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Antegrade continence enemas in children with functional constipation and dyssynergic defecation: Go or no go?
Maria E Knaus1, Peter L Lu2, Anan Lu3
1Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, 611 E. Livingston Ave., FB Suite 6B1, 700 Children's Drive, Columbus, OH 43205, USA.
Insights
Antegrade continence enemas (ACEs) effectively treat severe constipation and fecal incontinence in children, even those with dyssynergic defecation. Further research is needed to identify predictors of poor outcomes.
Area of Science:
- Pediatric Surgery
- Gastroenterology
- Colorectal Surgery
Background:
- Functional constipation is a common pediatric condition often refractory to medical management.
- Antegrade continence enemas (ACEs), such as the Malone appendicostomy or cecostomy, offer a surgical solution for severe cases.
- Preoperative anorectal manometry (AMAN) may provide insights into defecatory dysfunction.
Purpose of the Study:
- To evaluate the outcomes of pediatric patients with functional constipation following ACE procedures.
- To determine if preoperative anorectal manometry (AMAN) findings, specifically dyssynergic defecation, correlate with ACE outcomes.
Main Methods:
- Retrospective review of pediatric patients with functional constipation undergoing ACE (Malone appendicostomy or cecostomy).
- Inclusion criteria: availability of preoperative AMAN data; exclusion criteria: colonic resection.
- Data collected: demographics, clinical characteristics, AMAN results, and post-ACE outcomes. Descriptive statistics were used.
Main Results:
- Thirty-nine patients (median age 8.9 years) with severe constipation and/or fecal incontinence were analyzed.
- 90% of patients achieved continence with daily flushes post-ACE; 15% transitioned to laxatives alone.
- Of 15 patients with AMAN, 14 (93%) had dyssynergic defecation, and 86% of these achieved continence with ACE.
Conclusions:
- ACEs are a successful treatment for severe pediatric functional constipation and fecal incontinence, including cases with dyssynergic defecation.
- The study suggests ACEs are effective even in the presence of manometrically proven dyssynergic defecation.
- Larger studies are required to identify predictors of suboptimal outcomes after ACE procedures.
Objective:
To assess outcomes of children with functional constipation after antegrade continence enemas (ACEs) and determine if pre operative anorectal manometry (AMAN) findings, including dyssynergic defecation, are associated with outcomes.
Methods:
A retrospective review of pediatric patients with functional constipation who received a Malone appendicostomy or cecostomy after failed medical management was conducted. Patients were included if they had AMAN data prior to their operation. Patients that underwent colonic resection were excluded. Demographics, clinical characteristics, manometry results, and post ACE outcomes were obtained. Descriptive statistics were performed.
Results:
Thirty-nine patients were identified with median age at ACE of 8.9 years (IQR: 7.2-12.6) and median follow-up of 2.5 years (IQR: 1.8-3.2 years). Twenty patients (51%) were female and most (35, 92%) were White. All patients had severe constipation prior to ACE and 59% had fecal incontinence. Thirty-four patients (87%) received a Malone and 5 (13%) received a cecostomy. Post ACE, 35 (90%) were clean with daily flushes and 6 (15%) eventually successfully transitioned to laxatives only. Awake AMAN and balloon expulsion test were performed in 15 patients, with 14 (93%) displaying evidence of dyssynergic defecation. Twelve of 14 of patients (86%) with dyssynergia were clean with ACE at follow-up. because of the majority of patients being clean post ACE, there was limited power to detect predictors of poor outcomes.
Conclusions:
ACEs are successful treatment options for patients with severe constipation and fecal incontinence, including those with dyssynergic defecation. Larger studies are needed to identify factors predictive of poor outcomes.
Level Of Evidence:
III.
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