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Surgically treated intractable constipation in children evaluated with colonic manometry
Alisha Gupta1, Sonia Basson1, Osvaldo Borrelli2
1Department of Specialist Neonatal and Pediatric Surgery, Great Ormond Street Hospital, London, United Kingdom.
Insights
Surgical management for intractable constipation (IC) in children, guided by colonic manometry (CM), shows varied success rates. Procedures like antegrade colonic enema (ACE) and ostomy can improve bowel evacuation, but some patients require ongoing treatment or further surgery.
Area of Science:
- Pediatric surgery
- Gastroenterology
- Colorectal surgery
Background:
- Intractable constipation (IC) is defined as constipation unresponsive to optimal conventional treatment for at least three months.
- Colonic manometry (CM) is a recommended diagnostic tool for evaluating pediatric IC.
- Surgical intervention is considered for children with IC who do not respond to conservative measures.
Purpose of the Study:
- To review the surgical outcomes of children diagnosed with intractable constipation (IC).
- To evaluate the effectiveness of different surgical procedures, including antegrade colonic enema (ACE), colostomy, and ileostomy, in managing pediatric IC.
- To assess the role of colonic manometry (CM) in guiding surgical decisions for IC.
Main Methods:
- A retrospective review of medical records of children with IC treated surgically between 2006 and 2018.
- Surgical interventions included antegrade colonic enema (ACE), colostomy, or ileostomy.
- Success was defined as adequate bowel evacuation without the need for further unplanned surgery.
Main Results:
- Sixty-seven children underwent surgery, with 56 included based on preoperative CM.
- Success rates varied by surgical approach and colonic dysfunction pattern: ACE (75% for normal, 61% for left-sided, 60% for pancolonic), colostomy (70% for left-sided), and ileostomy (100% for left-sided, 100% for pancolonic).
- At long-term follow-up, 10 patients were off all treatment and doing well, while others remained on ACE washouts or had ostomies.
Conclusions:
- Surgical management can be effective for intractable constipation (IC) in children.
- Colonic manometry (CM) plays a crucial role in guiding the selection of appropriate surgical interventions for pediatric IC.
- A significant proportion of patients achieve adequate bowel evacuation and improved quality of life following surgical treatment.
Background:
'Intractable constipation' (IC) is constipation unresponsive to 3 months of optimal conventional treatment. Colonic manometry (CM) is recommended as a diagnostic modality for evaluation of these children. This study aimed to review outcomes of children with IC who were managed surgically at a single tertiary care center.
Methods:
Records of children with IC who were treated with ACE (antegrade colonic enema), colostomy, or ileostomy (2006-2018) were reviewed. "Success" was defined as adequate evacuation without need for further unplanned surgery. Data are median (range).
Results:
Sixty-seven children underwent surgery, of whom 56 with preoperative CM were included. Age at surgery was 8.6 (3.3-15.1) years. Eight had normal manometry and underwent ACE with 75% success. Thirty-six had left-sided dysfunction and underwent ACE (18), colostomy (14) or ileostomy (4) as initial intervention with 61, 70, and 100% success. Twelve with pancolonic dysfunction underwent ACE (6) or ileostomy (6) with 60 and 100% success. Twenty underwent repeat manometry 2.2 years (10 months-7.6 years) after surgery. Of 18 with stoma, 8 had resolution or improvement and of these, 7 underwent stoma reversal with a simultaneous ACE. Two patients with ACE had improvement, 1 is still on ACE washouts, and 1 is off all treatment. Ten with persistent dysfunction remain diverted. At 3.2 years (4 months-9.9 years) follow-up, 18 remain on ACE washouts, 9 have colostomy, 19 ileostomy, and 10 are off treatment and doing well.
Conclusion:
We present a large series of patients who were surgically managed for IC. CM may guide therapy in these children.
Type Of Study:
Retrospective comparative study LEVEL OF EVIDENCE: Level III.
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