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Antegrade Continence Enemas for Pediatric Functional Constipation: A Systematic Review
Charlotte A L Jonker1, Julia M J van der Zande2, Marc A Benninga3
1Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Department of Pediatric Surgery, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Amsterdam UMC, University of Amsterdam, Pediatric Gastroenterology and Nutrition, Pediatric Surgery, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands; Amsterdam Reproduction and Development Research Institute, Amsterdam, the Netherlands.
Insights
Antegrade continence enema (ACE) surgery shows variable success and complication rates for children with functional constipation. Further research is needed for standardized ACE treatment guidelines in pediatric care.
Area of Science:
- Pediatric Surgery
- Gastroenterology
- Clinical Outcomes Research
Background:
- Functional constipation (FC) significantly impacts children's quality of life despite conservative treatments.
- Antegrade continence enema (ACE) surgery is considered for refractory pediatric FC.
- This review assesses ACE surgery outcomes in pediatric functional constipation.
Purpose of the Study:
- To systematically review the outcomes of Antegrade continence enema (ACE) surgery in children with functional constipation (FC).
Main Methods:
- Systematic review of 13 studies (477 children) published up to March 2024.
- Evaluated primary outcome: treatment success (defecation/incontinence frequency).
- Assessed secondary outcomes: ACE cessation, complications, HRQoL, and satisfaction; quality of evidence was evaluated.
Main Results:
- Treatment success rates for ACE surgery in pediatric FC varied widely (32%-100%).
- Complication rates ranged from 6% to 100%, with 0%-34% requiring surgical intervention.
- Improvements in health-related quality of life (HRQoL) and high patient/parent satisfaction were reported.
Conclusions:
- ACE surgery outcomes for pediatric functional constipation demonstrate significant variability in success and complication rates.
- There is a critical need for standardized definitions and treatment guidelines for ACE surgery in children.
- Further research should focus on establishing uniform protocols for ACE procedures in pediatric FC management.
Background:
Despite optimal conservative and medical treatment, some children with functional constipation (FC) continue to experience symptoms. Antegrade continence enema (ACE) surgery has been suggested as the primary surgical option after less invasive pharmacological and non-pharmacological interventions have not been effective. The purpose of this systematic review was to assess the outcomes of ACE for children with FC.
Methods:
Electronic databases were searched (inception-March 2024) for studies evaluating ACE surgery performed in children with FC. The primary outcome was treatment success (as defined in the original manuscript), including at least defecation frequency and/or fecal incontinence frequency. Secondary outcomes were cessation of ACE, complications, health-related quality of life (HRQoL) and patient/parent satisfaction. Quality of evidence was evaluated based on tools from the New-Ottawa Scale and Joanna Bridge Institute.
Results:
Thirteen studies were included, representing 477 children with FC treated with either an appendicostomy or a cecostomy. Reported treatment success rates varied widely, ranging from 32% to 100%. ACE treatment was stopped in 15% due to treatment success and in 8% due to treatment failure, leading to more invasive surgery. Complication rates ranged from 6% to 100%, requiring surgical intervention in 0% to 34%. An improvement in HRQoL following ACE treatment was reported in all three studies that assessed HRQoL. The two studies assessing patient/parent satisfaction, reported high satisfaction rates.
Conclusion:
Reported treatment success and complication rates following ACE surgery for children with FC vary widely. This systematic review highlights the necessity for uniform definitions and treatment guidelines for ACE surgery in children with FC.
Level Of Evidence:
III.
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