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Homan M, Thomson M, Bontems P, Saccomani MD, Dias JA, Faraci S, Furlano R, Hojsak I, Ledder O, Slae M, Narula P, Nita AF, Norsa L, Oliva S, Papadopoulou A, Romano C, Rybak A, Spyropoulou V, Tambucci R, Tzivinikos C, van Wijk M, Borrelli O. Drugs in focus: Botulinum toxin in the therapy of gastrointestinal disorders in children. J Pediatr Gastroenterol Nutr 2024. [PMID: 39315663 DOI: 10.1002/jpn3.12376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Revised: 08/10/2024] [Accepted: 09/05/2024] [Indexed: 09/25/2024]
Abstract
What is Known
Botulinum toxin (BoNT) causes muscle relaxation by inhibiting acetylcholine release from presynaptic motor neurons at the neuromuscular junction.What is New
In children with achalasia, BoNT can be considered only in patients in whom rapid weight gain is important to improve surgical outcomes.
BoNT has been suggested for treating cricopharyngeal achalasia and delayed gastric emptying.
Anal achalasia and constipation after Hirschsprung disease corrective surgery are very promising indications for BoNT use.
In selected children with resistant type of functional constipation and chronic anal fissure, BoNT is a viable option for treating.
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Affiliation(s)
- Matjaž Homan
- Department of Gastroenterology, Hepatology, and Nutrition, University Children's Hospital, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Mike Thomson
- Department of Paediatric Gastroenterology, Sheffield Children's Hospital NHS FT and University of Sheffield, Sheffield, UK
| | - Patrick Bontems
- Paediatric Gastroenterology, Hôpital Universitaire des Enfants Reine Fabiola, Université Libre de Bruxelles, Brussels, Belgium
| | | | - Jorge Amil Dias
- Department of Gastroenterology, Hospital Lusíadas, Porto, Portugal
| | - Simona Faraci
- Gastroenterology and Nutrition Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Raoul Furlano
- Department of Gastroenterology, University Children's Hospital Basel (UKBB), University of Basel, Basel, Switzerland
| | - Iva Hojsak
- Children's Hospital Zagreb, University of Zagreb Medical School, Zagreb, Croatia
| | - Oren Ledder
- Juliet Keidan Institute of Pediatric Gastroenterology, Shaare Zedek Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Mordechai Slae
- Pediatric Gastroenterology, Hepatology and Nutrition Unit, Hadassah University Hospital, Jerusalem, Israel
| | - Priya Narula
- Department of Paediatric Gastroenterology, Sheffield Children's Hospital NHS FT and University of Sheffield, Sheffield, UK
| | - Andreia Florina Nita
- Paediatric Gastroenterology Department, Great Ormond Street Hospital, London, UK
| | - Lorenzo Norsa
- Pediatric Department, Children's Hospital Vittore Buzzi, University of Milan, Milan, Italy
| | - Salvatore Oliva
- Pediatrci Gastroenterology and Liver Unit, Maternal and Child Health Department, Sapienza-University of Rome, Rome, Italy
| | - Alexandra Papadopoulou
- Division of Gastroenterology and Hepatology, First Department of Pediatrics, University of Athens, Children's Hospital Agia Sofia, Athens, Greece
| | - Claudio Romano
- Claudio Romano Pediatric Gastroenterology and Cystic Fibrosis Unit, University of Messina, Messina, Italy
| | - Anna Rybak
- Paediatric Gastroenterology Department, Great Ormond Street Hospital, London, UK
| | - Vasiliki Spyropoulou
- Division of Gastroenterology, Hepatology and Nutrition, University Children's Hospital Zurich, Zurich, Switzerland
| | - Renato Tambucci
- Gastroenterology and Nutrition Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Christos Tzivinikos
- Pediatric Gastroenterology Department, Al Jalila Children's Specialty Hospital, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai, United Arab Emirates
| | - Michiel van Wijk
- Emma Children's Hospital-Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Osvaldo Borrelli
- Paediatric Gastroenterology Department, Great Ormond Street Hospital, London, UK
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van der Zande JMJ, Koppen IJN, Yacob D, Sanchez RE, Puri NB, Vaz K, Di Lorenzo C, Benninga MA, Lu PL. Current practice in the care of children with functional constipation: What is the hold up? J Pediatr Gastroenterol Nutr 2024; 79:301-308. [PMID: 38924156 DOI: 10.1002/jpn3.12295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 04/22/2024] [Accepted: 06/05/2024] [Indexed: 06/28/2024]
Abstract
OBJECTIVES For children with intractable functional constipation (FC), there are no evidence-based guidelines for subsequent evaluation and treatment. Our objective was to assess the practice patterns of a large, international cohort of pediatric gastroenterologists. METHODS We administered a survey to physicians who attended the 2nd World Congress of Pediatric Neurogastroenterology and Motility held in Columbus, Ohio (USA) in September 2023. The survey included 29 questions on diagnostic testing, nonpharmacological and pharmacological treatment, and surgical options for children with intractable FC. RESULTS Ninety physicians from 18 countries completed the survey. For children with intractable FC, anorectal manometry was the most commonly used diagnostic test. North American responders were more likely than Europeans to use stimulant laxatives (97% vs. 77%, p = 0.032), prosecretory medications (69% vs. 8%, p < 0.001), and antegrade continence enemas (ACE; 83% vs. 46%, p = 0.009) for management. Europeans were more likely than North Americans to require colonic transit testing before surgery (85% vs. 30%, p < 0.001). We found major differences in management practices between Americans and the rest of the world, including use of prosecretory drugs (73% vs. 7%, p < 0.001), anal botulinum toxin injections (81% vs. 58%, p = 0.018), ACE (81% vs. 58% p = 0.018), diverting ileostomies (56% vs. 26%, p = 0.006), and colonic resections (42% vs. 16%, p = 0.012). No differences were found when respondents were compared by years of experience. CONCLUSIONS Practice patterns in the evaluation and treatment of children with intractable FC differ widely among pediatric gastroenterologists from around the world. A clinical guideline regarding diagnostic testing and surgical decision-making is needed.
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Affiliation(s)
- Julia M J van der Zande
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Ilan J N Koppen
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Desale Yacob
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Raul E Sanchez
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Neetu B Puri
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Karla Vaz
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Carlo Di Lorenzo
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Marc A Benninga
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Peter L Lu
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, USA
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3
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Maselli KM, Shah NR, Speck KE. Approach to Constipation in Children: Recommendations for Evaluation and Management. Adv Pediatr 2024; 71:195-211. [PMID: 38944484 DOI: 10.1016/j.yapd.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2024]
Abstract
Constipation is common in childhood, and most patients can be successfully managed by their primary care provider. However, some patients will require more specialized management either due to an underlying congenital colorectal disorder such as Hirschsprung disease or anorectal malformation or due to severe functional constipation that is refractory to medical management.
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Affiliation(s)
- Kathryn M Maselli
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, C.S. Mott Children's Hospital, 1540 E. Hospital Drive, Ann Arbor, MI 48109-4211, USA
| | - Nikhil R Shah
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, C.S. Mott Children's Hospital, 1540 E. Hospital Drive, Ann Arbor, MI 48109-4211, USA
| | - Karen Elizabeth Speck
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, C.S. Mott Children's Hospital, 1540 E. Hospital Drive, Ann Arbor, MI 48109-4211, USA.
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Lu C, Zhu Y, Zhang W, Xu B. A New Method in Dealing With Children's Condylar Fracture by Botulinum Toxin A Injection in Lateral Pterygoid Muscle. J Craniofac Surg 2024:00001665-990000000-01745. [PMID: 38953580 DOI: 10.1097/scs.0000000000010450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2024] [Accepted: 05/31/2024] [Indexed: 07/04/2024] Open
Abstract
Condylar is one of the most vulnerable sites to be traumatized in pediatric mandible fracture, while temporomandibular joint ankylosis might be the most severe complication of condylar fracture in children. There exists a long-time controversy on the treatment of condylar fractures in children. Considering the risk of facial nerve injury and a certain probability of absorption or even ankylosis after open reduction and internal fixation (ORIF) of condylar fractures, a series of nonsurgical approaches are preferred in cases without severe malocclusion or shortening of the ramus. Our treatment plan was carried out through combining procedures of Botulinum toxin A injection in lateral pterygoid muscle with ORIF of para symphyseal fracture; subsequently, a conservative way of the occlusal splint with elastic traction was performed. Three patients of bilateral or unilateral condylar fractures, aged between 2 y and 6 y, were involved in this treatment. After more than 1 year's follow-up, the occlusion was satisfactory in all patients. Condylar remodeling was approximately complete in 3 months, and no unwanted complications were observed. We may expect this method to offer a new idea when dealing with children's condylar fracture.
