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Current Surgical Management of Pediatric Idiopathic Constipation: A Systematic Review of Published Studies
Sotirios Siminas1, Paul D Losty
1*Department of Paediatric Surgery, Royal Manchester Children's Hospital, Manchester, UK †Department of Academic Paediatric Surgery, Institute of Child Health, University of Liverpool, Liverpool, UK ‡Department of Paediatric Surgery, Alder Hey Children's Hospital NHS Foundation Trust, Eaton Road, Liverpool, UK.
Insights
Surgery for pediatric idiopathic constipation (IC) shows varied success but lacks high-quality evidence. Surgeons need improved strategies for managing this condition when bowel programs fail.
Area of Science:
- Pediatric Surgery
- Gastroenterology
- Clinical Outcomes Research
Background:
- Pediatric idiopathic constipation (IC) often requires surgical intervention after conservative bowel management fails.
- Surgical decisions for pediatric IC are guided by factors like rectal biopsy, transit studies, and anorectal manometry.
- A systematic review is needed to critically evaluate surgical outcomes for pediatric IC.
Purpose of the Study:
- To systematically review and critically evaluate the outcomes of surgical interventions for pediatric idiopathic constipation (IC).
- To assess the effectiveness and morbidity associated with different surgical procedures for pediatric IC.
Main Methods:
- A systematic literature search was conducted across MEDLINE (PubMed), Google Scholar, and EMBase for English-language articles.
- Included studies were peer-reviewed publications with a minimum of 3 patients and defined clinical outcomes.
- Data extraction focused on surgical procedures, success rates, morbidity, and follow-up duration.
Main Results:
- Forty-five reports involving 1157 patients were analyzed, with limited randomized controlled trials and small patient numbers.
- The antegrade continence enema (ACE) operation demonstrated 82% success but with significant morbidity and reoperations.
- Colon resection and pull-through operations had 79% good outcomes but 17% morbidity and 10% revisional surgery.
- Anal dilatation showed no outcome improvement; botulinum toxin and internal sphincter myectomy had similar short-term efficacy.
- Permanent colostomy was successful in 86% of refractory IC cases.
Conclusions:
- Surgical management of pediatric IC is supported by low-quality evidence, with no single operation established as "best practice."
- Current evidence suggests significant morbidity and reoperation rates across various surgical approaches.
- There is a critical need for surgeons to develop enhanced care strategies and improve treatment protocols for pediatric IC.
Objective:
Surgery for pediatric idiopathic constipation (IC) is undertaken after failure of bowel management programs. Decisions are influenced by rectal biopsy, transit studies, megacolon/megarectum, degree of soiling/incontinence, and anorectal manometry profile(s). A systematic review of ALL published studies critically evaluates outcomes of surgery for IC.
Methods:
MEDLINE (PubMed), Google Scholar, and EMBase were searched for English-language articles only. Studies included (1) peer-review publications with 3 or more patients, and (2) clinical outcomes defined by authors.
Results:
Forty-five reports (1157 patients) met full inclusion criteria. Only 2 papers were randomized controlled trials. Many had small patient numbers (median n = 16; range: 3-114). Twenty-three described heterogenous populations with variant pathology. Follow-up was short (median = 1.5 years: range: 3 months-14 years). The antegrade continence enema operation (ACE)-[open/laparoscopic assisted, cecostomy, or "left sided" ACE]-was judged as successful in 82% of cases, although high morbidity and reoperations were reported. Colon resection and pull through operations had "good" outcome(s) in 79% of children with 17% reporting significant morbidity and a 10% incidence of revisional surgery. Anal dilatation did not improve outcome(s). Botulinum toxin injection scored equally effective compared to internal sphincter myectomy in short-term follow-up. Permanent colostomy was considered successful in 86% of refractory IC cases.
Conclusions:
Surgical management and outcome(s) for pediatric IC are based on low-quality evidence. No single operation was considered "best practice." This study crucially highlights that surgeons must develop better care strategies.
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