1
|
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.
Collapse
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.
| |
Collapse
|
2
|
Melkonian V, Wehrli L, Bischoff A, Cooper EH, Ketzer J, Judd-Glossy L, de la Torre L. Transanal proximal rectosigmoidectomy: a single-center experience in surgically treated severe medically refractory idiopathic constipation. Pediatr Surg Int 2024; 40:169. [PMID: 38954056 DOI: 10.1007/s00383-024-05764-3] [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] [Accepted: 06/27/2024] [Indexed: 07/04/2024]
Abstract
PURPOSE To present the functional results after a transanal proximal rectosigmoidectomy in patients with severe idiopathic constipation in which medical treatment has failed. METHODS Patients with severe idiopathic constipation who underwent transanal proximal rectosigmoidectomy (TPRS) at Children's Hospital Colorado between June 2019 and March 2024 were included in the study. We compared multiple pre- and post-operative outcome measures and the patient's bowel regimen before and after resection. RESULTS Fourteen patients underwent TPRS, 10 of whom were male. The average age at the time of surgery was 10.1 years (range 5-19). Seven patients have moderate to severe autism. Constipation-related clinic visits, family calls, procedural intervention, emergency room visits, and hospitalizations notably decreased frequency after TPRS. Laxative dosages and enema volume requirements were also reduced after surgery. Before surgery, all the patients suffered from daily fecal accidents, while post-operatively, all were completely free of stool accidents. CONCLUSION In our experience, for patients who suffer from severe medically refractory idiopathic constipation, TPRS has provided improvement in their symptoms and decreased the complications inherent to this chronic disease. Parents and patients attest to a profound positive transformation in their quality of life after surgery.
Collapse
Affiliation(s)
- Vatche Melkonian
- International Center for Colorectal and Urogenital Care, Children's Hospital Colorado, Aurora, CO, USA.
| | - Lea Wehrli
- International Center for Colorectal and Urogenital Care, Children's Hospital Colorado, Aurora, CO, USA
| | - Andrea Bischoff
- International Center for Colorectal and Urogenital Care, Children's Hospital Colorado, Aurora, CO, USA
| | - Emily H Cooper
- Research Outcomes in Children's Surgery, Center for Children's Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jill Ketzer
- International Center for Colorectal and Urogenital Care, Children's Hospital Colorado, Aurora, CO, USA
| | - Laura Judd-Glossy
- International Center for Colorectal and Urogenital Care, Children's Hospital Colorado, Aurora, CO, USA
| | - Luis de la Torre
- International Center for Colorectal and Urogenital Care, Children's Hospital Colorado, Aurora, CO, USA
| |
Collapse
|
3
|
van der Zande JMJ, Lu PL. Review article: Management of the child with refractory constipation. Aliment Pharmacol Ther 2024. [PMID: 38923030 DOI: 10.1111/apt.17847] [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: 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.
Collapse
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
| |
Collapse
|
4
|
Quitadamo P, Tambucci R, Mancini V, Campanozzi A, Caldaro T, Giorgio V, Pensabene L, Isoldi S, Mallardo S, Fusaro F, Staiano A, Salvatore S, Borrelli O. Diagnostic and therapeutic approach to children with chronic refractory constipation: Consensus report by the SIGENP motility working group. Dig Liver Dis 2024; 56:406-420. [PMID: 38104028 DOI: 10.1016/j.dld.2023.11.037] [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: 04/21/2023] [Revised: 11/15/2023] [Accepted: 11/29/2023] [Indexed: 12/19/2023]
Abstract
Constipation is a common problem in children, accounting for about 3% of all primary care visits and up to 25% of referrals to paediatric gastroenterologists. Although polyethylene glycol often proves effective, most children require prolonged treatment and about 50% of them have at least one relapse within the first 5 years after initial recovery. When conventional treatment fails, children are considered to have refractory constipation. Children with refractory constipation deserve specialist management and guidance. Over the last decades, there has been a remarkable increase in our knowledge of normal and abnormal colonic and anorectal motility in children, and a number of different techniques to measure transit and motility have been developed. The present review analyses the possible diagnostic investigations for children with refractory constipation, focusing on their actual indications and their utility in clinical practice. Moreover, we have also analytically reviewed medical and surgical therapeutic options, which should be considered in selected patients in order to achieve the best clinical outcome.
Collapse
Affiliation(s)
- Paolo Quitadamo
- Pediatric Gastroenterology and Epatology Unit, Santobono-Pausilipon Children's Hospital, Naples, Italy.
| | - Renato Tambucci
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Valentina Mancini
- Department of Pediatrics and Neonatology, San Carlo Hospital, Milan, Italy
| | - Angelo Campanozzi
- Pediatrics, Department of Medical and Surgical Sciences, University of Foggia
| | - Tamara Caldaro
- Digestive Endoscopy and Surgery Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Valentina Giorgio
- UOC Pediatria, Fondazione Policlinico Universitario A. Gemelli IRCSS, Roma, Italy
| | - Licia Pensabene
- Department of Medical and Surgical Sciences, Pediatric Unit, University "Magna Graecia" of Catanzaro, Catanzaro, Italy
| | - Sara Isoldi
- Pediatric Gastroenterology and Epatology Unit, Santobono-Pausilipon Children's Hospital, Naples, Italy; Maternal and Child Health Department, Sapienza - University of Rome, Santa Maria Goretti Hospital, Polo Pontino, Latina, Italy
| | - Saverio Mallardo
- Maternal and Child Health Department, Sapienza - University of Rome, Santa Maria Goretti Hospital, Polo Pontino, Latina, Italy
| | - Fabio Fusaro
- Department of Medical and Surgical Neonatology, Newborn Surgery Unit, Digestive and Endoscopic Surgery, Gastroenterology and Nutrition, Intestinal Failure Rehabilitation Research Group, Bambino Gesù Children's Hospital Research Institute, Rome, Italy
| | - Annamaria Staiano
- Department of Translational Medical Science, Section of Pediatrics, University "Federico II", Naples, Italy
| | - Silvia Salvatore
- Pediatric Department, Ospedale "F. Del Ponte", University of Insubria, Varese, Italy
| | - Osvaldo Borrelli
- Division of Neurogastroenterology and Motility, Department of Paediatric Gastroenterology, UCL Institute of Child Health and Great Ormond Street Hospital, London, UK
| |
Collapse
|
5
|
Todhunter-Brown A, Booth L, Campbell P, Cheer B, Cowie J, Elders A, Hagen S, Jankulak K, Mason H, Millington C, Ogden M, Paterson C, Richardson D, Smith D, Sutcliffe J, Thomson K, Torrens C, McClurg D. Strategies used for childhood chronic functional constipation: the SUCCESS evidence synthesis. Health Technol Assess 2024; 28:1-266. [PMID: 38343084 PMCID: PMC11017632 DOI: 10.3310/pltr9622] [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: 02/15/2024] Open
Abstract
Background Up to 30% of children have constipation at some stage in their life. Although often short-lived, in one-third of children it progresses to chronic functional constipation, potentially with overflow incontinence. Optimal management strategies remain unclear. Objective To determine the most effective interventions, and combinations and sequences of interventions, for childhood chronic functional constipation, and understand how they can best be implemented. Methods Key stakeholders, comprising two parents of children with chronic functional constipation, two adults who experienced childhood chronic functional constipation and four health professional/continence experts, contributed throughout the research. We conducted pragmatic mixed-method reviews. For all reviews, included studies focused on any interventions/strategies, delivered in any setting, to improve any outcomes in children (0-18 years) with a clinical diagnosis of chronic functional constipation (excluding studies of diagnosis/assessment) included. Dual reviewers applied inclusion criteria and assessed risk of bias. One reviewer extracted data, checked by a second reviewer. Scoping review: We systematically searched electronic databases (including Medical Literature Analysis and Retrieval System Online, Excerpta Medica Database, Cumulative Index to Nursing and Allied Health Literature) (January 2011 to March 2020) and grey literature, including studies (any design) reporting any intervention/strategy. Data were coded, tabulated and mapped. Research quality was not evaluated. Systematic reviews of the evidence of effectiveness: For each different intervention, we included existing systematic reviews judged to be low risk of bias (using the Risk of Bias Assessment Tool for Systematic Reviews), updating any meta-analyses with new randomised controlled trials. Where there was no existing low risk of bias systematic reviews, we included randomised controlled trials and other primary studies. The risk of bias was judged using design-specific tools. Evidence was synthesised narratively, and a process of considered judgement was used to judge certainty in the evidence as high, moderate, low, very low or insufficient evidence. Economic synthesis: Included studies (any design, English-language) detailed intervention-related costs. Studies were categorised as cost-consequence, cost-effectiveness, cost-utility or cost-benefit, and reporting quality evaluated using the consensus health economic criteria checklist. Systematic review of implementation factors: Included studies reported data relating to implementation barriers or facilitators. Using a best-fit framework synthesis approach, factors were synthesised around the consolidated framework for implementation research domains. Results Stakeholders prioritised outcomes, developed a model which informed evidence synthesis and identified evidence gaps. Scoping review 651 studies, including 190 randomised controlled trials and 236 primary studies, conservatively reported 48 interventions/intervention combinations. Effectiveness systematic reviews studies explored service delivery models (n = 15); interventions delivered by families/carers (n = 32), wider children's workforce (n = 21), continence teams (n = 31) and specialist consultant-led teams (n = 42); complementary therapies (n = 15); and psychosocial interventions (n = 4). One intervention (probiotics) had moderate-quality evidence; all others had low to very-low-quality evidence. Thirty-one studies reported evidence relating to cost or resource use; data were insufficient to support generalisable conclusions. One hundred and six studies described implementation barriers and facilitators. Conclusions Management of childhood chronic functional constipation is complex. The available evidence remains limited, with small, poorly conducted and reported studies. Many evidence gaps were identified. Treatment recommendations within current clinical guidelines remain largely unchanged, but there is a need for research to move away from considering effectiveness of single interventions. Clinical care and future studies must consider the individual characteristics of children. Study registration This study is registered as PROSPERO CRD42019159008. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 128470) and is published in full in Health Technology Assessment; Vol. 28, No. 5. See the NIHR Funding and Awards website for further award information.