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Affiliation(s)
- Chenpei Lu
- Department of Oral and Craniomaxillofacial Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- National Clinical Research Center for Oral Diseases, Shanghai, China
- Shanghai Key Laboratory of Stomatology & Shanghai Research Institute of Stomatology, Shanghai, China
| | - Yanfei Zhu
- Department of Oral and Craniomaxillofacial Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- National Clinical Research Center for Oral Diseases, Shanghai, China
- Shanghai Key Laboratory of Stomatology & Shanghai Research Institute of Stomatology, Shanghai, China
| | - Wenbin Zhang
- Department of Oral and Craniomaxillofacial Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- National Clinical Research Center for Oral Diseases, Shanghai, China
- Shanghai Key Laboratory of Stomatology & Shanghai Research Institute of Stomatology, Shanghai, China
| | - Bing Xu
- Department of Oral and Craniomaxillofacial Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Wolfson S, Saps M. Recent advances in treating constipation in children. Expert Rev Gastroenterol Hepatol 2024; 18:325-338. [PMID: 39034812 DOI: 10.1080/17474124.2024.2383636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2024] [Accepted: 07/19/2024] [Indexed: 07/23/2024]
Abstract
INTRODUCTION Functional constipation (FC) is a common childhood condition, diagnosed via the Rome IV criteria. Standard therapy includes lifestyle and dietary modification followed by initiation of osmotic laxative therapy. About 30% of children continue to experience symptoms related to FC despite appropriate management. New pharmacologic, surgical, and neuromodulatory therapies for FC are now available for use in adult and pediatric populations. In 2023, the first pharmacologic agent, linaclotide, obtained FDA approval for treatment of FC in children 6-17 years old. AREAS COVERED This article reviews current and emerging pharmacologic, surgical, and neuromodulation therapies for the management of FC in pediatric patients. Efficacy and safety data regarding each of these modalities was reviewed and discussed. EXPERT OPINION Advancements in therapeutics available for the management of FC necessitate further investigation on safety and efficacy in pediatric populations. Careful consideration should be taken in choosing an available treatment with limited pediatric evidence as adult and pediatric FC have different underlying pathophysiology and require a different therapeutic approach. Standardization of methodology and pediatric endpoints are needed to optimize ability to compare efficacy of different treatments. We predict the future of pediatric FC management will include a personalized approach to care, resulting in improved outcomes.
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Affiliation(s)
- Sharon Wolfson
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Miguel Saps
- Division of Pediatric Gastroenterology,Hepatology and Nutrition, University of Miami, Miami, FL, USA
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van der Zande JMJ, Lu PL. Management of the child with refractory constipation. Aliment Pharmacol Ther 2024; 60 Suppl 1:S42-S53. [PMID: 38923030 DOI: 10.1111/apt.17847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 11/28/2023] [Accepted: 12/14/2023] [Indexed: 06/28/2024]
Abstract
BACKGROUND Caring for children with constipation refractory to conventional treatment can be challenging and management practices vary widely. AIMS To review recent advances in the evaluation and treatment of children with refractory constipation and to propose an algorithm that incorporates the latest evidence and our institutional experience. METHODS We performed a literature review on diagnostic tests and treatment options for children with refractory constipation. RESULTS Evaluation of a child with refractory constipation seeks to better understand factors contributing to an individual child's presentation. Anorectal manometry evaluating for a rectal evacuation disorder and colonic manometry evaluating for colonic dysmotility can guide subsequent treatment. For the child who has not responded to conventional treatment, a trial of newer medications like linaclotide can be helpful. Transanal irrigation offers a safe and effective alternative for families able to administer daily rectal treatment. Despite mixed evidence in children, pelvic floor biofeedback therapy can help some children with pelvic floor dyssynergia. For younger children unable to cooperate with pelvic floor therapy, or older children with refractory symptoms, internal anal sphincter botulinum toxin injection can be beneficial. Antegrade continence enema treatment can be effective for children with either normal colonic motility or segmental dysmotility. Sacral nerve stimulation is generally reserved for symptoms that persist despite antegrade continence enemas, particularly if faecal incontinence is prominent. In more severe cases, temporary or permanent colonic diversion and segmental colonic resection may be needed. CONCLUSIONS Recent advances offer hope for children with refractory constipation.
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Affiliation(s)
- Julia M J van der Zande
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, USA
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Peter L Lu
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, USA
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Walther M, Müller H, Weiß C, Carbon R, Diez S, Besendörfer M. A comparative observational study on intrasphincteric injections with Botulinum toxin vs. enteral neuromodulation in chronic refractory constipation. BMC Pediatr 2023; 23:448. [PMID: 37684559 PMCID: PMC10486061 DOI: 10.1186/s12887-023-04217-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 07/27/2023] [Indexed: 09/10/2023] Open
Abstract
PURPOSE Botulinum toxin injections in the anal sphincter apparatus (Botox) and enteral neuromodulation (ENM) are options for treatment of refractory chronic constipation. We present a retrospective comparative observational study. PATIENTS AND METHODS From 2014 to 2022, pediatric patients with chronic constipation were either treated with Botox or ENM with continuation of conservative treatment. Comparison was conducted regarding the primary outcome variables defecation frequency, stool consistency, and abdominal pain. Secondary outcomes were fecal incontinence, enuresis, change of medication and safety of treatment. RESULTS 19 Botox patients (10 boys, 9 girls, 12 patients with Hirschsprung disease (HD), 7 patients with functional constipation (FC)) were compared to 24 ENM patients (18 boys, 6 girls, 12 HD patients, 7 FC patients). Groups differed significantly in age (5.0 years (Botulinum toxin) and 6.5 years (ENM), mean values, p-value 0.008). Improvement of constipation was seen in 68% (n = 13/19) of Botox and 88% (n = 21/24) of ENM patients (p = 0.153). Influence of etiology on therapeutic effects was not observed. Complications were minor. CONCLUSIONS Botox and ENM can be considered as valuable and effective treatment options in refractory chronic constipation. Prospective, large-population studies should be designed to enable improved evidence.
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Affiliation(s)
- Mona Walther
- Department of Surgery, Section of Pediatric Surgery, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, Loschgestrasse 15, 91054, Erlangen, Germany
| | - Hanna Müller
- Neonatology and Pediatric Intensive Care, Department of Pediatrics, University Hospital Marburg, 35043, Baldingerstraße, Marburg, Germany
| | - Christel Weiß
- Department of Medical Statistics, Biomathematics, and Information Processing, Medical Faculty, Mannheim of Heidelberg University, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Roman Carbon
- Department of Surgery, Section of Pediatric Surgery, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, Loschgestrasse 15, 91054, Erlangen, Germany
| | - Sonja Diez
- Department of Surgery, Section of Pediatric Surgery, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, Loschgestrasse 15, 91054, Erlangen, Germany.
| | - Manuel Besendörfer
- Department of Surgery, Section of Pediatric Surgery, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), University Hospital Erlangen, Loschgestrasse 15, 91054, Erlangen, Germany
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8
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Bokova E, Svetanoff WJ, Rosen JM, Levitt MA, Rentea RM. State of the Art Bowel Management for Pediatric Colorectal Problems: Functional Constipation. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1078. [PMID: 37371309 DOI: 10.3390/children10061078] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 06/15/2023] [Accepted: 06/16/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND Functional constipation (FC) affects up to 32% of the pediatric population, and some of these patients are referred to pediatric surgery units to manage their constipation and/or fecal incontinence. The aim of the current paper is to report the recent updates on the evaluation and management of children with FC as a part of a manuscript series on bowel management in patients with anorectal malformations, Hirschsprung disease, spinal anomalies, and FC. METHODS A literature search was performed using Medline/PubMed, Google Scholar, Cochrane, and EMBASE databases and focusing on the manuscripts published within the last 5-10 years. RESULTS The first step of management of children with FC is to exclude Hirschsprung disease with a contrast study, examination under anesthesia, anorectal manometry (AMAN). If AMAN shows absent rectoanal inhibitory reflex, a rectal biopsy is performed. Internal sphincter achalasia or high resting pressures indicate botulinum toxin injection. Medical management options include laxatives, rectal enemas, transanal irrigations, and antegrade flushes. Those who fail conservative treatment require further assessment of colonic motility and can be candidates for colonic resection. The type of resection (subtotal colonic resection vs. Deloyer's procedure) can be guided with a balloon expulsion test. CONCLUSION Most of the patients with FC referred for surgical evaluation can be managed conservatively. Further studies are required to determine an optimal strategy of surgical resection in children unresponsive to medical treatment.
