Purpose <p>Antegrade continence enema (ACE) appendicostomy is widely used in children with complex colorectal and neurogenic bowel conditions, yet data from resource-constrained settings remain limited. We aimed to describe the experience of a single-center pediatric cohort in a low-middle-income country (LMIC).</p> Methods <p>A retrospective review of all ACE procedures performed between 2012 and 2026 was conducted. Demographics, diagnoses, indications, complications, surgeries, and functional outcomes (assessed with Milan Bowel Function Questionnaire) were collected from clinical and operative records. Descriptive statistics were applied.</p> Results <p>Forty-five children (80% male) underwent ACE procedures, with a median age of 8.3 years. Most had appendicostomy; two required cecostomy intraoperatively. The most common diagnosis was anorectal malformation (<i>n</i> = 33, 73.3%), followed by neurogenic bowel (<i>n</i> = 7, 15.5%). Eight patients (17.7%) underwent a concomitant Mitrofanoff procedure. The main complication was skin-level stricture (<i>n</i> = 17, 37.8%), representing the only indication for surgical revision (<i>n</i> = 15, 33.3%), with a median time to revision of 5.5 months. Nearly all patients achieved clinical success, with high satisfaction reported on the questionnaire.</p> Conclusion <p>ACE appendicostomy is an effective and satisfactory option in LMICs, with outcomes comparable to high-income settings, supported by careful patient selection and ongoing quality improvement efforts.</p>