Antegrade Continence Enema Approaches: Outcomes, Lessons Learned and Overall Burden in a Mixed Urban–Rural Population

<b>Background</b>: Antegrade continence enemas (ACEs) are administered by appendicostomy or cecostomy to manage bowel conditions. Cecostomies utilize buttons while appendicostomies utilize the appendix for colonic flushing. This study evaluates the outcomes and overall burden of these procedures in a mixed urban-rural population, highlighting unique social determinants of health (SDoH) and access factors. <b>Methods</b>: A retrospective cohort analysis of 31 pediatric patients was conducted at a tertiary academic hospital where 8 underwent a Malone-type ACE (MACE) and 23 underwent a laparoscopic cecostomy (LC) between 2014 and 2024. <b>Results</b>: Age at surgery was significantly higher in the MACE group versus the LC group (14.6 vs. 8.1 years). Patients who underwent MACE had longer hospital stays than patients who underwent LC (7.5 vs. 4.5 days, <i>p</i> = 0.014) and significantly higher 30-day readmissions (5 vs. 2, <i>p</i> = 0.001). Granulation tissue was significant in LC (82.6%) compared to MACE (13.5%, <i>p</i> = 0.001). Moreover, need for surgical revision occurred more in the MACE group (25%). Analysis of SDoH revealed that most of the cohort lived in areas with low childhood opportunity and high socioeconomic deprivation, particularly those undergoing MACE. Financially, MACE was associated with substantially higher total, direct, and indirect costs than LC, with the difference in total cost reaching statistical significance. <b>Conclusions</b>: In this setting,10-year complication rates were low. This reflects the development of a new dedicated longitudinal bowel management program in mid-Missouri. Functional outcomes at the end of the 10-year period were comparable between both cohorts with the achievement of continence. These findings support tailoring surgical approaches to patient needs.