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Affiliation(s)
- Elizaveta Bokova
- Comprehensive Colorectal Center, Department of Surgery, Children's Mercy Hospital, Kansas City, MO 64108, USA
| | - Wendy Jo Svetanoff
- Comprehensive Colorectal Center, Department of Surgery, Children's Mercy Hospital, Kansas City, MO 64108, USA
| | - John M Rosen
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Children's Mercy Kansas City, Kansas City, MO 64108, USA
- Department of Pediatrics, University of Missouri-Kansas City, Kansas City, MO 64108, USA
| | - Marc A Levitt
- Division of Colorectal and Pelvic Reconstruction, Children's National Medical Center, Washington, DC 20001, USA
| | - Rebecca M Rentea
- Comprehensive Colorectal Center, Department of Surgery, Children's Mercy Hospital, Kansas City, MO 64108, USA
- Department of Surgery, University of Missouri-Kansas City, Kansas City, MO 64108, USA
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de Geus A, Koppen IJN, Flint RB, Benninga MA, Tabbers MM. An Update of Pharmacological Management in Children with Functional Constipation. Paediatr Drugs 2023; 25:343-358. [PMID: 36941393 PMCID: PMC10097737 DOI: 10.1007/s40272-023-00563-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/19/2023] [Indexed: 03/23/2023]
Abstract
Functional constipation is a common problem in childhood worldwide and has a great impact on social, physical, and emotional functioning of affected children and their caregivers. It is a clinical diagnosis based on the Rome IV criteria. Non-pharmacological treatment involves education, demystification, lifestyle advice, and toilet training. Pharmacological treatment consists of disimpaction, maintenance treatment, and eventually weaning if possible. Polyethylene glycol is considered as the first choice of laxative for both disimpaction and maintenance treatment. Different osmotic laxatives, stimulant laxatives, lubricants, and enemas are available as alternative pharmacological treatment options. Novel drugs are emerging but evidence to support the widespread application of these drugs in the pediatric population is often lacking and more high-quality research is needed in this field. If children remain symptomatic despite optimal pharmacological treatment, botulinum toxin injections in the anal sphincter can be considered as an alternative, more invasive treatment option. This review provides an update on currently available literature concerning the pharmacologic treatment of functional constipation in children.
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Affiliation(s)
- Anna de Geus
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital/Academic Medical Center, Meibergdreef 9, 1105, Amsterdam, AZ, The Netherlands
| | - Ilan J N Koppen
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital/Academic Medical Center, Meibergdreef 9, 1105, Amsterdam, AZ, The Netherlands
| | - Robert B Flint
- Department of Clinical Pharmacy, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Division of Neonatology, Department of Paediatrics, Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Marc A Benninga
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital/Academic Medical Center, Meibergdreef 9, 1105, Amsterdam, AZ, The Netherlands
| | - Merit M Tabbers
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital/Academic Medical Center, Meibergdreef 9, 1105, Amsterdam, AZ, The Netherlands.
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Bokova E, McKenna E, Krois W, Reck CA, Al-Shamaileh T, Jacobs SE, Tiusaba L, Russell TL, Darbari A, Feng C, Badillo AT, Levitt MA. Reconstructing the anal sphincters to reverse iatrogenic overstretching following a pull-through for Hirschsprung disease. One-year outcomes. J Pediatr Surg 2023; 58:484-489. [PMID: 36470689 DOI: 10.1016/j.jpedsurg.2022.10.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 10/11/2022] [Accepted: 10/31/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND In patients with Hirschsprung disease (HSCR), soiling may be related to anal sphincter damage following the initial pull-through. No optimal treatment has been developed for such patients, although enemas (rectal or antegrade) have been applied with some success. We present the one-year outcomes of a new technique for anal sphincter reconstruction. METHODS All patients with HSCR referred from other institutions for post pull-through soiling were studied. Seven patients with patulous sphincters underwent sphincter reconstruction. Six had a full preoperative evaluation and were included in the study. Their 12-month outcomes were assessed. RESULTS All six patients had soiling without voluntary bowel movements (VBMs). One patient was clean on Malone flushes when referred. Three underwent pre- and post-reconstruction non-sedated three-dimensional anorectal manometry, and objectively were able to close their sphincters following the reconstruction. All patients without Down syndrome (4 of 6) showed improvement in the abbreviated Baylor Continence Scale (4.5 vs. 0.75). One patient has achieved total bowel control without antegrade flushes, three now have VBMs which they did not have before but have occasional accidents and use antegrade flushes intermittently. They reported higher productivity, the ability to participate in sports and be away from home with confidence in their regimen. Two of 6 patients have Down syndrome and required a redo pull-through for other indications and underwent empiric sphincter reconstruction. For these two patients we do not have an outcomes assessment. CONCLUSIONS A new technique for sphincter reconstruction shows promising results in improvement of bowel control at one year. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Elizaveta Bokova
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, D.C., USA.
| | - Elise McKenna
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, D.C., USA
| | - Wilfried Krois
- Comprehensive Center for Pediatrics, Department of Surgery, Clinical Department of Pediatric Surgery, Medical University of Vienna, Vienna, Austria
| | - Carlos A Reck
- Comprehensive Center for Pediatrics, Department of Surgery, Clinical Department of Pediatric Surgery, Medical University of Vienna, Vienna, Austria
| | - Tamador Al-Shamaileh
- Department of General Surgery, Faculty of Medicine, Mu'tah University, Kerak, Jordan
| | - Shimon E Jacobs
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, D.C., USA
| | - Laura Tiusaba
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, D.C., USA
| | - Teresa L Russell
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, D.C., USA
| | - Anil Darbari
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, D.C., USA
| | - Christina Feng
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, D.C., USA
| | - Andrea T Badillo
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, D.C., USA
| | - Marc A Levitt
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington, D.C., USA
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Jacobs SE, Tiusaba L, Bokova E, Russell TL, Al-Shamaileh T, Feng C, Badillo AT, Darbari A, Levitt MA. Functional constipation refractory to medical management: The colon is the problem. J Pediatr Surg 2023; 58:246-250. [PMID: 36411110 DOI: 10.1016/j.jpedsurg.2022.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 10/14/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Management of refractory constipation in children has not been standardized. We propose a protocolized approach which includes a contrast enema, anorectal manometry and exclusion of Hirschsprung disease (HD). For those without HD or with normal sphincters, an assessment of the colonic motility may be needed. The subgroups of dysmotility include (1) slow motility with contractions throughout, (2) segmental dysmotility (usually the sigmoid), or (3) a diffusely inert colon. We offered a Malone appendicostomy in all groups with the hope that this would avoid colonic resection in most cases. METHODS Patients with medically refractory constipation were reviewed at a single institution (2020 to 2021). For patients without HD or an anal sphincter problem, assessment of colonic motility using colonic manometry was performed followed by a Malone appendicostomy for antegrade flushes. RESULTS Of 196 patients evaluated for constipation refractory to medical management, 22 were felt to have a colonic motility cause. These patients underwent colonic manometry and Malone appendicostomy. 13 patients (59%) had a slow colon but with HAPCs throughout, 5 (23%) had segmental dysmotility, and 4 (18%) had a diffuse colonic dysmotility. 19 (86%) responded well to antegrade flushes with 17 reporting no soiling and 2 having occasional accidents. 3 patients (14%) failed flushes and underwent a colon resection within 6-month following Malone procedure. CONCLUSION We propose a protocol for medically refractory constipation which provides a collaborative framework to standardize evaluation and management of these patients with antegrade flushes, which aids in avoidance of colonic resection in most cases. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Shimon E Jacobs
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, 111 Michigan Avenue NW, Washington DC 20010, United States
| | - Laura Tiusaba
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, 111 Michigan Avenue NW, Washington DC 20010, United States
| | - Elizaveta Bokova
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, 111 Michigan Avenue NW, Washington DC 20010, United States
| | - Teresa L Russell
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, 111 Michigan Avenue NW, Washington DC 20010, United States
| | | | - Christina Feng
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, 111 Michigan Avenue NW, Washington DC 20010, United States
| | - Andrea T Badillo
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, 111 Michigan Avenue NW, Washington DC 20010, United States
| | - Anil Darbari
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, 111 Michigan Avenue NW, Washington DC 20010, United States
| | - Marc A Levitt
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, 111 Michigan Avenue NW, Washington DC 20010, United States.
