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The effect of multidisciplinary colorectal clinic on Malone antegrade continence enema (MACE) outcomes
Neha R. Malhotra, MD, Glen A. Lau, MD, Austen D. Slade, MD, Zachary J. Kastenberg, MD, MS, Sarah Zobell, APRN, Michael D. Rollins, MD, M. Chad Wallis, MD.
University of Utah, Salt Lake City, UT, USA.

Introduction
The Malone antegrade continence enema (MACE) allows patients to perform colonic irrigation, manage fecal incontinence and empty in a more predictable manner, improve social continence. Various technical modifications have improved outcomes and decreased complications. A critical component to success is regular follow-up and adherence to a bowel program; therefore, it has been suggested that a team approach to bowel management should be employed. We hypothesized that a multi-disciplinary colorectal clinic would improve surgical outcomes in patients with MACE.
Materials and Methods
A multi-disciplinary colorectal clinic (CRC) was implemented at our institution in 2011. This clinic, led by a general surgeon, is a collaborative effort between general surgeons, urologists, gastroenterologists and gynecologists and utilizes physicians, advanced practice providers and nurses as well as social workers and nutritionists. All patients undergoing MACE are eligible to follow in CRC, regardless of operating service. Patients undergoing MACE in the two years prior (2009, 2010) and the two years after (2011, 2012) were identified and a retrospective chart review was performed. Outcomes of patients who were followed in CRC were compared to those who did not follow in CRC (control group). Univariate analysis was performed using chi-square tests for categorical variables. A small sample size precluded multivariate analysis. Mann-Whitney test was used to analyze non-parametric variables. Statistical significance was determined by a p value of < 0.05. Statistical analysis was performed using SPSS Version 25 (IBM, Armonk, NY).
Results
59 patients were identified in the four years prior to and after initiation of CRC; 35 (59.3%) patients were followed in CRC and 24 (40.7%) were not. Patients in CRC were more likely to have phone appointments (CRC median 3, control median 0; p =<0.01), but had comparable numbers of clinic visits (CRC median 4, control median 6; p = 0.17). There was no difference in post-operative ED visits (p = 0.09), unscheduled post-operative clinic visits (p = .90), early complications (p = 0.24), late complications (p = 0.93), or reoperations (p = .60; skin level revision p = 0.97, takedown p = 0.97, re-do MACE p = 0.40) in either cohort. Patients undergoing MACE by general surgery were more likely to be seen in the CRC than urology patients (14.3% of urology MACE, 76.7% of general surgery MACE during the study period; p <0.01).
Conclusion
Our study did not show a difference in surgical outcomes with follow-up in a multidisciplinary colorectal clinic; this may have been due to limited sample size. Our results do show a significant increase in phone visits and a non-significant decrease in clinic visits. There was no difference in post-operative ED visits, patient phone calls or unscheduled visits. Further work is necessary to determine if increased phone follow-up with potentially decreased clinic visits improves patient satisfaction and decreases cost of care.


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