Collapse
Affiliation(s)
- Alex Todhunter-Brown
- Nursing, Midwifery and Allied Health Professions (NMAHP) Research Unit, Glasgow Caledonian University, Glasgow, UK
| | - Lorna Booth
- Nursing, Midwifery and Allied Health Professions (NMAHP) Research Unit, Glasgow Caledonian University, Glasgow, UK
| | - Pauline Campbell
- Nursing, Midwifery and Allied Health Professions (NMAHP) Research Unit, Glasgow Caledonian University, Glasgow, UK
| | - Brenda Cheer
- ERIC, The Children's Bowel and Bladder Charity, Bristol, UK
| | - Julie Cowie
- Nursing, Midwifery and Allied Health Professions (NMAHP) Research Unit, Glasgow Caledonian University, Glasgow, UK
| | - Andrew Elders
- Nursing, Midwifery and Allied Health Professions (NMAHP) Research Unit, Glasgow Caledonian University, Glasgow, UK
| | - Suzanne Hagen
- Nursing, Midwifery and Allied Health Professions (NMAHP) Research Unit, Glasgow Caledonian University, Glasgow, UK
| | | | - Helen Mason
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Glasgow, UK
| | | | | | - Charlotte Paterson
- Nursing, Midwifery and Allied Health Professions (NMAHP) Research Unit, University of Stirling, Stirling, UK
| | | | | | | | - Katie Thomson
- Nursing, Midwifery and Allied Health Professions (NMAHP) Research Unit, Glasgow Caledonian University, Glasgow, UK
- Department of Occupational Therapy, Human Nutrition and Dietetics, Glasgow Caledonian University, Glasgow, UK
| | - Claire Torrens
- Nursing, Midwifery and Allied Health Professions (NMAHP) Research Unit, University of Stirling, Stirling, UK
| | - Doreen McClurg
- Nursing, Midwifery and Allied Health Professions (NMAHP) Research Unit, Glasgow Caledonian University, Glasgow, UK
| |
Collapse
|
6
|
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.
Collapse
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
| |
Collapse
|
7
|
Bokova E, Svetanoff WJ, Levitt MA, Rentea RM. Pediatric Bowel Management Options and Organizational Aspects. CHILDREN 2023; 10:children10040633. [PMID: 37189882 DOI: 10.3390/children10040633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 03/20/2023] [Accepted: 03/22/2023] [Indexed: 03/30/2023]
Abstract
A bowel management program (BMP) to treat fecal incontinence and severe constipation is utilized for patients with anorectal malformations, Hirschsprung disease, spinal anomalies, and functional constipation, decreasing the rate of emergency department visits, and hospital admissions. This review is part of a manuscript series and focuses on updates in the use of antegrade flushes for bowel management, as well as organizational aspects, collaborative approach, telemedicine, the importance of family education, and one-year outcomes of the bowel management program. Implementation of a multidisciplinary program involving physicians, nurses, advanced practice providers, coordinators, psychologists, and social workers leads to rapid center growth and enhances surgical referrals. Education of the families is crucial for postoperative outcomes, prevention, and early detection of complications, especially Hirschsprung-associated enterocolitis. Telemedicine can be proposed to patients with a defined anatomy and is associated with high parent satisfaction and decreased patient stress in comparison to in-person visits. The BMP has proved to be effective in all groups of colorectal patients at a 1- and 2-year follow-up with social continence achieved in 70–72% and 78% of patients, respectively, and an improvement in the patients’ quality of life. A transitional care to adult program is essential to maintain the same quality of care, and continuity of care and to achieve desired long-term outcomes as the patient reaches adult age.
Collapse
|
8
|
Patient driven change: Is collaborative care the future of medicine? Lessons learned from the care of children with colorectal problems. J Pediatr Surg 2023; 58:189-197. [PMID: 36418202 DOI: 10.1016/j.jpedsurg.2022.10.023] [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: 09/28/2022] [Accepted: 10/11/2022] [Indexed: 11/21/2022]
Abstract
A basic premise in the care of complex patients is that experience, increased volume of cases, and an integrated, multi-disciplinary approach yields improved outcomes. Is this true using the example of the care of children with colorectal and pelvic reconstructive needs? This review gives a brief historical context on how care for this patient group evolved, delineates the key elements to create a collaborative care model, and describes multiple advances that have been developed, based on the model, which have improved patient care and quality of life. LEVEL OF EVIDENCE: Review.
Collapse
|
9
|
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.
Collapse
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.
| |
Collapse
|
10
|
Smith CA, Kwon EG, Nicassio L, Glazer D, Avansino J, Durham MM, Frischer J, Calkins C, Rentea RM, Ralls M, Saadai P, Badillo A, Fuller M, Wood RJ, Rollins MD, Van Leeuwen K, Reeder RW, Lewis KE, Rice-Townsend SE. Fecal continence disparities in patients with idiopathic constipation treated at referral institutions for pediatric colorectal surgery. J Pediatr Surg 2023; 58:56-63. [PMID: 36283846 DOI: 10.1016/j.jpedsurg.2022.09.024] [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: 09/01/2022] [Accepted: 09/16/2022] [Indexed: 01/07/2023]
Abstract
PURPOSE Fecal continence is a concern for many patients with idiopathic constipation and can significantly impact quality of life. It is unknown whether racial, ethnic, and socioeconomic disparities are seen in fecal continence within the idiopathic constipation population. We aimed to evaluate fecal continence and associated demographic characteristics in children with idiopathic constipation referred for surgical evaluation. METHODS A multicenter retrospective study of children with idiopathic constipation was performed at sites participating in the Pediatric Colorectal and Pelvic Learning Consortium (PCPLC). All patients >3y of age with idiopathic constipation diagnosis were included. The primary outcome was fecal continence, categorized as complete (no accidents ever), daytime (no accidents during the day), partial (occasional incontinence day/night), and none (incontinent). We evaluated for associations between fecal continence and race, sex, age, insurance status, and other patient-level factors, employing Kruskal-Wallis and trend tests. RESULTS 458 patients with idiopathic constipation from 12 sites were included. The median age of diagnosis was 4.1 years. Only 25% of patients referred for surgical evaluation were completely continent. Age at the visit was significantly associated with fecal continence level (p = 0.002). In addition, patients with public and mixed public and private insurance had lower levels of continence (p<0.001). Patients with developmental delay were also more likely to have lower continence levels (p = 0.009) while diagnoses such as anxiety, ADD/ADHD, autism, depression, obsessive-compulsive disorder were not associated. Approximately 30% of patients had an ACE operation (antegrade continence enema) at a median age of 9.2 years at operation. Black patients were significantly less likely to undergo ACE operation (p = 0.016) when compared to white patients. CONCLUSION We observed data that suggest differences in fecal incontinence rates based on payor status. Further investigation is needed to characterize these potential areas of disparate care. LEVEL OF EVIDENCE Level III.