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Tian L, Ma C, Deng Z, Zhu T, Zhao X, He Y, Wei M, Feng J, Yu D. Treatment of postoperative intestinal dysfunction of hirschsprung's disease based on the principle of "anorectal balance". Front Surg 2022; 9:996455. [PMID: 36386515 PMCID: PMC9649898 DOI: 10.3389/fsurg.2022.996455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 10/06/2022] [Indexed: 09/14/2023] Open
Abstract
PURPOSE Radical surgery is the most effective treatment for Hirschsprung's disease. However, some children still have symptoms of intestinal dysfunction such as constipation, abdominal distension, and recurrent enterocolitis after operation. The purpose of this study was to evaluate treatment outcomes of postoperative intestinal dysfunction in children with Hirschsprung's disease by using the principle of "anorectal balance". METHODS The clinical data of postoperative intestinal dysfunction in children with Hirschsprung's disease in the single treatment group from July 2019 to July 2021 were retrospectively analyzed. All the enrolled children underwent botulinum toxin injection (2.5 U/kg); 3 to 6 months later, the injection was performed again; the children who had received more than two botulinum toxin injections underwent the internal sphincter myectomy. Anorectal manometry was performed routinely after operation, and abdominal distension and defecation were recorded. RESULTS A total of thirty children with postoperative intestinal dysfunction underwent radical surgery for Hirschsprung's disease were included in this study. Symptoms of constipation, abdominal distension and enterocolitis were improved after botulinum toxin injections in most children compared to before surgery (P < 0.01). After re-injection of botulinum toxin in twelve children, the frequency of defecation increased, the anal resting pressure decreased, and the clinical symptoms were relieved again (P < 0.05). Eleven children underwent internal sphincter myectomy, and the symptoms of constipation, abdominal distension and enterocolitis were significantly improved after the operation (P < 0.01). CONCLUSION Botulinum toxin injection and internal sphincter myectomy based on the principle of "anorectal balance" can effectively reduce the resting pressure of the anus and relieve intestinal dysfunction, and have satisfactory clinical effect.
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Affiliation(s)
- Li Tian
- Department of Pediatric Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Clinical Center of Hirschsprung's Disease and Allied Disorders, Wuhan, China
| | - Chensen Ma
- Department of Pediatric Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Clinical Center of Hirschsprung's Disease and Allied Disorders, Wuhan, China
| | - Zhengdong Deng
- Department of Pediatric Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Clinical Center of Hirschsprung's Disease and Allied Disorders, Wuhan, China
| | - Tianqi Zhu
- Department of Pediatric Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Clinical Center of Hirschsprung's Disease and Allied Disorders, Wuhan, China
| | - Xiang Zhao
- Department of Pediatric Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Clinical Center of Hirschsprung's Disease and Allied Disorders, Wuhan, China
| | - Ying He
- Department of Pediatric Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Clinical Center of Hirschsprung's Disease and Allied Disorders, Wuhan, China
| | - Mingfa Wei
- Department of Pediatric Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Clinical Center of Hirschsprung's Disease and Allied Disorders, Wuhan, China
| | - Jiexiong Feng
- Department of Pediatric Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Clinical Center of Hirschsprung's Disease and Allied Disorders, Wuhan, China
| | - Donghai Yu
- Department of Pediatric Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Clinical Center of Hirschsprung's Disease and Allied Disorders, Wuhan, China
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Shen ZY, Zhang J, Bai YZ, Zhang SC. Diagnosis and management of fecal incontinence in children and adolescents. Front Pediatr 2022; 10:1034240. [PMID: 36330370 PMCID: PMC9623001 DOI: 10.3389/fped.2022.1034240] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 09/27/2022] [Indexed: 11/30/2022] Open
Abstract
Fecal incontinence (FI) is a commonly occurring disease of high concern. It is characterized by voluntary and involuntary defecation in children and adolescents. It is not only a physical disease but also a psychological and behavioral disorder. FI poses a serious burden on individuals and their families and therefore has become a social problem. Unfortunately, the management of FI among children is still a challenge because the etiology varies widely. Constipation has been found to be the most common cause, while sphincter dysfunction and neurogenic abnormalities may also play a role. Currently, no consensus guidelines exist, and the criteria for selecting optional methods remain unclear. It is therefore necessary to improve the efficacy of diagnosis and management strategies of FI in children. This review focused on the classification and etiology, discussed the diagnosis and management methods of FI in children and adolescents, and aimed to guide future studies.
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Affiliation(s)
- Zhe-Ying Shen
- Department of Pediatric Surgery, Shengjing Hospital of China Medical University, Shenyang, China
| | - Jin Zhang
- Department of Pediatric Orthopedics, Dalian Women and Children’s Medical Center, Dalian, China
| | - Yu-Zuo Bai
- Department of Pediatric Surgery, Shengjing Hospital of China Medical University, Shenyang, China
| | - Shu-Cheng Zhang
- Department of Pediatric Surgery, Shengjing Hospital of China Medical University, Shenyang, China
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Classen M, Righini-Grunder F, Schumann S, von Gontard A, de Laffolie J. Constipation in Children and Adolescents. DEUTSCHES ARZTEBLATT INTERNATIONAL 2022; 119:697-708. [PMID: 36261928 PMCID: PMC9830679 DOI: 10.3238/arztebl.m2022.0309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 04/24/2022] [Accepted: 08/16/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND According to a population-based study, approximately 6.8% of children and adolescents in Germany suffer from acute or chronic constipation. It can be of organic or functional origin and may be associated with comorbid disturbances, particularly fecal incontinence. METHODS We selectively searched the PubMed and Google Scholar databases for articles with the keywords "constipation," "children and adolescents," and "incontinence". Recommendations are based on the AWMF guideline on constipation and fecal incontinence and on international guidelines and reviews. RESULTS More than 90% of cases of chronic constipation are of functional origin. Organic causes vary with age and call for targeted differential diagnosis. Invasive tests are only rarely necessary. Functional constipation may be associated with fecal and urinary incontinence, and the relative risk of urinary tract infections is 2.2 to 6.5. There may be associated psychological symptoms and mental disorders in 30-50% of cases. The cornerstone of treatment is patient and parent education, along with laxative medication and toilet training. Instructional programs have been found effective in otherwise refractory cases. CONCLUSION The treatment of constipation in childhood should begin as soon as the differential diagnostic evaluation is completed. The education of parents, follow-up at close intervals, and drug treatment and behavioral therapy that are adapted to the symptoms can improve quality of life.
