. In this case, you got the whole appendix for the Malone and the Mitrofenov was done with a small bowel segment. Dr. Frischer, what are your thoughts on this original plan of no plication? First and foremost, what Mark is alluding to is the, the shared appendix, which is the best case scenario when a patient needs both a channel to drain the bladder and a channel to give themselves a antigrade content enema. Utilizing a shared appendix has been well studied. About 60% of the time, there is success with using a split appendix. However, about 40% of the time, you just can't make it work. But just know you need to go into that operation having multiple outs and your outs are basically two, right? You could do a Monty Mitrofenov using small bowel to make that conduit, or you could do a Neo Malone and use it, a sequel or right colon flap to make a channel. It's important to remember that a Malone procedure, regardless of approach, does have morbidity associated with it. The most common complication is stricture occurring in 17 to 20% of patients. Less commonly, patients can experience leakage, like our case study today. The first thing you need to know is if they are cleaning themselves out. If they're not doing their enemas or they're backed up and the enemas are not effective. So that was one thing that we did. Another thing you can try doing too is thickening them up a little bit so that whatever's coming into the right colon is a little bit thicker. And so you could use some, you could try some water-soluble fiber to see if that helps and then flush that out with the enema. Neither of those maneuvers were successful with this individual. So that's why we did the original plication and redo plication. The original management of the leakage though was by a urologist who was using the deflux procedure. This was common management for reflux through the ureter and in the late 2000s was extrapolated to mitrafenovs as well. It comes down to Pusselli's law, right? Pusselli's law is the flow of fluid through a tube and it's based on the radius to the fourth power and length. So if you take your appendix and you have a narrow appendix or a long appendix, the odds of that flow of fluid getting all the way to the end is based on those two factors. And so a longer appendix, sometimes you didn't plicate on those patients. I mean, I have to say, I'm sort of speechless that we're talking about physics with Jason Frischer. Frankly, what I learned from physics, you got to write it out every single step, prove to yourself that you can do it. And I think that's very appropriate for surgeons who are training. You've got to put yourself in the position. You got to say, can I do this by myself? Would I need help? And you got to get to that point. So I learned that life lesson the hard way in physics. So the longer the appendix, the less likely it will leak and you shouldn't need to plicate. However, Dr. Frischer and Levitt did their own study where they did 10 malones in a row without plicating and five leaked. So then we decided they're all getting plicated. So we plicate them all. And I haven't had a leakage in a long, long time, several years. So I think it's a very effective strategy. But how do you decide which appendix can be split? So basically we came up with these rules, which really seem to work. If you have a short and stumpy appendix, that appendix is best for the malone and the metrophonov ought to be made from small bowel. If you have a five to seven centimeter appendix, that's not enough to share. And that ought to go for the metrophonov because long term, the metrophonovs do much better. So therefore you need to make a neo malone. And then if the appendix is seven centimeters or greater, then it can be split. And in my opinion, you really need two centimeters minimum for the malone and you need five centimeters minimum for the metrophonov. Dr. Frischer's research has shown that a neo malone does just as well as a malone. So if you can only use the appendix for one channel, it should be the metrophonov because an appendix-based metrophonov does much better than a small bowel monty. I have a fourth version of that diagram where you're in that five to seven or even four to seven centimeter range where I give 90% of the appendix to the urologist. And then I do a sort of extension of the appendiceal stump into the cecum, lengthening that channel by either using a non-cutting, non-pin endo TA stapler or by hand sewing it with non-absorbable braided suture. Are there any other questions, tips or tricks you would like to share before we move on to the next part of this case? Jeff is how do you wrap? Because I've watched my own partners wrap two different ways. Sometimes that's dictated by blood supply and sometimes it's dictated just by the surgeon, but there's the Nissen type wrap where you could go make a window in the mesentery and bring a piece of cecum all the way around wrapping. Or there's just the sort of fold over the appendix 180 wrap from both ends to sort of cover the appendix. And so any thoughts on that technique? I kind of base that on what the mesentery looks like. You know, if it's a kind of a broader base mesentery and you lay the appendix down, that's when I'll kind of make the window and do the wrap through the mesentery versus sometimes the mesentery is very adherent. Like kind of that one vessel and it's not a broad-based