Collapse
Affiliation(s)
| | - Eustina G Kwon
- Seattle Children's Hospital, Seattle, WA, United States.
| | | | - Deb Glazer
- Seattle Children's Hospital, Seattle, WA, United States
| | | | - Megan M Durham
- Emory + Children's Pediatric Institute, Atlanta, GA, United States
| | - Jason Frischer
- Cincinnati Children's Hospital, Cincinnati, OH, United States
| | - Casey Calkins
- Children's Hospital of Wisconsin, Milwaukee, WI, United States
| | | | - Matthew Ralls
- C.S. Mott Children's Michigan, Ann Arbor, MI, United States
| | | | | | - Megan Fuller
- Boys Town National Research Hospital, Boys Town, NE, United States
| | - Richard J Wood
- Nationwide Children's Hospital, Columbus, OH, United States
| | - Michael D Rollins
- Primary Children's Hospital, University of Utah, Salt Lake City, UT, United States
| | | | - Ron W Reeder
- University of Utah, Salt Lake City, UT, United States
| | | | | | | |
Collapse
|
11
|
Tan YW, Chacon CS, Geoghegan N, Saxena A, Clarke S, Haddad M, Choudhry M. Late Diagnosis of Hirschsprung's Disease: Definition and Implication on Core Outcomes. Eur J Pediatr Surg 2022; 32:512-520. [PMID: 35263774 DOI: 10.1055/s-0042-1744147] [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: 11/04/2022]
Abstract
INTRODUCTION Late diagnosis of Hirschsprung's disease (LDHD) may carry a poor prognosis. Its definition remains unclear and its implication on HD-related core outcomes has not been fully reported. METHODS A single-center 20-year series was reviewed to include HD with follow-up of 1 year or more post pull-through (PT) and aged 5 years or older. We investigated six core outcomes derived from NETS1HD study by comparing the groups dichotomized by four time points using age at diagnosis (44-week gestation, 6 months, 1 year, and 3 years). Following establishment of definition of LDHD, the outcomes and complications were compared with timely diagnosis of HD (TDHD). RESULTS Forty-nine out of eighty-six HD were included. The definition of LDHD was found to be HD diagnosed at 1 year of age or later because 3/6 core outcomes were significantly worse than TDHD. Nine patients (18%) had LDHD-median age at diagnosis 42 months (12-89) and PT performed at 57 months (12-103), mostly Soave (73%); a covering stoma was performed in 7/9, significantly higher than TDHD in 10/40 (p = 0.001). LDHD was associated with increased unplanned surgery (78% vs. 30%, p = 0.019), fecal incontinence (100% vs. 62%, p = 0.01), and permanent stoma (33% vs. 5%, p = 0.037). Major complications (56% vs. 20%, p = 0.043) and redo PT (33% vs. 5%, p = 0.037) were also higher in LDHD. CONCLUSION LDHD could be defined as HD diagnosis at or over 1 year of age. LDHD was associated with more preoperative stoma, major postoperative complications, unplanned reoperation, and worse HD-related core outcomes.
Collapse
Affiliation(s)
- Yew-Wei Tan
- Department of Paediatric Surgery, Chelsea and Westminster Hospital, Chelsea, London, United Kingdom
| | - Carmen Sofia Chacon
- Department of Paediatric Surgery, Chelsea and Westminster Hospital, Chelsea, London, United Kingdom
| | - Niamh Geoghegan
- Department of Paediatric Surgery, Chelsea and Westminster Hospital, Chelsea, London, United Kingdom
| | - Amulya Saxena
- Department of Paediatric Surgery, Chelsea and Westminster Hospital, Chelsea, London, United Kingdom.,Department of Paediatric Surgery, Imperial College London, London, United Kingdom
| | - Simon Clarke
- Department of Paediatric Surgery, Chelsea and Westminster Hospital, Chelsea, London, United Kingdom.,Department of Paediatric Surgery, Imperial College London, London, United Kingdom
| | - Munther Haddad
- Department of Paediatric Surgery, Chelsea and Westminster Hospital, Chelsea, London, United Kingdom.,Department of Paediatric Surgery, Imperial College London, London, United Kingdom
| | - Muhammad Choudhry
- Department of Paediatric Surgery, Chelsea and Westminster Hospital, Chelsea, London, United Kingdom
| |
Collapse
|
12
|
Rajindrajith S, Devanarayana NM, Benninga MA. Childhood constipation: Current status, challenges, and future perspectives. World J Clin Pediatr 2022; 11:385-404. [PMID: 36185096 PMCID: PMC9516492 DOI: 10.5409/wjcp.v11.i5.385] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 12/23/2021] [Accepted: 07/06/2022] [Indexed: 02/05/2023] Open
Abstract
Constipation in children is a major health issue around the world, with a global prevalence of 9.5%. They present to clinicians with a myriad of clinical signs. The Rome IV symptom-based criteria are used to diagnose functional constipation. Functional constipation is also a huge financial burden for healthcare system and has a detrimental impact on health-related quality of life of children. There are various risk factors identified globally, including centrally connected factors such as child abuse, emotional and behavioral issues, and psychological stress. Constipation is also precipitated by a low-fiber diet, physical inactivity, and an altered intestinal microbiome. The main pathophysiological mechanism is stool withholding, while altered rectal function, anal sphincter, pelvic floor, and colonic dysfunction also play important roles. Clinical evaluation is critical in making a diagnosis, and most investigations are only required in refractory patients. In the treatment of childhood constipation, both nonpharmacological (education and de-mystification, dietary changes, toilet training, behavioral interventions, biofeedback, and pelvic floor physiotherapy), and pharmacological (osmotic and stimulant laxatives and novel drugs like prucalopride and lubiprostone) interventions are used. For children with refractory constipation, transanal irrigation, botulinum toxin, neuromodulation, and surgical treatments are reserved. While frequent use of probiotics is still in the experimental stage, healthy dietary habits, living a healthy lifestyle and limiting exposure to stressful events, are all beneficial preventive measures.
Collapse
Affiliation(s)
- Shaman Rajindrajith
- Department of Paediatrics, Faculty of Medicine, University of Colombo, Colombo 00800, Sri Lanka
- University Paediatric Unit, Lady Ridgeway Hospital for Children, Colombo 00800, Sri Lanka
| | | | - Marc A Benninga
- Department of Pediatric Gastroenterology and Nutrition, Emma Children Hospital, Amsterdam University Medical Center, Amsterdam 1105AZ, The Netherlands
| |
Collapse
|
13
|
Tan YW, Chacon CS, Sherwood W, Haddad M, Choudhry M. A Critical Analysis of Rectal Biopsy to Exclude Hirschsprung's Disease. Eur J Pediatr Surg 2022; 32:184-190. [PMID: 33550578 DOI: 10.1055/s-0041-1722858] [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: 12/11/2022]
Abstract
INTRODUCTION Most Hirschsprung's disease (HD) are diagnosed in young children with increased risk ("red flag"). Older children (>6 months) require open rectal biopsy (ORB) with its own impact on risk and resources. We investigated if "red flag", age, and sex used in combination could exclude HD. MATERIALS AND METHODS "Red flags" are risk factors associated with HD, including neonatal bowel obstruction, genetic association, failure of passage of meconium in <48 hours, infantile constipation, distension with vomiting, or family history. All rectal biopsies (2015-2018) were reviewed for indications, methods, and histopathological findings. Logistic regression analysis was adopted to assess predictive value of "red flag," age, and sex (p < 0.05* was significant). RESULTS A total of 187 children underwent 84 suction rectal biopsies and 113 ORBs (n = 197 in total). Final histopathological diagnoses were non-HD (n = 154) and HD (n = 43). Total 78% of rectal biopsies were non-HD, of which 63% by ORB. Non-HD was associated with absence of "red flag" (49 vs. 16%*), increased age at biopsy (22 months vs. 28 days*), >6 months old (62 vs. 30%*), and female gender (54 vs. 16%*), compared with HD. In the absence of "red flag," 7/82 (9%) had HD (negative predictive value = 91%). Logistic regression analysis found absent "red flag" predicted non-HD biopsy with odds ratio 4.77 (1.38, 16.47), corrected for age and sex. CONCLUSION Negative rectal biopsy rate for HD is very high. The majority required ORB. Although "red flag" and gender, but not age, have strong predictive values, it is inadequate for excluding HD. This study supports the need for alternative strategies in excluding HD.