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Affiliation(s)
| | | | | | - Alexander von Gontard
- Psychiatric Services Graubünden (PDGR), Outpatient Services for Child and Adolescent Psychiatry, Chur, Switzerland; Governor Kremers Centre, Department of Urology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Jan de Laffolie
- Department of General Pediatrics and Neonatology, Justus Liebig University Giessen, Standort Giessen,*Kindergastroenterologie, Abt. Allgemeine Pädiatrie und Neonatologie Universitätsklinikum Giessen und Marburg, Standort Giessen Feulgenstr. 12, 35392 Giessen, Germany
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15
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Systematic appraisal of the guidelines for the diagnosis and treatment of Hirschsprung's disease. Pediatr Surg Int 2022; 38:1197-1208. [PMID: 35867125 DOI: 10.1007/s00383-022-05151-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/04/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Some guidelines for management of Hirschsprung's disease (HSCR, HD) have been developed, but their quality is vague. This study will systematically assess the quality of guidelines and analyze the key recommendations and the best evidence for guidelines. METHODS Applicable guidelines were retrieved using a systematic search of databases. The Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool was used to assess the quality of the guidelines. Then, the recommendations and evidence for the included guidelines were extracted and compared. RESULTS A total of nine guidelines were included in this study, and only one had an overall standardized score of more than 60%, indicating that it is worthy of recommendation. The problems identified included ambiguous and low-quality evidence; obvious distributional heterogeneity among the recommendations; a lack of in-depth discussion on the interpretation of staging, diagnostic methods, conservative treatment, and surgical staging of disease. CONCLUSION The quality of guidelines varies widely, and there is a lack of high-quality professional opinions and supporting evidence for the main recommendations. At present, only comprehensive guidelines can be considered high-quality and there is still room for improvement.
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Ahmad H, Rentea RM, Knaus ME, Wilbur JG, Halaweish I, Langer JC, Levitt MA, Wood RJ. Routine botulinum toxin injection one month after a Swenson pull-through does not change the incidence of Hirschsprung associated enterocolitis. J Pediatr Surg 2022; 57:1453-1457. [PMID: 34991869 DOI: 10.1016/j.jpedsurg.2021.11.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 10/21/2021] [Accepted: 11/11/2021] [Indexed: 12/01/2022]
Abstract
PURPOSE Patients with Hirschsprung disease (HD) are at risk of Hirschsprung associated enterocolitis (HAEC) following pull-through. The purpose of this study was to determine if routine Botulinum toxin (BT) injected one-month post pull-through decreases the incidence of HAEC. METHODS We reviewed patients who underwent a primary (not redo) pull-through operation for HD between April 2014 to December 2019. Over the most recent 18 months, BT was administered routinely one-month post-pull-through procedure; these patients were compared to the prior group that did not receive routine BT. A HAEC episode was defined as one that required initiation of treatment for obstructive symptoms in the inpatient or outpatient setting with antibiotics and irrigations. Categorical variables were compared using the nonparametric chi-square test or Fisher's exact test. Continuous variables were compared using the two-tailed Student's t-test. P-value <0.05 was determined to be statistically significant. RESULTS A total of 70 patients underwent Swenson pull-through during the study period (52% male). There were no statistically significant differences in demographics in the BT vs. non-BT group. Routine post-pull-through BT was given in 28 patients and did not significantly change HAEC incidence compared to the non-BT group (12/28, 43% vs. 16/42, 38%. P = 0.691). Of note, the BT group patients developed HAEC significantly sooner than the patients in the non-BT group (37.5 days vs. 253 days, p = 0.029). More patients in the BT group (n = 18, 64%) required at least one subsequent BT injection compared to the patients in the non-BT group (n = 11, 26%. P = 0.001). CONCLUSIONS We conclude that routine postoperative botulinum toxin injection given one month postoperatively from Swenson pull-through did not change the incidence of HAEC. A prospective controlled study is necessary to confirm these findings.
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Affiliation(s)
- Hira Ahmad
- Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, 611 E. Livingston Ave., Columbus, Ohio, 43205
| | - Rebecca M Rentea
- Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, 611 E. Livingston Ave., Columbus, Ohio, 43205
| | - Maria E Knaus
- Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, 611 E. Livingston Ave., Columbus, Ohio, 43205
| | - Jameson G Wilbur
- Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, 611 E. Livingston Ave., Columbus, Ohio, 43205
| | - Ihab Halaweish
- Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, 611 E. Livingston Ave., Columbus, Ohio, 43205
| | - Jacob C Langer
- Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, 611 E. Livingston Ave., Columbus, Ohio, 43205
| | - Marc A Levitt
- Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, 611 E. Livingston Ave., Columbus, Ohio, 43205
| | - Richard J Wood
- Department of Pediatric Colorectal and Pelvic Reconstructive Surgery, Nationwide Children's Hospital, 611 E. Livingston Ave., Columbus, Ohio, 43205.
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Baaleman DF, Hallagan A, Halleran DR, Orsagh-Yentis DK, Levitt MA, Wood RJ, Benninga MA, Bali N, Vaz KH, Yacob D, Di Lorenzo C, Lu PL. Anal Botulinum Toxin in Children with Hirschsprung Disease and Functional Constipation: A Prospective Cohort study. Eur J Pediatr Surg 2022; 33:241-248. [PMID: 35853466 DOI: 10.1055/s-0042-1751048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Anal sphincter botulinum toxin injections (BTIs) are used in the treatment of children with severe defecation disorders, including Hirschsprung disease (HD) and functional constipation (FC). Our objective was to evaluate the outcomes of BTI in these children. MATERIALS AND METHODS We performed a prospective cohort study of children undergoing BTI from July 2018 to December 2018. We recorded perceived effect of the BTI, including effectiveness ranging from 0 (not at all effective) to 4 (extremely effective). In addition, we recorded symptoms and the Cleveland Clinic Constipation Score (CCCS). Data were collected at baseline and at 2 weeks, 2 months, and 4 months post-injection. RESULTS Forty-two children (HD = 25, FC = 17) were included in the study (median age 4.3 years, IQR 2.4-7.2, 52% male). Twenty-two (88%) children with HD and eight (47%) children with FC had previously undergone a BTI. BTIs were perceived effective in 16 (76%) and 12 (71%) children with HD and eight (47%) and seven (47%) children with FC at 2 weeks and 2 months follow-up, respectively. Effectiveness was not rated differently between groups except at the 2-month follow-up, when patients with HD rated the BTI more effective compared to those with FC (median 2 [HD] vs. median 1 [FC], p = 0.022). Over the course of the study, 17/39 (44%) children reported self-limiting adverse effects such as fecal incontinence and pain at the injection site. CONCLUSION Anal sphincter BTIs can be effective in the treatment of constipation in both HD and FC patients.
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Affiliation(s)
- Desiree F Baaleman
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, United States.,Department of Pediatric Gastroenterology, Amsterdam UMC, Emma Childrens' Hospital UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Alexandra Hallagan
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, United States.,College of Medicine, The Ohio State University, Columbus, Ohio, United States
| | - Devin R Halleran
- Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, Ohio, United States
| | - Danielle K Orsagh-Yentis
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, United States
| | - Marc A Levitt
- Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, Ohio, United States
| | - Richard J Wood
- Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, Ohio, United States
| | - Marc A Benninga
- Department of Pediatric Gastroenterology, Amsterdam UMC, Emma Childrens' Hospital UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Neetu Bali
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, United States
| | - Karla H Vaz
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, United States
| | - Desale Yacob
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, United States
| | - Carlo Di Lorenzo
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, United States
| | - Peter L Lu
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital, Columbus, Ohio, United States
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Characterizing the use of botulinum toxin in patients with Hirschsprung disease treated at referral institutions for pediatric colorectal surgery. J Pediatr Surg 2022; 57:1033-1039. [PMID: 35292167 DOI: 10.1016/j.jpedsurg.2022.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 02/01/2022] [Indexed: 02/07/2023]
Abstract
PURPOSE Botulinum toxin (BT) is used to treat pediatric patients with Hirschsprung disease (HD) with obstructive symptoms. We aimed to characterize use of BT in HD patients across pediatric colorectal surgery referral centers. METHODS A multicenter retrospective study of BT use in children (0-18y) with HD was performed using the Pediatric Colorectal and Pelvic Learning Consortium (PCPLC) between 2017 and 2021. Sites with <10 HD patients recorded were excluded. Patterns were evaluated using Fisher's exact, Wilcoxon rank-sum, Kruskal-Wallis, and Cochran-Armitage trend test. RESULTS 494 patients at 8 centers were included. 118 (23.9%) received at least one BT injection. Among patients who required redo pullthrough procedures, 53.1% received BT compared to 22.7% of patients who only underwent one pullthrough (p<0.001). Age at pullthrough was also significantly associated (p = 0.021). A lower proportion of Hispanic patients received BT (9.6% vs. 26.3%;p = 0.006). Percentage of HD patients receiving BT varied significantly across sites (p<0.001). CONCLUSIONS Use of BT in patients with HD varies widely with greater use in patients who underwent redo surgery and in those who underwent pullthrough at an older age. Hispanic patients received less BT. These findings highlight the need to develop consensus guidelines and for further study on timing of injections and potential disparities in care. LEVEL OF EVIDENCE III.
