Medline ® Abstracts for References 118,124,125
of 'Chronic functional constipation and fecal incontinence in infants and children: Treatment'
Antegrade colonic enemas and intestinal diversion are highly effective in the management of children with intractable constipation.
Christison-Lagay ER, Rodriguez L, Kurtz M, St Pierre K, Doody DP, Goldstein AM
J Pediatr Surg. 2010;45(1):213.
PURPOSE: Intractable constipation in children is an uncommon but debilitating condition. When medical therapy fails, surgery is warranted; but the optimal surgical approach has not been clearly defined. We reviewed our experience with operative management of intractable constipation to identify predictors of success and to compare outcomes after 3 surgical approaches: antegrade continence enema (ACE), enteral diversion, and primary resection.
METHODS: A retrospective review of pediatric patients undergoing ACE, diversion, or resection for intractable, idiopathic constipation from 1994 to 2007 was performed. Satisfactory outcome was defined as minimal fecal soiling and passage of stool at least every other day (ACE, resection) or functional enterostomy without abdominal distension (diversion).
RESULTS: Forty-four patients (range = 1-26 years, mean = 9 years) were included. Sixteen patients underwent ACE, 19 underwent primary diversion (5 ileostomy, 14 colostomy), and 9 had primary colonic resections. Satisfactory outcomes were achieved in 63%, 95%, and 22%, respectively. Of the 19 patients diverted, 14 had intestinal continuity reestablished at a mean of 27 months postdiversion, with all of these having a satisfactory outcome at an average follow-up of 56 months. Five patients underwent closure of the enterostomy without resection, whereas the remainder underwent resection of dysmotile colon based on preoperative colonic manometry studies. Of those undergoing ACE procedures, age younger than 12 years was a predictor of success, whereas preoperative colonic manometry was not predictive of outcome. Second manometry 1 year post-ACE showed improvement in all patients tested. On retrospective review, patient noncompliance contributed to ACE failure.
CONCLUSIONS: Antegrade continence enema and enteral diversion are very effective initial procedures in the management of intractable constipation. Greater than 90% of diverted patients have an excellent outcome after the eventual restoration of intestinal continuity. Colon resection should not be offered as initial therapy, as it is associated with nearly 80% failure rate and the frequent need for additional surgery.
Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
Surgery and constipation: when, how, yes, or no?
Levitt MA, Peña A
J Pediatr Gastroenterol Nutr. 2005;41 Suppl 1:S58.
Division of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA. firstname.lastname@example.org
Treatment of severe childhood constipation with restorative proctocolectomy.
Asipu D, Jaffray B
Arch Dis Child. 2010;95(11):867.
OBJECTIVE: To describe the clinical features of children with severe constipation and their outcome after restorative proctocolectomy.
DESIGN: Observational study and health status questionnaire using gastrointestinal quality of life score (GIQL).
SETTING: English regional paediatric surgery service.
PATIENTS: Five children were identified, with severe constipation, whose symptoms had not improved with either prolonged medical therapy or colonic lavage using an antegrade colonic enema procedure. All had required a stoma to resolve their constipation. Intervention All underwent restorative proctocolectomy.
RESULTS: All children are stooling through their anus. The mean stool frequency is 6/day. None have daytime incontinence, and none require any further therapy for constipation. Complication rates have been low with no permanent morbidity. The mean GIQL 3 years following restorative proctocolectomy was 89 (SD 29).
CONCLUSIONS: In highly selected cases, restorative proctocolectomy may allow resolution of the symptoms of severe constipation and avoid leaving a child with a permanent stoma.
Department of Paediatric Surgery, The Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne, UK.