mesentery and then those you can kind of lay down and wrap the cecum around it. The situation where the appendiceal mesentery parallels the appendix, you can basically just wrap the cecum around the appendix like a fundoplication. A more typical situation where the mesentery is fenestrated and then you ought to go make a window, I usually make one window at the very bottom and then plicate through that window. Otherwise you crunch up the mesentery. So then the other thing to consider is if you're doing a fundoplication wrap, you got to see which direction you want to lay your appendix. That's a huge little pearl, Mark, because I have seen obstruction at the ileocecal valve because of the creation of a Malone. So paying attention to the ileocecal location in reference to how you make your Malone and the plication is important. Another technique is to imbricate or push the appendix in and pull the cecum up around the appendix. Then suture between the appendix and the cecum. It's not commonly used, but it's another option. As Dr. Levitt said, it's important to know all the possible options before going into the case. Just maybe one other thought, especially as we maybe historically have left these longer appendices without a plication. How often have you seen patients present with spalduos around the appendix? And if so, what have we done over time to mitigate for that? So I have only seen it once confirmed, but I think it's pretty rare. I personally have seen it. And so I think it happened, but we used to tack the cecum underneath the fascia to fixate it. I don't tack the cecum anymore, but I definitely make the appendix just what I need it to be so that the cecum is underneath the umbilicus. I don't leave a long stemmed appendix hanging. I have seen small bowel volvulize around the appendix, no question, but it's only been two or three cases. It's also important to recognize that visualizing a floppy cecum with the laparoscope does not just mean it may be an easy malone. It also means that this patient could have a volvulus and we should be checking the alignment of trites before completing the case. Is there anything about how you position the appendix to try to think about how you could avoid retrograde catheterization or reflux into the ilium? A very interesting question, Sir Avincino. The answer is no. I usually just do the plication the way it looks good. And I hope for a competent iliosecal valve. When I do a neomalone, I try very hard to orient in such a way that the catheter is going to enter into the right colon. That brings us back to the primary topic of this discussion, troubleshooting malones. What are some diagnostic tests that you couldn't do prior to surgery? And what about during surgery to make sure you aren't refluxing into the TI? If you have a patient that's not doing well and the flushes are not working, or if they're getting significant symptoms like nausea in particular, you have to do a contrast study through your malone and check and see if there's reflux into the terminal ilium because your malone is ineffective. Every time I do a plication and every stitch I throw and tie down, I always pass the tube to make sure it passes in the direction I want it to do. But again, that's not how the body's going to, how it's going to lie when it's intracorporeal and you can get in trouble. I love that you mentioned that because when we did the replication on the patient I presented, I passed the tube and it went just fine. I actually don't pass the catheter each time, but we use a 10 French coup d'et as a bougie and then I do the plication around that and then of course I check to make sure it casts and that usually works. It's usually not one offending stitch if you've left the bougie in for the whole time. The good news is that most patients don't have any problems post-procedure. Only 10 to 20% will actually have issues with their malone. What about developing stenosis? Is there any way to mitigate that? I think actually that the stenosis rate can be minimized. A couple of things that we've done over the years is we use a 10 French tube, not eight. We leave it in for a month. We cath it twice a day. Many like to have an indwelling tube. So we use a G-tube device, but now they make them in 10 French. And I think if that stents the channel for many months, I do believe that our incidence of stenosis has gone down because of that. If the canal is stenosed, interventional radiology can dilate the tract and place a tube to stand it open for months if needed. I do have concerns about the tubes we leave in. And I could tell you, yes, you can't get a stenosis if you leave a tube in. That's physically impossible. But you're stenting that tract open. So there's a chance of leakage, right? Your valve no longer is as pertinent because you have a stent across the valve. That's one. Two, the bigger problem I've seen is when it's leaving tubes in, our amount of prolapse has increased. And I think there's a pressure on the appendiceal base pushing up mucosa and the prolapse rate has increased. So the common problems with Malone's are leakage, reflux, stenosis, and now prolapse. But it sounds like prolapse is most likely secondary to prolonged stenting. What can we learn from our urology colleagues? I think you're right. That's the etiology. But you are exchanging one problem for another. Interestingly, we learned a lot from our urologists