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19
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Sajankila N, DeRoss A, Lipman JM. Approach to the Adult Colorectal Patient with a History of Pediatric Abdominal Surgery. Clin Colon Rectal Surg 2022; 35:177-186. [PMID: 35966376 PMCID: PMC9374533 DOI: 10.1055/s-0042-1742412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Children with colorectal diseases often undergo operative management in their youth. As these patients become adult, it is important for surgeons to understand their postoperative anatomy as well as the pathophysiology of their diseases. Here, we present a description of common colorectal diseases of childhood that may have significant impact on patients' presentations as adult. We also discuss the diagnosis and management of conditions that are usually seen early in life but may present during adulthood as well.
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Affiliation(s)
- Nitin Sajankila
- Department of General Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Anthony DeRoss
- Department of Pediatric General Surgery, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Jeremy M. Lipman
- Department of Colorectal Surgery, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, Ohio
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20
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Anorectal Manometry in Children: The Update on the Indications and the Protocol of the Procedure. J Pediatr Gastroenterol Nutr 2022; 74:440-445. [PMID: 35001039 DOI: 10.1097/mpg.0000000000003379] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Anorectal disorders are common in children. They are related to structural and/or functional abnormalities of the anorectum or pelvic floor with a variety of symptoms. Therefore, diagnostic tests to evaluate anorectal function can help to better understand the underlying pathophysiology and aetiology as well as facilitate patient management. During the past decades, substantial efforts have been made to improve anorectal function testing; however, more advanced investigations might lead to difficulties in interpretation. Additionally, a great diversity of equipment and protocols are used among centres, which may lead to heterogeneous interpretation of results. More studies to standardize methods of testing and validate reference values are strongly recommended in children. This review updates on the current indications and the protocol of anorectal manometry.
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The utilization of botulinum toxin for Hirschsprung disease. Semin Pediatr Surg 2022; 31:151161. [PMID: 35690464 DOI: 10.1016/j.sempedsurg.2022.151161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Patients with Hirschsprung disease (HD) can struggle with persistent obstructive symptoms even after a successful pull-through. These symptoms lead to stasis of stool and can result in Hirschsprung associated enterocolitis (HAEC). Recurrent episodes of HAEC warrant further workup; if there are no signs of mechanical obstruction or an aganglionic pull-through, the use of botulinum toxin injections to the internal anal sphincter has been utilized to relieve these symptoms. In this review, we describe the variations in botulinum toxin injection use and describe ongoing studies to prevent obstructive symptoms and Hirschsprung-associated enterocolitis (HAEC). Botulinum toxin injection utilization has been described for obstructive symptoms after HD pull-through, in the setting of active HAEC, and has been proposed to be part of the treatment algorithm for prevention of HAEC after pull-through. Dosing utilized for the injections, along with the complications, are also described. Prospective, multi-institutional trials are needed to identify the effectiveness of botulinum toxin injections in the outpatient/prophylactic setting as current data suggest some benefits in preventing future obstructive symptoms; however, other studies have conflicting results.
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22
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Role of Pelvic Organ Crosstalk in Dysfunction of the Bowel and Bladder. CURRENT BLADDER DYSFUNCTION REPORTS 2022. [DOI: 10.1007/s11884-022-00645-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Koppen IJN, Benninga MA. Functional Constipation and Dyssynergic Defecation in Children. Front Pediatr 2022; 10:832877. [PMID: 35252068 PMCID: PMC8890489 DOI: 10.3389/fped.2022.832877] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 01/06/2022] [Indexed: 12/22/2022] Open
Abstract
Defecation is a complex physiological process, which relies on intricate mechanisms involving the autonomic and somatic nervous system, the pelvic floor muscles, and the anal sphincter complex. Anorectal dysfunction may result in constipation, a bothersome defecation disorder that can severely affect daily lives of children and their families. In this review, we focus on different mechanisms underlying anorectal dysfunction and specific treatment options aimed at improving defecation dynamics in children with functional constipation.
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Affiliation(s)
- Ilan J N Koppen
- Department of Paediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Marc A Benninga
- Department of Paediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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Abstract
Providing adequate and appropriate nutrition to children with medical complexity (CMC) is often a challenging task. These patients are a diverse group whose varying nutritional needs must be carefully assessed and monitored. Optimal feeding and nutrition strategies in CMC require an individual approach and may include oral, enteral (gastric or jejunal), or parenteral provision of nutrients. Complications of enteral feeding, including those associated with medical devices such as feeding tubes, are common, and provider familiarity with some of the more common complaints is helpful. We provide here a summary of different feeding approaches, with exploration of the rationale for each, as well as discussion of common complications and some practical troubleshooting tips.
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Roorda D, Oosterlaan J, van Heurn E, Derikx J. Intrasphincteric botulinum toxin injections for post-operative obstructive defecation problems in Hirschsprung disease: A retrospective observational study. J Pediatr Surg 2021; 56:1342-1348. [PMID: 33288128 DOI: 10.1016/j.jpedsurg.2020.11.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 11/11/2020] [Accepted: 11/21/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND Patients with Hirschsprung disease may have obstructive symptoms after resection of the aganglionic segment. Botulinum toxin (BT) injections can help improve faecal passage by relaxing the internal anal sphincter. This study assess effect of BT injections and aims to identify factors associated with receiving BT injections and favourable response to the first BT injection. METHODS A retrospective study was performed in a cohort of consecutive patients treated for Hirschsprung disease in our centre between 2003 and 2017. The indication for BT injections was obstructive defecation problems that were non-responsive to high-dose laxatives or rectal irrigation, or an episode of Hirschsprung-associated enterocolitis (HAEC). Effectiveness of BT injections was measured in terms of clinical improvement. Relationships between factors associated with receiving BT injections and with response to the first BT injection were tested with group comparison and logistic regression. RESULTS Forty-one out of 131 patients received BT injections (31%) with a median of two injections (range 1-11). All patients had obstructive defecation problems non-responsive to high-dose laxatives or rectal irrigation, two patient also had an episode of HAEC. Twenty-five out of 41 patients (61%) had clinical improvement after first injection. In 29 of the 41 patients (71%) spontaneous defecation or treatment with laxatives only was achieved. Adverse effects were seen in 12 out of 41 patients (29%) after 14 injections (16%), and consisted of anal pain, temporary loss of stools and dermatitis. Patients who received BT injections more often had long segment disease, more often required laxatives or rectal irrigation and had longer length of hospital stay, both after corrective surgery and in follow-up. None of the tested factors was associated with clinical improvement after first BT injection. CONCLUSION Our findings show that BT injections effectively treat obstructive defecation problems in the majority of patients with Hirschsprung disease with mild adverse effects. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Daniëlle Roorda
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, Department of Pediatric Surgery, Amsterdam Gastroenterology and Metabolism Research Institute and Amsterdam Reproduction and Development Research Institute, Amsterdam, Netherlands; Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Follow Me Aftercare Program, Department of Pediatrics, Amsterdam Reproduction and Development Research Institute, Amsterdam, Netherlands.
| | - Jaap Oosterlaan
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Follow Me Aftercare Program, Department of Pediatrics, Amsterdam Reproduction and Development Research Institute, Amsterdam, Netherlands
| | - Ernest van Heurn
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, Department of Pediatric Surgery, Amsterdam Gastroenterology and Metabolism Research Institute and Amsterdam Reproduction and Development Research Institute, Amsterdam, Netherlands
| | - Joep Derikx
- Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Vrije Universiteit Amsterdam, Department of Pediatric Surgery, Amsterdam Gastroenterology and Metabolism Research Institute and Amsterdam Reproduction and Development Research Institute, Amsterdam, Netherlands
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Rajindrajith S, Devanarayana NM, Thapar N, Benninga MA. Functional Fecal Incontinence in Children: Epidemiology, Pathophysiology, Evaluation, and Management. J Pediatr Gastroenterol Nutr 2021; 72:794-801. [PMID: 33534361 DOI: 10.1097/mpg.0000000000003056] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
ABSTRACT Functional fecal incontinence (FI) is a worldwide problem in children and comprises constipation-associated FI and nonretentive FI. Irrespective of pathophysiology, both disorders impact negatively on the psychological well-being and quality of life of affected children. A thorough clinical history and physical examination using the Rome IV criteria are usually sufficient to diagnose these conditions in most children. Evolving investigations such as high-resolution anorectal and colonic manometry have shed new light on the pathophysiology of functional FI. Although conventional interventions such as toilet training and laxatives successfully treat most children with constipation-associated FI, children with nonretentive FI need more psychologically based therapeutic options. Intrasphincteric injection of botulinum toxin, transanal irrigation and, in select cases, surgical interventions have been used in more resistant children with constipation-associated FI.