Collapse
Affiliation(s)
- Yew-Wei Tan
- Department of Paediatric Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - Carmen Sofia Chacon
- Department of Paediatric Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - William Sherwood
- Department of Paediatric Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - Munther Haddad
- Department of Paediatric Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| | - Muhammad Choudhry
- Department of Paediatric Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, United Kingdom
| |
Collapse
|
14
|
Leung AK, Hon KL. Paediatrics: how to manage functional constipation. Drugs Context 2021; 10:dic-2020-11-2. [PMID: 33828605 PMCID: PMC8007206 DOI: 10.7573/dic.2020-11-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 01/06/2021] [Indexed: 12/22/2022] Open
Abstract
Background Despite being a common problem in childhood, functional constipation is often difficult to manage. This article provides a narrative updated review on the evaluation, diagnosis and management of childhood functional constipation. Methods A PubMed search was performed with Clinical Queries using the key term ‘functional constipation’. The search strategy included clinical trials, meta-analyses, randomized controlled trials, observational studies and reviews. The search was restricted to the English literature and to the paediatric population. The information retrieved from the above search was used in the compilation of the present article. Results A detailed history and thorough physical examination are important in the evaluation of a child with constipation to establish the diagnosis of functional constipation as per the Rome IV criteria and to catch ‘red flags’ suggestive of organic causes of constipation. These ‘red flags’ include delayed passage of meconium, ribbon stool, rectal bleeding/blood in the stool unless attributable to an anal fissure, failure to thrive, severe abdominal distension, absent anal wink/cremasteric reflex, tight and empty rectum on digital examination and explosive expulsion of liquid stool and gas on withdrawal of the finger, hair tuft/dimple/lipoma/haemangioma in the lumbosacral area, and an anteriorly displaced anus. For functional constipation, pharmacological therapy consists of faecal disimpaction and maintenance therapy. This can be effectively accomplished with oral medications, rectal medications or a combination of both. The most commonly used and most effective laxative is polyethylene glycol. Non-pharmacological management consists of education, behavioural modification and dietary interventions. The combination of pharmacological therapy and non-pharmacological management increases the chance of success. Conclusion Polyethylene glycol is the medication of first choice for both disimpaction and maintenance therapy. If polyethylene glycol is not available or is poorly tolerated, lactulose is the preferred alternative. Other laxatives may be considered as second-line therapy if treatment with osmotic laxatives fails or is insufficient. Maintenance treatment should be continued for at least 2 months. Early treatment will result in a faster and shorter treatment course.
Collapse
Affiliation(s)
- Alexander Kc Leung
- Department of Pediatrics, University of Calgary, and Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Kam Lun Hon
- Department of Paediatrics, The Chinese University of Hong Kong, Shatin, Hong Kong.,Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong
| |
Collapse
|
15
|
Levitt MA. New and exciting advances in pediatric colorectal and pelvic reconstructive surgery - 2021 update. Semin Pediatr Surg 2020; 29:150992. [PMID: 33288140 DOI: 10.1016/j.sempedsurg.2020.150992] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Caring for children with colorectal and pelvic reconstructive needs is complex and requires a lifelong commitment from clinicians devoted to the field. There has been a myriad of advances that have improved care and it has become clear that an integrated, multi-disciplinary approach maximizes the goal of improving the quality of life of children afflicted with these conditions. The purpose of this review is to briefly discuss the history of this field and to describe the key advances that have improved patients' lives.
Collapse
|
16
|
Zhang N, Hou L, Yan P, Li X, Wang Y, Niu J, Feng L, Li J, Yang K, Liu X. Electro-acupuncture vs. sham electro-acupuncture for chronic severe functional constipation: A systematic review and meta-analysis. Complement Ther Med 2020; 54:102521. [PMID: 33183657 DOI: 10.1016/j.ctim.2020.102521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 07/17/2020] [Accepted: 07/17/2020] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES To assess the efficacy of electro-acupuncture (EA) relative to sham electro-acupuncture (sham EA) in treating chronic severe functional constipation (CSFC). METHODS A comprehensive search for relevant studies published between January 1, 1951 and May 14, 2020 was conducted in PubMed, the Cochrane Library, Chinese Biomedical Literature Database, Web of Science, and EMbase. Two investigators independently selected studies, extracted data, and assessed the quality of the included studies. The software Endnote X9 was used for screening articles, and the Review Manager 5.3 for analyzing data. RESULTS The meta-analyses involved 6 studies and 1457 individuals. The pooled results favored the EA group for the increase of complete spontaneous bowel movements (CSBMs) per week in the fourth week (MD = 0.80, P = 0.001) during treatment, and further improved in the eight weeks (MD = 1.25, P < 0.001). During the follow-up period, significant changes in CSBMs per week were seen in the experimental group (MD = 1.38, P = 0.008); the effect decreased in the twelfth week (MD = 0.87, P < 0.001). There was no significant difference in the Bristol stool scale score between the two groups in the fourth week (MD = 0.40, P = 0.08), but significant differences were observed in the eighth week (MD = 0.40, P = 0.03). A significant reduction in patient assessment of constipation quality of life (PAC-QOL) score were observed in the EA group during treatment (SMD = -0.83, P < 0.001). No serious adverse events were reported. CONCLUSIONS EA had favorable effects on CSFC, and the longer the treatment duration was, the better was the effect, but the effect showed a certain period of validity. However, the results may be influenced by the clinical heterogeneity of acupuncture points, depth of needling, intensity, and frequency of EA.
Collapse
Affiliation(s)
- Na Zhang
- School of Public Health, Evidence-Based Social Science Research Center, Lanzhou University, Lanzhou, China; Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China; Evidence Based Social Science Research Center, Lanzhou University, Lanzhou, China; Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, China
| | - Liangying Hou
- School of Public Health, Evidence-Based Social Science Research Center, Lanzhou University, Lanzhou, China; Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China; Evidence Based Social Science Research Center, Lanzhou University, Lanzhou, China; Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, China
| | - Peijing Yan
- Department of Epidemiology and Health Statistics, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Xiuxia Li
- School of Public Health, Evidence-Based Social Science Research Center, Lanzhou University, Lanzhou, China; Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China; Evidence Based Social Science Research Center, Lanzhou University, Lanzhou, China; Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, China
| | - Yongfeng Wang
- Gansu University of Chinese Medicine, Lanzhou, China
| | - Junqiang Niu
- The First Hospital of Lanzhou University, Lanzhou, China
| | - Lufang Feng
- School of Public Health, Evidence-Based Social Science Research Center, Lanzhou University, Lanzhou, China; Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China; Evidence Based Social Science Research Center, Lanzhou University, Lanzhou, China; Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, China
| | - Jingwen Li
- School of Public Health, Evidence-Based Social Science Research Center, Lanzhou University, Lanzhou, China; Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China; Evidence Based Social Science Research Center, Lanzhou University, Lanzhou, China; Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, China
| | - Kehu Yang
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China; Evidence Based Social Science Research Center, Lanzhou University, Lanzhou, China; Key Laboratory of Evidence Based Medicine and Knowledge Translation of Gansu Province, Lanzhou, China; Department of Epidemiology and Health Statistics, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China.
| | - Xingrong Liu
- School of Public Health, Evidence-Based Social Science Research Center, Lanzhou University, Lanzhou, China.
| |
Collapse
|
17
|
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.
Collapse
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
| |
Collapse
|
18
|
Ambartsumyan L, Khlevner J, Nurko S, Rosen R, Kaul A, Pandolfino JE, Ratcliffe E, Yacob D, Li BU, Punati J, Sood M, Rao SSC, Levitt MA, Cocjin J, Rodriguez L, Flores A, Rosen JM, Belkind-Gerson J, Saps M, Garza JM, Fortunato J, Schroedl RL, Keefer L, Friedlander J, Heuckeroth RO, Rao M, El-Chammas K, Vaz K, Chumpitazi BP, Sanghavi R, Matta S, Danialifar T, Di Lorenzo C, Darbari A. Proceedings of the 2018 Advances In Motility and In NeuroGastroenterology: AIMING for the Future Single Topic Symposium. J Pediatr Gastroenterol Nutr 2020; 71:e59-e67. [PMID: 32287151 PMCID: PMC8451965 DOI: 10.1097/mpg.0000000000002720] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Motility and functional disorders are common in children and often debilitating, yet these disorders remain challenging to treat effectively. At the 2018 Annual North American Society for Pediatric Gastroenterology, Hepatology and Nutrition meeting, the Neurogastroenterology and Motility Committee held a full day symposium entitled, 2018 Advances In Motility and In NeuroGastroenterology - AIMING for the future. The symposium aimed to explore clinical paradigms in pediatric gastrointestinal motility disorders and provided a foundation for advancing new scientific and therapeutic research strategies. METHODS The symposium brought together leading experts throughout North America to review the state of the art in the diagnosis and management of motility and functional disorders in children. Presentations were divided into esophageal, antral duodenal, and colorectal modules. Each module included oral presentations by experts in the respective fields, leading to thought-provoking discussions. There were 2 breakout sessions with small group discussions on select topics, focusing on defining scientific insights into the diagnosis and management of pediatric functional gastrointestinal and motility disorders in a systematic, segment-based approach. CONCLUSIONS The field of neurogastroenterology has made remarkable progress in the last decade. The current report summarizes the major learning points from the symposium highlighting the diagnosis and promising therapies on the horizon for pediatric neurogastrointestinal and motility disorders.