on a regular basis. They almost never get a stenosis of their metrophenol. Why? They cath it every four hours. So what we did is we started cathing the Malone tract. If you are a catheter twice a day, and that has reduced the stenosis rate. Thank you. That's great insight. Let's get back to our case. You've wrapped your appendix twice, and currently there is no leakage. But what if it does leak again? One thing I would consider, especially after two wraps, is how long is that appendix, right? Because is that a problem? And do we need to lengthen the channel to help with the leak? Yeah. And that's what we did on the second. The exposed appendix, when we went backwards, was probably about three to four centimeters. And we wrapped most of that up. So actually, the exposed appendix was probably a centimeter that we brought up to the umbilicus. Again, when we were both doing the plication, and then after the plication was done, we repassed the tube. And now we can't pass it. So you could see like a bend in the tract that is likely the point of obstruction. We're likely going to take that patient back and try to see where it's kinked. So for this patient, you could leave an indwelling tube. However, he wants to be able to catheterize his malone. What else can we do for this young man? Then he needs a malone plug for a few months and then start, you know, basically keeping the malone plug out for a shorter and shorter time each day. And sort of like taper the time that the tract is allowed to live alone. Another potential problem is that you can't visualize the malone access. How would you troubleshoot that? I took a Lone Star ring and Lone Star pins, and I put them in the umbilicus to get incredible exposure to the umbilicus. And then we saw the hole. And then we got a catheter in the tiny little hole. So it's not so easy to blind puncture a malone tract, but you have a very thin appendix underneath it. And it's pretty easy to go into the sidewall. So myself and some of the interventional radiologists here have become very skilled at this and maybe a few tricks to share as well. One, probably many of them do this, where we blow up a balloon on a Foley catheter, occlude the umbilicus, and inject dye to see if there's a little pinhole tract that you could find. Because you're now not allowing that contrast to leak out of the umbilicus. And you get a pressurized system in and inject dye, and it'll find any micro hole that's still there. That's really interesting. Isn't there a way to use ultrasound as well? You use ultrasound, just like you'd find an appendix. We know where it's going to be, around the umbilicus. And then we needle, localize the lumen of the appendix, ultrasound guided, and we've rescued a few malones that way as well. That's a really neat technique. I bet the patients are grateful when you've reestablished access. Hira, do you have any questions for our experts today? Have you ever seen appendicitis in a malone? It's impossible. Well, unless the hole closes. Unless the hole closes. Great question. We get asked this all the time. In pathophysiology, there's no obstruction. You can't get an obstructed appendix. Now, I have once gone in to do a malone, and the patient had appendicitis. So we aborted the procedure, treated the patient medically, and three months later went in and did a malone. The appendix is pretty important to save in patients who may need a malone or mitrafenov in the future. Which patients are you less likely to remove the appendix during your lads or appendicitis? We do not take out the appendix in a first crones or ARM patient or a kid with spine issues. Or an absent sacrum. There's a whole bunch of spina bifida. No one is obligating you to take out the appendix. And I will tell you, in South Africa, they never take out the appendix as part of a lads. It's just not done. It's a United States thing. It's important to know the basics of pediatric surgery, the patient's anatomy, and potential needs in the future. Hira, did you have any other question? When you do a malone, do you always send your appendix to pathology? Oh, another good question. I do. It's thanks to our pathologists that insisted. I asked them if we need to send the tip of the appendix, and they insisted. And guess what? Three months later, one of them had a carcinoid. A neuroendocrine tumor. I just saw the patient today from doing an appendectomy, but it's volatile tissue that can carry this tumor. So I think you have to send it to make sure there's no tumor there. This was such a great discussion. In summary, malones are great for patients who need a mechanical assistance with their bowel clearing, such as those with continence issues who can't take medication, for functional constipation patients with colonic dysmotility, ARM patients who have no potential for continence, and spina bifida patients who may also need a mitrofenov. We were able to review some key technical points and how to manage key complications when they arise. Thank you all for joining us for this episode of the Colorectal Quiz, and remember to download the Stay Current app from the Apple App Store or the Google Play Store to check out the images and algorithms we discussed in this episode. Additionally, remember to follow us on social media and check out our YouTube channel for more pediatric surgery content.

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