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Affiliation(s)
- Shaman Rajindrajith
- Department of Pediatrics, Faculty of Medicine, University of Colombo, Colombo 8
| | | | - Nikhil Thapar
- Department of Gastroenterology, Hepatology and Liver Transplant, Queensland Children's Hospital, Brisbane, Australia
| | - Marc Alexander Benninga
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Krois W, Reck CA, Darbari A, Badillo A, Levitt MA. A technique to reconstruct the anal sphincters following iatrogenic stretching related to a pull-through for Hirschsprung disease. J Pediatr Surg 2021; 56:1242-1246. [PMID: 33358008 DOI: 10.1016/j.jpedsurg.2020.12.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 11/25/2020] [Accepted: 12/01/2020] [Indexed: 12/29/2022]
Abstract
Soiling and fecal incontinence are troubling complications which can occur after a pull-through for Hirschsprung disease. They can usually be improved with proper medical management, but in some cases are the result of an anatomic defect related to overstretching of the sphincters and/or damage of the anal canal. For such patients the treatment of this true fecal incontinence is limited to a structured bowel management program with ante- or retrograde enemas to achieve social continence. Herein we report two such patients with overstretched sphincters and loss of the dentate line after an initial pull-through and describe a sphincter tightening technique to improve bowel control.
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Affiliation(s)
- Wilfried Krois
- Comprehensive Center for Pediatrics, Department of Surgery, Clinical Department of Pediatric Surgery, Medical University of Vienna, Vienna, Austria.
| | - Carlos A Reck
- Comprehensive Center for Pediatrics, Department of Surgery, Clinical Department of Pediatric Surgery, Medical University of Vienna, Vienna, Austria
| | - Anil Darbari
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington DC, USA
| | - Andrea Badillo
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington DC, USA
| | - Marc A Levitt
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, Washington DC, USA
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Radwan AB, Gadallah MA, Shahawy MR, Albagdady AA, Talaat AA. Can botulinum toxin help in managing children with functional constipation and obstructed defecation? J Pediatr Surg 2021; 56:750-753. [PMID: 32739102 DOI: 10.1016/j.jpedsurg.2020.06.044] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/21/2020] [Accepted: 06/26/2020] [Indexed: 01/16/2023]
Abstract
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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Affiliation(s)
- Ahmed B Radwan
- Pediatric Surgery Department, Faculty of Medicine, Ain-Shams University, Cairo, Egypt.
| | - Mohamed A Gadallah
- Pediatric Surgery Department, Faculty of Medicine, Ain-Shams University, Cairo, Egypt
| | - Mohammed R Shahawy
- General Surgery Department, Faculty of Medicine, Ain-Shams University, Cairo, Egypt
| | - Ayman A Albagdady
- Pediatric Surgery Department, Faculty of Medicine, Ain-Shams University, Cairo, Egypt
| | - Ayman A Talaat
- General Surgery Department, Faculty of Medicine, Ain-Shams University, Cairo, Egypt
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Baaleman DF, Malamisura M, Benninga MA, Bali N, Vaz KH, Yacob D, Di Lorenzo C, Lu PL. The not-so-rare absent RAIR: Internal anal sphincter achalasia in a review of 1072 children with constipation undergoing high-resolution anorectal manometry. Neurogastroenterol Motil 2021; 33:e14028. [PMID: 33301220 PMCID: PMC8047870 DOI: 10.1111/nmo.14028] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 09/21/2020] [Accepted: 10/16/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND Our objective is to describe the prevalence of patients with internal anal sphincter achalasia (IASA) without Hirschsprung disease (HD) among children undergoing anorectal manometry (ARM) and their clinical characteristics. METHODS We performed a retrospective review of high-resolution ARM studies performed at our institution and identified patients with an absent rectoanal inhibitory reflex (RAIR). Clinical presentation, medical history, treatment outcomes, and results of ARM and other diagnostic tests were collected. We compared data between IASA patients, HD patients, and a matched control group of patients with functional constipation (FC). KEY RESULTS We reviewed 1,072 ARMs and identified 109 patients with an absent RAIR, of whom 28 were diagnosed with IASA. Compared to patients with FC, patients with IASA had an earlier onset of symptoms and were more likely to have abnormal contrast enema studies. Compared to patients with HD, patients with IASA were more likely to have had a normal timing of meconium passage, a later onset of symptoms, and were diagnosed at an older age. At the latest follow-up, the majority of patients diagnosed with IASA (54%) were only using oral laxatives. Over half of patients with IASA had been treated with anal sphincter botulinum toxin injection, and 55% reported a positive response. CONCLUSIONS AND INFERENCES Patients diagnosed with IASA may represent a more severe patient population compared to patients with FC, but have a later onset of symptoms compared to patients with HD. They may require different treatments for their constipation and deserve further study.
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Affiliation(s)
- Desiree F. Baaleman
- Division of Pediatric Gastroenterology, Hepatology, and NutritionDepartment of PediatricsNationwide Children’s HospitalColumbusOHUSA
- Department of Pediatric Gastroenterology and NutritionEmma Children’s Hospital, Amsterdam UMCUniversity of Amsterdam & VU UniversityAmsterdamthe Netherlands
- Amsterdam UMCUniversity of Amsterdam, Gastroenterology and HepatologyAmsterdam Gastroenterology Endocrinology MetabolismAmsterdamthe Netherlands
| | - Monica Malamisura
- Division of Pediatric Gastroenterology, Hepatology, and NutritionDepartment of PediatricsNationwide Children’s HospitalColumbusOHUSA
- Digestive endoscopy and surgery UnitBambino Gesù Children’s Hospital IRCCSRomeItaly
| | - Marc A. Benninga
- Department of Pediatric Gastroenterology and NutritionEmma Children’s Hospital, Amsterdam UMCUniversity of Amsterdam & VU UniversityAmsterdamthe Netherlands
| | - Neetu Bali
- Division of Pediatric Gastroenterology, Hepatology, and NutritionDepartment of PediatricsNationwide Children’s HospitalColumbusOHUSA
| | - Karla H. Vaz
- Division of Pediatric Gastroenterology, Hepatology, and NutritionDepartment of PediatricsNationwide Children’s HospitalColumbusOHUSA
| | - Desale Yacob
- Division of Pediatric Gastroenterology, Hepatology, and NutritionDepartment of PediatricsNationwide Children’s HospitalColumbusOHUSA
| | - Carlo Di Lorenzo
- Division of Pediatric Gastroenterology, Hepatology, and NutritionDepartment of PediatricsNationwide Children’s HospitalColumbusOHUSA
| | - Peter L. Lu
- Division of Pediatric Gastroenterology, Hepatology, and NutritionDepartment of PediatricsNationwide Children’s HospitalColumbusOHUSA
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Impact of Botulinum Toxin on Hirschsprung-Associated Enterocolitis After Primary Pull-Through. J Surg Res 2021; 261:95-104. [PMID: 33422904 DOI: 10.1016/j.jss.2020.12.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 11/09/2020] [Accepted: 12/08/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Hirschsprung-associated enterocolitis (HAEC) is a serious potential complication after primary pull-through surgery for Hirschsprung's disease (HSCR). Administration of anal botulinum toxin (BT) injection may improve obstructive symptoms at the internal anal sphincter, leading to improved fecal passage. The timing of administration and effects on delay or prevention of HAEC are unknown. We hypothesized that BT administration increased the postoperative time to HAEC and aimed to investigate whether anal BT administration after primary pull-through surgery for HSCR is associated with increased time to inpatient HAEC admission development. METHODS We performed a retrospective cohort study examining children with HSCR at US children's hospitals from 2008 to 2018 using the Pediatric Health Information System database with an associated primary pull-through operation performed before 60 d of age. The intervention assessed was the administration of BT concerning the timing of primary pull-through, and two groups were identified: PRO (received BT at or after primary pull-through, before HAEC) and NOT (never received BT, or received BT after HAEC). The primary outcome was time from pull-through to the first HAEC admission. The Cox proportional hazards model was developed to examine the BT administration effect on the primary outcome after controlling for patient-level covariates. RESULTS We examined a total of 1439 children (67 in the PRO and 1372 in the NOT groups). A total of 308 (21.4%) developed at least one episode of HAEC, including 76 (5.3%) who had two or more episodes. Between 2008 and 2018, the frequency of BT administration has increased from three to 20 hospitals with a frequency of administration between 2.2% and 16.2%. Prophylactic BT (PRO) was not associated with increased time to HAEC event on adjusted analysis. CONCLUSIONS Among children with HSCR undergoing primary pull-through surgery, prophylactic BT administration did not demonstrate increased time to first HAEC event. A better-powered study with prophylactic BT is required to determine the effect on HAEC occurrence and timing. LEVEL OF EVIDENCE Level II (retrospective cohort study).
