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Colonic diversion for intractable constipation in children: colonic manometry helps guide clinical decisions
J Villarreal1, M Sood, T Zangen
1Pediatric Gastrointestinal Motility Center, Children's Hospital of Orange County, Orange, California, U.S.A.
Insights
Temporary diversion surgery improved colonic motility in children with severe constipation and dilated colons. Colonic manometry can help identify patients who may benefit from surgical interventions like resection or reanastomosis.
Area of Science:
- Pediatric Gastroenterology
- Colorectal Surgery
Background:
- Colonic manometry is crucial for differentiating functional constipation from colonic neuromuscular disease in children.
- Chronic colonic dilation can impede accurate manometric interpretation.
Purpose of the Study:
- To evaluate the efficacy of temporary diverting ostomies in improving colonic motility in children with intractable constipation and colonic dilation.
- To assess the predictive value of colonic manometry in guiding surgical interventions.
Main Methods:
- Colonic manometry was performed on 375 children; 12 with chronic dilation were selected.
- Twelve children (mean age 4 years) with ineffective medical treatment underwent diverting ostomies.
- Pathologic diagnoses included intestinal neuronal dysplasia, hypoganglionosis, and hollow visceral myopathy.
Main Results:
- After 6-30 months, 11 of 12 diverted colons were no longer dilated.
- Defecation problems resolved in 10 of 12 children post-treatment.
- Motility normalized in 4 diverted colons, leading to recommendations for reanastomosis.
Conclusions:
- Temporary diversion can improve colonic motility in select cases of intractable childhood constipation with colonic distention.
- Colonic manometry is a valuable tool for predicting surgical success in these patients.
Background:
Colonic manometry helps discriminate functional and behavioral causes for childhood constipation from colonic neuromuscular disease.
Methods:
Of 375 colonic manometries performed for clinical indications, 12 could not be interpreted because of chronic colonic dilation. Based on colonic manometries that showed either no contractions or an absence of the gastrocolonic response or an absence of high-amplitude propagating contractions, the authors recommended diverting colostomies or ileostomies in 12 chronically constipated children (mean age, 4 years; range, 2-14 years, 5 boys). Before study, medical treatment was ineffective in all children. These children had persistently dilated colons with pathologic diagnoses of intestinal neuronal dysplasia (n = 4), hypoganglionosis (n = 2), hollow visceral myopathy (n = 1), and normal (n = 5).
Results:
Six to 30 months after diversion, the authors restudied all the children. Eleven of 12 diverted colons were no longer dilated. In two patients, abnormal motility involving the entire colon was unchanged from the initial study, small bowel motility was abnormal, and we recommended no further surgery. In two cases, the colon remained abnormal but small bowel motility was normal, and we recommended subtotal colectomy and ileoproctostomy. In four cases, the left colon remained abnormal, but the right colon was normal, and we recommended reanastomosis after left hemicolectomy. In four cases, motility in the diverted colons was normal, including a gastrocolonic response and high-amplitude propagating contractions, and the authors recommended reanastomosis. Defecation problems resolved in 10 of 12 when followed up 5 to 30 months after treatment.
Conclusion:
These data suggest that in some cases of intractable childhood constipation associated with colonic distention, temporary diversion improved colonic motility. Colonic manometry may be used to predict which patients will benefit from resection or reanastomosis.
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