Collapse
Affiliation(s)
| | - Julie Khlevner
- Division of Gastroenterology, Hepatology and Nutrition, Columbia University College of Physicians and Surgeons, New York, NY
| | - Samuel Nurko
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA
| | - Rachel Rosen
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA
| | - Ajay Kaul
- Division of Gastroenterology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229
| | - John E. Pandolfino
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, IL
| | | | - Desale Yacob
- Division of Gastroenterology, Nationwide Children’s Hospital, Columbus, OH
| | - B U.K. Li
- Division of Pediatric Gastroenterology and Nutrition, Medical College of Wisconsin, Milwaukee, WI
| | - Jaya Punati
- Division of Gastroenterology, Children’s Hospital of Los Angeles, Los Angeles, CA
| | - Manu Sood
- Division of Pediatric Gastroenterology and Nutrition, Medical College of Wisconsin, Milwaukee, WI
| | - Satish SC Rao
- Division of Gastroenterology, Department of Medicine, Augusta University Medical Center, Augusta, GA
| | - Marc A Levitt
- Division of Colorectal Surgery, Children’s National Hospital, Washington, DC
| | - Jose Cocjin
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children’s Mercy Kansas City, Kansas City, MO
| | - Leonel Rodriguez
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Yale School of Medicine, New Haven, CT
| | - Alejandro Flores
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA
| | - John M Rosen
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children’s Mercy Kansas City, Kansas City, MO
| | - Jaime Belkind-Gerson
- Division of Gastroenterology, Hepatology and Nutrition, Children’s Hospital of Colorado, Aurora, CO
| | - Miguel Saps
- Division of Pediatric Gastroenterology and Nutrition, University of Miami, Miami, FL
| | - Jose M Garza
- Children’s Center for Digestive Health Care, Atlanta, GA
| | - John Fortunato
- Division of Gastroenterology, Ann & Robert H Lurie Children’s Hospital, Chicago, IL
| | - Rose L Schroedl
- Division of Gastroenterology, Nationwide Children’s Hospital, Columbus, OH
| | - Laurie Keefer
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Joel Friedlander
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Yale School of Medicine, New Haven, CT
| | - Robert O. Heuckeroth
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania and The Children's Hospital of Philadelphia - Research Institute, Philadelphia, PA
| | - Meenakshi Rao
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA
| | - Khalil El-Chammas
- Division of Gastroenterology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229
| | - Karla Vaz
- Division of Gastroenterology, Nationwide Children’s Hospital, Columbus, OH
| | | | - Rina Sanghavi
- Division of Pediatric Gastroenterology, University of Texas Southwestern Medical Center Dallas, TX
| | - Sravan Matta
- Pediatric Gastroenterology and Nutrition, Kaiser Permanente Sacramento Medical Center, Sacramento, CA
| | - Tanaz Danialifar
- Division of Gastroenterology, Children’s Hospital of Los Angeles, Los Angeles, CA
| | - Carlo Di Lorenzo
- Division of Gastroenterology, Nationwide Children’s Hospital, Columbus, OH
| | - Anil Darbari
- Division of Pediatric Gastroenterology and Nutrition, Children’s National Hospital, Washington, DC
| |
Collapse
|
19
|
Chen Y, Xu M, Hou T, Wang L, Feng X, Li Y. Efficacy and safety of moxibustion for patients with functional constipation: A protocol for systematic review and meta analysis. Medicine (Baltimore) 2020; 99:e20910. [PMID: 32664085 PMCID: PMC7360324 DOI: 10.1097/md.0000000000020910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 05/26/2020] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION The objective of this review is to assess the efficacy and safety of moxibustion for treating patients with functional constipation (FC). METHODS AND ANALYSIS We will electronically search the following databases: OVID MEDLINE, EMBASE, PubMed, Web of Science, the Cochrane Central Register of Controlled Trials, Cochrane library, CINAHL, AMED, China Network Knowledge Infrastructure, Wan-fang Database, China Biomedical Literature Database, and other resources from inception to October 2019, without any language restrictions. Randomised-controlled trials will be included. The primary outcome is the improvement in mean complete spontaneous bowel movements and stool form (utilize the Bristol Stool Form Scale [BSFS]). Secondary outcomes involve the degree of difficulty in defecation, proportion of responders, mean transit time, health-related quality of life, and adverse events rate. The methodological quality will be assessed using the Cochrane risk of bias tool. RESULTS This work will summarize clinical evidence to assess the effectiveness and safety of moxibustion treatment for FC patients. CONCLUSION This systematic review and meta-analysis will provide current evidence of the efficacy and safety of moxibustion treating FC. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42020157955.
Collapse
|
20
|
Svetanoff WJ, Dekonenko C, Dorman RM, Osuchukwu O, Carrasco A, Gatti JM, Rentea RM. Optimization of Pediatric Bowel Management Using an Antegrade Enema Troubleshooting Algorithm. J Surg Res 2020; 254:247-254. [PMID: 32480068 DOI: 10.1016/j.jss.2020.04.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/17/2020] [Accepted: 04/18/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND A successful flush is the ability to flush through the appendicostomy or cecostomy channel, empty the flush through the colon, and achieve fecal cleanliness. We evaluated our experience with patients who were having flush difficulties based on a designed algorithm. METHODS Eight patients with flush difficulties were initially evaluated. Based on the need for additional surgery versus changes in bowel management therapy (BMT), we developed an algorithm to guide future management. The algorithm divided flush issues into before, during, and after flushing. Children aged <20 y who presented with flush issues from September 2018 to August 2019 were evaluated to determine our algorithm's efficacy. Specific outcomes analyzed included changes in BMT versus need for additional surgery. RESULTS After algorithm creation, 29 patients were evaluated for flush issues. The median age was 8.4 y (interquartile range: 6, 14); 66% (n = 19) were men. Underlying diagnoses included anorectal malformations (n = 17), functional constipation (n = 7), Hirschsprung's disease (n = 2), spina bifida (n = 2), and prune belly (n = 1). A total of 35 flush issues/complaints were noted: 29% before the flush, 9% during the flush, and 63% after the flush. Eighty percent of issues before the flush required surgical intervention, wherease 92% of issues during or after the flush were managed with changes in BMT. CONCLUSIONS Most flush issues respond to changes in BMT. This algorithm can help delineate which types of flush issues would benefit from surgical intervention and what problems might be present if patients are not responding to changes in their flush regimen.
Collapse
Affiliation(s)
| | | | - Robert M Dorman
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO
| | - Obiyo Osuchukwu
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO
| | - Alonso Carrasco
- Department of Urology, Children's Mercy Hospital, Kansas City, MO
| | - John M Gatti
- Department of Urology, Children's Mercy Hospital, Kansas City, MO
| | - Rebecca M Rentea
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO.
| |
Collapse
|
21
|
Noviello C, Nobile S, Romano M, Mazzarini A, Papparella A, Cobellis G. Functional constipation or redundancy of the colon? Indian J Gastroenterol 2020; 39:147-152. [PMID: 32406008 DOI: 10.1007/s12664-020-01034-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 03/26/2020] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Constipation is a common problem in children, and most of the time, the cause is defined as functional. Our hypothesis is that children with functional refractory constipation had anatomic alterations of the colon. METHODS All children with chronic refractory constipation who visited our centre underwent accurate clinical examination, contrast enema (CE), anorectal manometry (ARM) and rectal suction biopsies (RSB). In case of functional constipation, three operators measured the size of the colon using radiograms and calculated the ratio based on the width of the second lumbar vertebra. The measurements carried out were compared with those reported in the literature on patients of the same age without constipation. RESULTS Over a period of 24 months, 69 patients with chronic refractory constipation, aged between 1 and 14 years, visited our department. A CE was performed on 67, and 2 were excluded because of anal stenosis. Sixty-five underwent anorectal manometry. Rectal suction biopsies were needed in 14 children, and 2 of them were found to have colonic aganglionosis. After a complete evaluation, 57 (82.61%) patients were diagnosed having functional constipation. By comparing the data of the patients with those of normal children reported by the other authors, we found that none of the measurements was statistically significant except for the rectosigmoid length: the mean value in one-year-old patients was 19.03 vs. 9.75, and in older children, it was 19.46 vs. 9.59. CONCLUSIONS Recognizing an anatomic anomaly in patients suffering from functional constipation is important for specific treatment, especially when the ratio (rectosigmoid length/L2) is higher than 15.