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Intrarectal Electromotive Botulinum Toxin Type A Administration in Children With Intractable Constipation: A Randomized Clinical Trial. Am J Gastroenterol 2020; 115:2060-2067. [PMID: 33009066 DOI: 10.14309/ajg.0000000000000940] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Children with refractory constipation might not respond to conventional medical treatments. In this study, we assessed the effectiveness of intrarectal botulinum toxin type A/electromotive drug administration (BoNTA/EMDA) on constipation in these children and compared its efficacy with routine intrasphincteric BoNTA injection. METHODS From 2017 to 2019, 60 children aged 5-13 years who fulfilled Rome III criteria for intractable constipation were enrolled and randomly assigned into 2 treatment groups. EMDA group (n = 30) underwent BoNTA/EMDA, whereas the control group (n = 30) received injection of BoNTA into the internal anal sphincter. A complete bowel habit diary (with data on the frequency of defecation per week, stool form, and the number of fecal soiling episodes), a constipation score questionnaire, and a visual pain score were recorded before treatment and at 1 month and 6 months after treatment. In addition, children in both groups were assessed with a constipation-related quality of life questionnaire. RESULTS After 1-month follow-up, treatment reduced the number of patients fulfilling the diagnostic criteria in both EMDA (24/30, 80%) and injection (25/30, 83.3%) groups (P < 0.001). The stool form was normalized in 73.3% (22/30) in EMDA group and 80% (24/30) in injection group after treatment. The median of constipation score and pain score decreased significantly in both groups after treatment (P < 0.001 and P < 0.001, respectively). DISCUSSION BoNTA/EMDA seems to be as effective as intrasphincteric BoNTA injection for treatment of intractable constipation. In addition, this technique is associated with less comorbidity, is less costly, and can be performed in an office-based setting without general anesthesia.
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Vilanova-Sanchez A, Levitt MA. Surgical Interventions for Functional Constipation: An Update. Eur J Pediatr Surg 2020; 30:413-419. [PMID: 32987436 DOI: 10.1055/s-0040-1716729] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Chronic idiopathic constipation, also known as functional constipation, is defined as difficult and infrequent defecation without an identifiable organic cause. Medical management with laxatives is effective for the majority of constipated children. However there is a subset of patients who may need evaluation by a surgeon. As constipation progresses, it can lead to fecal retention and rectal and sigmoid distension, which impairs normal colorectal motility. Surgical interventions are influenced by the results of: a rectal biopsy, transit studies, the presence of megacolon/megarectum on contrast enema, the degree of soiling/incontinence, anorectal manometry findings, and colonic motility evaluation. In this review, we describe the different surgical options available (intestinal diversion, antegrade enemas, sacral nerve stimulation, colonic resections, and Botulinum toxin injection) and provide guidance on how to choose the best procedure for a given patient.
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Affiliation(s)
- Alejandra Vilanova-Sanchez
- Deparment of Pediatric Surgery, Urogenital and Colorectal Unit, La Paz University Hospital Children Hospital, Madrid, Comunidad de Madrid, Spain
| | - Marc A Levitt
- Department of Pediatric Surgery, Children's National Medical Center, Washington, District of Columbia, United States
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Kyrklund K, Sloots CEJ, de Blaauw I, Bjørnland K, Rolle U, Cavalieri D, Francalanci P, Fusaro F, Lemli A, Schwarzer N, Fascetti-Leon F, Thapar N, Johansen LS, Berrebi D, Hugot JP, Crétolle C, Brooks AS, Hofstra RM, Wester T, Pakarinen MP. ERNICA guidelines for the management of rectosigmoid Hirschsprung's disease. Orphanet J Rare Dis 2020; 15:164. [PMID: 32586397 PMCID: PMC7318734 DOI: 10.1186/s13023-020-01362-3] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 03/18/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Hirschsprung's disease (HSCR) is a serious congenital bowel disorder with a prevalence of 1/5000. Currently, there is a lack of systematically developed guidelines to assist clinical decision-making regarding diagnostics and management. AIMS This guideline aims to cover the diagnostics and management of rectosigmoid HSCR up to adulthood. It aims to describe the preferred approach of ERNICA, the European Reference Network for rare inherited and congenital digestive disorders. METHODS Recommendations within key topics covering the care pathway for rectosigmoid HSCR were developed by an international workgroup of experts from 8 European countries within ERNICA European Reference Network from the disciplines of surgery, medicine, histopathology, microbiology, genetics, and patient organization representatives. Recommendation statements were based on a comprehensive review of the available literature and expert consensus. AGREE II and GRADE approaches were used during development. Evidence levels and levels of agreement are noted. RESULTS Thirty-three statements within 9 key areas were generated. Most recommendations were based on expert opinion. CONCLUSION In rare or low-prevalence diseases such as HSCR, there remains limited availability of high-quality clinical evidence. Consensus-based guidelines for care are presented.
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Affiliation(s)
- Kristiina Kyrklund
- Department of Pediatric Surgery, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| | - Cornelius E J Sloots
- Department of Pediatric Surgery, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Ivo de Blaauw
- Department of Surgery, Division of Pediatric Surgery, Radboudumc-Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Kristin Bjørnland
- Department of Pediatric Surgery, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Udo Rolle
- Department of Pediatric Surgery and Pediatric Urology, University Hospital Frankfurt, Frankfurt/M, Germany
| | - Duccio Cavalieri
- Department of Biology, University of Florence, A.Mor.Hi, The Italian Association for Hirschsprung's disease, Florence, Italy
| | - Paola Francalanci
- Pathology Unit, Bambino Gesù Children's Hospital, IRCSS, Rome, Italy
| | - Fabio Fusaro
- Neonatal Surgery Unit - Department of Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, IRCSS, Rome, Italy
| | - Annette Lemli
- SoMA, The German patient support organization for anorectal malformations and Hirschsprung Disease, Munich, Germany
| | - Nicole Schwarzer
- SoMA, The German patient support organization for anorectal malformations and Hirschsprung Disease, Munich, Germany
| | - Francesco Fascetti-Leon
- Pediatric Surgery, Department of Women's and Children's Health, University Hospital of Padua, Padua, Italy
| | - Nikhil Thapar
- UCL Great Ormond Street Institute of Child Health; Department of Pediatric Gastroenterology, Great Ormond Street Hospital for Children, London, UK
| | | | - Dominique Berrebi
- Department of Pediatric Pathology, Hôpital Universitaire Robert Debré, Paris Diderot University, Paris, France
| | - Jean-Pierre Hugot
- Department of Pediatric Gastroenterology, Hôpital Universitaire Robert Debré, Assistance Publique Hôpitaux de Paris, Université de Paris, Paris, France
| | - Célia Crétolle
- Department of Pediatric Surgery, University Hospital Necker-Enfants Malades, APHP centre, Paris University, Paris, France
| | - Alice S Brooks
- Department of Clinical Genetics, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Robert M Hofstra
- Department of Clinical Genetics, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Tomas Wester
- Department of Pediatric Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Mikko P Pakarinen
- Department of Pediatric Surgery, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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