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Can botulinum toxin help in managing children with functional constipation and obstructed defecation?
Ahmed B Radwan1, Mohamed A Gadallah1, Mohammed R Shahawy2
1Pediatric Surgery Department, Faculty of Medicine, Ain-Shams University, Cairo, Egypt.
Insights
Botulinum toxin injections did not significantly improve defecatory function in children with functional constipation and obstructed defecation when added to standard bowel management programs. Standard care alone yielded similar Rintala scores, indicating no added benefit from the toxin.
Area of Science:
- Pediatric Gastroenterology
- Colorectal Surgery
- Functional Bowel Disorders
Background:
- Functional constipation (FC) and obstructed defecation syndrome (ODS) are prevalent pediatric conditions.
- ODS involves impaired coordination of pelvic floor muscles during bowel movements.
- Botulinum toxin (BT) intraanal injections aim to relax the anal sphincter to aid defecation.
Purpose of the Study:
- To compare the efficacy of BT injections plus bowel management program (BMP) and senna-based laxatives (SBL) versus BMP and SBL alone in pediatric FC and ODS patients.
- To assess changes in Rintala scores as a measure of defecatory function.
Main Methods:
- A prospective randomized controlled study involving 40 pediatric patients with FC and ODS.
- Group A received BMP and SBL; Group B received BMP, SBL, and a single intraanal sphincteric BT injection.
- Rintala scores were evaluated pre-treatment, at 2 months, and 6 months post-management.
Main Results:
- No statistically significant difference in mean Rintala scores was observed between the two groups at any follow-up point (p > 0.05).
- Both groups showed similar improvements in defecatory function as measured by the Rintala score.
- No complications were reported following BT injections.
Conclusions:
- Intraanal sphincteric BT injection, using the specified technique and dose, did not provide additional improvement in defecatory function compared to BMP and SBL alone for pediatric FC with ODS.
- The findings suggest that standard bowel management protocols are sufficient for managing these conditions.
Background:
Functional constipation (FC) is a common pediatric healthcare problem worldwide. Obstructed defection syndrome (ODS) is frequently presented with an inability to coordinate the bowel movement with pelvic floor muscles. Botulinum toxin (BT) intraanal sphincteric injection can improve the obstructed defecation by relaxing the anal sphincter and reducing the required force to propel the stools.
Purpose:
This study aimed to compare the changes in Rintala scores (as a mean of assessing defecatory function), in children with FC and ODS, managed by BT injection, bowel management program (BMP), and senna based laxatives (SBL), versus a control group managed by BMP and SBL only.
Methods:
Prospective randomized controlled study, started at December 2017 on 40 pediatric patients, divided into 2 equal groups (group A: managed by BMP and SBL, group B: like group A with once intraanal sphincteric BT injection) suffering from FC, ODS, with contrast enema showing persistence of ≤90 rectoanal angle (RAA) even with trials of defecation. Patients were excluded if they have neuromuscular abnormalities, hypothyroidism, previous colorectal or anal surgery. Rintala score was assessed before treatment, at 2 months, and 6 months after management.
Results:
The study included 18 females (45%) and 22 males (55%). Group A had equal gender distribution and mean age of 6.9 years, while group B had 12 males with mean age of 7.35 years. The mean follow up period was 11.35 months in group A and 11.6 months in group B. Mean Rintala scores of both groups at initial presentation, 2 months and 6 months follow up were: group A: 9.10, 9.40, 10.90; group B: 9.30, 10.70, 11.05 respectively, and showed no statistically significant difference (p value: 0.884, 0.294, 0.923 respectively). No complications were detected from BT injection like allergic reactions, neuromuscular urinary or lower limbs disturbances.
Conclusion:
Intraanal sphincteric injection of botulinum toxin by the mentioned technique and dose, did not result in additional defecatory functional improvement (when assessed by Rintala score) over the routine protocol (using bowel management program and laxatives) of managing functional constipation with obstructed defecation. ANNOUNCEMENT: a preliminary report of this work was presented in the 34th Egyptian pediatric surgery association (EPSA) meeting in Cairo in November 2019.
Type Of Study:
Treatment/prospective study.
Level Of Evidence:
Level I.
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