Collapse
Affiliation(s)
- Carmine Noviello
- Pediatric Surgery Unit, Salesi Children Hospital, Via Corridoni, 11, 60128, Ancona, Italy.
| | - Stefano Nobile
- Department of Woman and Child Health and Public Health, Division of Neonatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, University Cattolica del Sacro Cuore, Rome, Italy
| | - Mercedes Romano
- Pediatric Surgery Unit, Salesi Children Hospital, Via Corridoni, 11, 60128, Ancona, Italy
| | - Alessandra Mazzarini
- Department of Radiological Sciences, Azienda Ospedaliero-Universitaria, Ancona, Italy
| | - Alfonso Papparella
- Pediatric Surgery Unit, Università degli Studi della Campania, Luigi Vanvitelli, Naples, Italy
| | - Giovanni Cobellis
- Pediatric Surgery Unit, Salesi Children Hospital, Via Corridoni, 11, 60128, Ancona, Italy
| |
Collapse
|
22
|
Southwell BR. Treatment of childhood constipation: a synthesis of systematic reviews and meta-analyses. Expert Rev Gastroenterol Hepatol 2020; 14:163-174. [PMID: 32098515 DOI: 10.1080/17474124.2020.1733974] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Introduction: Constipation occurs in many children and can become chronic. Many grow out of it but for one third, it continues into adulthood. For most patients, there is no identifiable organic disorder and it is classified as functional constipation.Areas covered: In 2016, treatment of childhood constipation was extensively reviewed by Rome IV. This review covers meta-analyses and evidence for treatment of paediatric constipation since 2016 and new emerging treatments.Expert opinion: Since 2016, meta-analyses conclude 1) fibre should be included in a normal diet, but further supplementation does not improve constipation; 2) probiotics may increase stool frequency in children, but evidence from larger RCTs is needed; 3) comparing laxatives, polyethylene glycol (PEG) is superior to placebo, lactulose and milk of magnesia, and 4) appendix stomas are effective and should be considered before surgery. Emerging areas of study include food intolerance, electrical stimulation and faecal microbiota transplant. For research, outcome measures need standardising to allow comparison between studies and allow meta-analyses. To assist this, validated GI instruments have been developed by Rome IV and PedsQl.
Collapse
Affiliation(s)
- Bridget R Southwell
- Murdoch Children's Research Institute, Urology Department, Royal Children's Hospital and Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| |
Collapse
|
23
|
Dranove J, Fleishman N, Reddy S, Teich S. Does the Oral-Anal Transit Test Correlate with Colonic Manometry Findings in Children with Refractory Constipation? Pediatr Gastroenterol Hepatol Nutr 2020; 23:137-145. [PMID: 32206626 PMCID: PMC7073376 DOI: 10.5223/pghn.2020.23.2.137] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 12/05/2019] [Indexed: 11/29/2022] Open
Abstract
PURPOSE The Oral-anal Transit Test (OTT) is a simple method of obtaining information about colonic transit. We aim to assess the correlation of OTT with the neuromuscular integrity of the colon determined by colonic manometry (CM). METHODS All patients who had OTT followed by CM were evaluated. Less than 6 of 24 markers remaining on OTT was considered normal. CM was performed per previously published guidelines. A normal CM was defined as at least one High Amplitude Propagating Contraction progressing from the most proximal sensor through the sigmoid colon. RESULTS A total of 34 patients underwent both OTT and CM (44% male, age 4-18 years, mean 11.5 years, 97% functional constipation +/- soiling, Hirschsprung's Disease). Of normal and abnormal OTT patients, 85.7% (6/7) and 18.5% (5/27) respectively had normal CM. When all markers progressed to at least the sigmoid colon, this was 100% predictive against colonic inertia. Greater than 50% of patients with manometric isolated sigmoid dysfunction had markers proximal to the recto-sigmoid. CONCLUSION OTT and CM are both valuable studies that assess different aspects of colonic function. OTT can be used as a screening test to rule out colonic inertia. However, the most proximal extent of remaining markers does not predict the anatomical extent of the manometric abnormality, particularly in isolated sigmoid dysfunction.
Collapse
Affiliation(s)
- Jason Dranove
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Atrium Health Levine Children's Hospital, Charlotte, NC, USA
| | - Nathan Fleishman
- Department of Pediatric Gastroenterology, Children's Mercy Hospital, Kansas City, MO, USA
| | - Saigopala Reddy
- Department of Public Health, UNC Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Steven Teich
- Division of Pediatric Surgery, Atrium Health Levine Children's Hospital, Charlotte, NC, USA
| |
Collapse
|
24
|
Gupta A, Basson S, Borrelli O, Lindley K, Thapar N, Saliakellis E, Curry J, Blackburn S. Surgically treated intractable constipation in children evaluated with colonic manometry. J Pediatr Surg 2020; 55:265-268. [PMID: 31757505 DOI: 10.1016/j.jpedsurg.2019.10.046] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Accepted: 10/26/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND 'Intractable constipation' (IC) is constipation unresponsive to 3 months of optimal conventional treatment. Colonic manometry (CM) is recommended as a diagnostic modality for evaluation of these children. This study aimed to review outcomes of children with IC who were managed surgically at a single tertiary care center. METHODS Records of children with IC who were treated with ACE (antegrade colonic enema), colostomy, or ileostomy (2006-2018) were reviewed. "Success" was defined as adequate evacuation without need for further unplanned surgery. Data are median (range). RESULTS Sixty-seven children underwent surgery, of whom 56 with preoperative CM were included. Age at surgery was 8.6 (3.3-15.1) years. Eight had normal manometry and underwent ACE with 75% success. Thirty-six had left-sided dysfunction and underwent ACE (18), colostomy (14) or ileostomy (4) as initial intervention with 61, 70, and 100% success. Twelve with pancolonic dysfunction underwent ACE (6) or ileostomy (6) with 60 and 100% success. Twenty underwent repeat manometry 2.2 years (10 months-7.6 years) after surgery. Of 18 with stoma, 8 had resolution or improvement and of these, 7 underwent stoma reversal with a simultaneous ACE. Two patients with ACE had improvement, 1 is still on ACE washouts, and 1 is off all treatment. Ten with persistent dysfunction remain diverted. At 3.2 years (4 months-9.9 years) follow-up, 18 remain on ACE washouts, 9 have colostomy, 19 ileostomy, and 10 are off treatment and doing well. CONCLUSION We present a large series of patients who were surgically managed for IC. CM may guide therapy in these children. TYPE OF STUDY Retrospective comparative study LEVEL OF EVIDENCE: Level III.
Collapse
Affiliation(s)
- Alisha Gupta
- Department of Specialist Neonatal and Pediatric Surgery, Great Ormond Street Hospital, London, United Kingdom
| | - Sonia Basson
- Department of Specialist Neonatal and Pediatric Surgery, Great Ormond Street Hospital, London, United Kingdom
| | - Osvaldo Borrelli
- Division of Neurogastroenterology and Motility, Department of Pediatric Gastroenterology, Great Ormond Street Hospital, London, United Kingdom
| | - Keith Lindley
- Division of Neurogastroenterology and Motility, Department of Pediatric Gastroenterology, Great Ormond Street Hospital, London, United Kingdom
| | - Nikhil Thapar
- Division of Neurogastroenterology and Motility, Department of Pediatric Gastroenterology, Great Ormond Street Hospital, London, United Kingdom
| | - Efstratios Saliakellis
- Division of Neurogastroenterology and Motility, Department of Pediatric Gastroenterology, Great Ormond Street Hospital, London, United Kingdom
| | - Joseph Curry
- Department of Specialist Neonatal and Pediatric Surgery, Great Ormond Street Hospital, London, United Kingdom
| | - Simon Blackburn
- Department of Specialist Neonatal and Pediatric Surgery, Great Ormond Street Hospital, London, United Kingdom.
| |
Collapse
|
25
|
Xu M, Zhang W, Wang L, Feng X, Li Y. The effect and safety of acupuncture on patients with functional constipation: Protocol for a systematic review and meta-analysis of high quality RCTs. Medicine (Baltimore) 2019; 98:e18125. [PMID: 31804322 PMCID: PMC6919459 DOI: 10.1097/md.0000000000018125] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Accepted: 10/28/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Functional constipation (FC) is a prevalent clinical disease that affects a considerable proportion of the population of all ages. Persistent FC significantly reduces quality of life and influences physical and emotional well-being, as well as consumes many substantial healthcare resources. Acupuncture originates from Traditional Chinese Medicine (TCM), and emerging evidence of several randomized controlled trials (RCTs) published suggest that acupuncture has positive effects for FC. Since 2019, several new results of high quality RCTs about acupuncture treatment for FC have been published. Thus a systematic review will be designed to appraise the effectiveness and safety of acupuncture for improvement of FC in patients based on high quality RCTs. METHODS We carried out a rigorous literature search in English and Chinese electronic database from inception to present. Two reviewers will identify relevant studies, extract and manage trial information, and then assess the risk of bias in included studies by the Cochrane risk of bias assessment tool. Only high quality RCTs will be included. Data will be synthesized by either fixed-effects or random-effects model regarding to a heterogeneity test. The primary outcome measurement will be the change from baseline in mean complete spontaneous bowel movements and stool form. The secondary outcomes involved disappearance rate of symptoms, proportion of responders, mean transit time, health-related quality of life, and safety of intervention. Meta-analysis will be performed by using Cochrane's RevMan software. RESULTS This systematic review will summarize high quality clinical evidence to assess and appraise the effectiveness and safety of acupuncture treatment for FC patient. EXPECTED CONCLUSION This systematic review and meta-analysis will provide evidence to determine whether acupuncture treatment is an effective and safe therapy for the prevention and treatment of FC compared with medication treatment.
Collapse
Affiliation(s)
- Mingmin Xu
- School of Acupuncture–Moxibustion and Tuina
| | - Wei Zhang
- Office of Educational Administration
| | - Lu Wang
- School of Acupuncture–Moxibustion and Tuina
| | | | - Ying Li
- Graduate School, Chengdu University of Traditional Chinese Medicine, Chengdu 610075, China
| |
Collapse
|
26
|
De la Torre L, Cogley K, Cabrera-Hernández MA, Frias-Mantilla JE, Wehrli LA. Transanal proximal rectosigmoidectomy. A new operation for severe chronic idiopathic constipation associated with megarectosigmoid. J Pediatr Surg 2019; 54:2311-2317. [PMID: 31056347 DOI: 10.1016/j.jpedsurg.2019.04.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 03/10/2019] [Accepted: 04/03/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND At the severe end of the idiopathic constipation spectrum exist patients with chronic idiopathic constipation associated with an enormous megarectosigmoid, among whom few require surgery. We performed transanal proximal rectosigmoidectomy, involving preservation of a 5 cm rectal reservoir, to ameliorate inconsistent and unpredictable outcomes and fecal incontinence occurring in some patients operated on with other techniques. METHODS We retrospectively observed patients with chronic idiopathic constipation with megarectosigmoid who underwent transanal proximal rectosigmoidectomy during July 2017-May 2018. We analyzed sex, age, operation indication, complications, functional outcome, and time of follow-up. We statistically compared the dosage of laxative before and after the procedure. RESULTS Thirteen patients were included in the study. Median age during surgery was 8 years. In 9 cases, the indication for surgery was chronic intake of a daily high dose of Senna with failed weaning trials, and 4 had persistent fecal impaction with laxative-intolerance and refusal of rectal enemas. No intra/postoperative complications occurred. Currently, all 13 patients have daily voluntary bowel movements and no fecal accidents. Laxative dosage was significantly reduced (p = 0.007). Follow-up ranged 6-16 months. CONCLUSION Preliminary results suggest transanal proximal rectosigmoidectomy as an adequate alternative for patients requiring surgery for chronic idiopathic constipation with megarectosigmoid. TYPE OF STUDY Clinical research. LEVEL OF EVIDENCE Level III.
Collapse
Affiliation(s)
- Luis De la Torre
- Colorectal and Hirschsprung Center for Children, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, School of Medicine, Pittsburgh, USA.
| | - Kimberly Cogley
- Colorectal and Hirschsprung Center for Children, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, School of Medicine, Pittsburgh, USA.
| | - Maria A Cabrera-Hernández
- Colorectal and Hirschsprung Center for Children, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, School of Medicine, Pittsburgh, USA.
| | - José E Frias-Mantilla
- Colorectal and Hirschsprung Center for Children, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, School of Medicine, Pittsburgh, USA.
| | - Lea A Wehrli
- Colorectal and Hirschsprung Center for Children, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, School of Medicine, Pittsburgh, USA.
| |
Collapse
|
27
|
Development of a Patient-reported Experience and Outcome Measures in Pediatric Patients Undergoing Bowel Management for Constipation and Fecal Incontinence. J Pediatr Gastroenterol Nutr 2019; 69:e34-e38. [PMID: 30921256 DOI: 10.1097/mpg.0000000000002348] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
AIMS AND OBJECTIVES The aim of this review is develop a reliable and valid questionnaire that assesses patient-reported experience measures (PREMs) and patient-reported outcome measures (PROMs) of caregivers, families, and patients with severe constipation and fecal incontinence who failed conservative treatments and require a formal bowel management program (BMP). METHODS A 5-step iterative process was utilized to ensure the reliability and validity of the final instrument. Parents or guardians of patients undergoing our week-long BMP were first asked 20 open-ended questions aimed at understanding the challenges in managing their child's condition. Responses were transformed into an initial 41-item survey constituted of 2 constructs relating to PREMs (24 items) and PROMs (17 items). Survey items were then administered to 359 parents and guardians undergoing BMP. Cognitive interviews were performed with 20 families to assess face validity and to further refine the survey. Instrument readability and reliability was assessed by Flesch-Kincaid and Crohnbach α analyses. Items that weakly correlated were deleted to yield a final instrument that was both valid and reliable. RESULTS A 33-statement survey was developed that encompasses important physical and emotional health concerns, quality of life, treatment success, financial considerations, schooling, parental employment, and social concerns. The final instrument, the Patient-Reported Experience and Outcome Measure in a Bowel Management Program (PREOM-BMP), is divided into 2 separate constructs that assess important patient-reported experience (22 items) and outcome (11 items) measures. Reliability analyses on the final instrument yielded a Crohnbach α of 0.925. CONCLUSIONS The PREOM-BMP offers physicians and nursing professionals a brief and valid tool to measure the impact of a bowel management program on both the child and the family unit.
Collapse
|
28
|
Abstract
PURPOSE OF REVIEW Functional constipation (FC) in children is a common health problem with reported worldwide prevalence rates up to 32.2%. The majority of children with constipation respond to oral laxative treatment. After 5 years of intensive treatment, however, approximately 50% of children remain symptomatic. To discuss the evidence for new treatments in these children, including pre- and probiotics, pelvic physiotherapy, prucalopride, sacral nerve stimulation, and surgery, and to highlight the controversies surrounding them. RECENT FINDINGS Pre- and probiotics and prucalopride are not effective in the treatment of childhood constipation. Pelvic physiotherapy and sacral nerve stimulation are promising treatment options but larger trials are needed. Surgery for pediatric constipation is the treatment of last resort. Large, well-designed placebo-controlled trials with proper outcome measures, as suggested by the Rome foundation pediatric subcommittee on clinical trials, are necessary to provide more insight regarding the efficacy of new treatments in childhood constipation.
Collapse
|
29
|
A descriptive model for a multidisciplinary unit for colorectal and pelvic malformations. J Pediatr Surg 2019; 54:479-485. [PMID: 29778545 DOI: 10.1016/j.jpedsurg.2018.04.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Revised: 03/30/2018] [Accepted: 04/15/2018] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Patients with anorectal malformations (ARM), Hirschsprung disease (HD), and colonic motility disorders often require care from specialists across a variety of fields, including colorectal surgery, urology, gynecology, and GI motility. We sought to describe the process of creating a collaborative process for the care of these complex patients. METHODS We developed a model of a devoted center for these conditions that includes physicians, psychologists, social workers, nurses, and advanced practice nurses. Our weekly planning strategy includes a meeting with representatives of all specialties to review all patients prior to evaluation in our multidisciplinary clinic, followed by combined exams under anesthesia or surgical intervention as needed. RESULTS There are 31 people working directly in the Center at present. From the Center's start in 2014 until 2017, 1258 patients were cared for from all 50 United States and 62 countries. 360 patients had an ARM (110 had a cloacal malformation, 11 had cloacal exstrophy), 223 presented with HD, 71 had a spinal malformation or injury causing neurogenic bowel, 321 had severe functional constipation or colonic dysmotility, and 162 had other diagnoses including familial polyposis, Crohn's disease, or ulcerative colitis. We have had 170 multidisciplinary meetings, 170 multispecialty outpatient, and 52 nurse practitioner clinics. In our bowel management program we have seen a total of 514 patients in 36 sessions. CONCLUSION This is the first report describing the design of a multidisciplinary team approach for patients with colorectal and complex pelvic malformations. We found that approaching these patients in a collaborative way allows for combined medical and surgical decisions with many providers simultaneously, facilitates therapy, and can potentially improve patient outcomes. We hope that this model will help establish new-devoted centers in other locations to encourage centralized care for these rare malformations. LEVEL OF EVIDENCE IV.
Collapse
|
30
|
Abstract
Constipation is a common problem in children. Although most children respond to conventional treatment, symptoms persist in a minority. For children with refractory constipation, anorectal and colonic manometry testing can identify a rectal evacuation disorder or colonic motility disorder and guide subsequent management. Novel medications used in adults with constipation are beginning to be used in children, with promising results. Biofeedback therapy and anal sphincter botulinum toxin injection can be considered for children with a rectal evacuation disorder. Surgical management of constipation includes the use of antegrade continence enemas, sacral nerve stimulation, and colonic resection.
Collapse
Affiliation(s)
- Peter L Lu
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA.
| | - Hayat M Mousa
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of California, San Diego, Rady Children's Hospital, 3030 Children's Way, San Diego, CA 92123, USA
| |
Collapse
|
31
|
Gasior A, Reck C, Vilanova-Sanchez A, Diefenbach KA, Yacob D, Lu P, Vaz K, Di Lorenzo C, Levitt MA, Wood RJ. Surgical management of functional constipation: An intermediate report of a new approach using a laparoscopic sigmoid resection combined with malone appendicostomy. J Pediatr Surg 2018; 53:1160-1162. [PMID: 29588075 DOI: 10.1016/j.jpedsurg.2018.02.074] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Accepted: 02/27/2018] [Indexed: 02/07/2023]
Abstract
INTRODUCTION We previously reported our surgical technique for functional constipation for patients who have failed medical management using a novel collaborative approach with gastroenterology input, pre-operative contrast enema, colonic manometry, and laxative protocol combined with a laparoscopic colonic resection with Malone appendicostomy. Now we report our intermediate outcomes. METHODS Patients who failed bowel management program for functional constipation were reviewed from 3/2014-2/2017. Patients with Hirschsprung disease, anorectal malformation, tethered cord, spina bifida, Trisomy 21, cerebral palsy, mitochondrial disease, or prior colon resection were excluded. RESULTS Of 31 patients (14 females; median age 12years, follow-up 10.3months) with functional constipation and failed medical management, 26 (84%) had preoperative colonic manometry which, in addition to the contrast enema, guided laparoscopic colon resection. Ten patients (32.3%) are clean with no flushes (1 takes no laxatives, 8 are on low dose laxatives only, and 1 patient was clean on laxatives but chose to switch back to flushes). Of the 21 patients that remain on antegrade flushes, 20 (95.2%) are clean, and one patient (4.8%) continues to soil. We define clean as no soiling and no abnormal stool burden on x-ray. Laxative trials are planned for all patients on an antegrade flush regimen. CONCLUSION Our intermediate results show that laparoscopic colon resection with Malone appendicostomy allows the majority of patients to be clean on antegrade flushes, and some to be on no or minimal laxatives. TYPE OF STUDY Retrospective review. LEVEL OF EVIDENCE 3.
Collapse
Affiliation(s)
- Alessandra Gasior
- Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, OH.
| | - Carlos Reck
- Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, OH
| | | | - Karen A Diefenbach
- Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, OH
| | - Desalegn Yacob
- Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, OH
| | - Peter Lu
- Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, OH
| | - Karla Vaz
- Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, OH
| | - Carlo Di Lorenzo
- Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, OH
| | - Marc A Levitt
- Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, OH
| | - Richard J Wood
- Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, OH
| |
Collapse
|
32
|
Cheng LS, Goldstein AM. Surgical Management of Idiopathic Constipation in Pediatric Patients. Clin Colon Rectal Surg 2018; 31:89-98. [PMID: 29487491 DOI: 10.1055/s-0037-1609023] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Constipation is a common childhood problem, but an anatomic or physiologic cause is identified in fewer than 5% of children. By definition, idiopathic constipation is a diagnosis of exclusion. Careful clinical evaluation and thoughtful use of imaging and other testing can help exclude specific causes of constipation and guide therapy. Medical management with laxatives is effective for the majority of constipated children. For those patients unresponsive to medications, however, several surgical options can be employed, including anal procedures, antegrade colonic enemas, colorectal resection, and intestinal diversion. Judicious use of these procedures in properly selected patients and based on appropriate preoperative testing can lead to excellent outcomes. This review summarizes the surgical options available for managing refractory constipation in children and provides guidance on how to choose the best procedure for a given patient.
Collapse
Affiliation(s)
- Lily S Cheng
- Department of General Surgery, University of California San Francisco, San Francisco, California
| | - Allan M Goldstein
- Department of Surgery, Harvard Medical School, Boston, Massachusetts.,Department of Pediatric Surgery, Massachusetts General Hospital, Boston, Massachusetts.,MassGeneral Hospital for Children, Boston, Massachusetts
| |
Collapse
|
33
|
Wu XD. Progress in research of functional constipation in children. Shijie Huaren Xiaohua Zazhi 2017; 25:2950-2955. [DOI: 10.11569/wcjd.v25.i33.2950] [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] [Indexed: 02/06/2023] Open
Abstract
Constipation is a common symptom in the children population, which can be a manifestation of organic diseases or may be caused by functional factors. More than 90% of cases of constipation in children are functional constipation (FC). As a physical and mental illness in childhood or even a public health problem, FC has multidimensional impacts on children and their families, posing a great healthcare burden on the society. The Rome Ⅳ criteria for diagnosis of functional gastrointestinal disorders were published in 2016, in which a global consensus was formed and modified for the diagnostic criteria of FC in children. However, there are still difficulties in the choice of FC treatments and assessment of its outcome not only because of the distinct understanding and application of the criteria but also because of the incomplete understanding of the pathogenesis of FC. Therefore, the pathophysiological mechanism of FC and its therapeutic efficacy evaluation should be further studied in the future.
Collapse
Affiliation(s)
- Xue-Dong Wu
- Department of Pediatric Surgery, the First Affiliated Hospital and Clinical Medical Research Center of Dali University, Dali 671000, Yunnan Province, China
| |
Collapse
|
34
|
Koppen IJN, Thompson BP, Ambeba EJ, Lane VA, Bates DG, Minneci PC, Deans KJ, Levitt MA, Wood RJ, Benninga MA, Di Lorenzo C, Yacob D. Segmental colonic dilation is associated with premature termination of high-amplitude propagating contractions in children with intractable functional constipation. Neurogastroenterol Motil 2017; 29:1-9. [PMID: 28524640 DOI: 10.1111/nmo.13110] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 04/18/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Colonic dilation is common in children with intractable functional constipation (FC). Our aim was to describe the association between segmental colonic dilation and colonic dysmotility in children with FC. METHODS We performed a retrospective study on 30 children with intractable FC (according to the Rome III criteria) who had undergone colonic manometry and contrast enema within a 12-month time period. Colonic diameter was measured at 5 cm intervals from the anal verge up to the splenic flexure. Moreover, the distance between the lateral margins of the pedicles of vertebra L2 was measured to provide a ratio (colonic diameter or length/distance between the lateral margins; "standardized colon size" [SCS]). All manometry recordings were visually inspected for the presence of high-amplitude propagating contractions (HAPCs); a parameter for colonic motility integrity. The intracolonic location of the manometry catheter sensors was assessed using an abdominal X-ray. KEY RESULTS Colonic segments with HAPCs had a significantly smaller median diameter than colonic segments without HAPCs (4.08 cm vs 5.48 cm, P<.001; SCS 1.14 vs 1.66, P=.001). Children with prematurely terminating HAPCs had significantly larger SCS ratios for colonic diameter than children with fully propagating HAPCs (P=.008). SCS ratios for the length of the rectosigmoid and the descending colon and the SCS ratio for sigmoid colon diameter were significantly larger in children with FC compared to a previously described normative population (P<.0001, P<.0001 and P=.0007 respectively). CONCLUSIONS & INFERENCES Segmental colonic dilation was associated with prematurely terminating HAPCs and may be a useful indicator of colonic dysmotility.
Collapse
Affiliation(s)
- I J N Koppen
- Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital/Academic Medical Center, Amsterdam, The Netherlands
| | - B P Thompson
- Department of Radiology, Nationwide Children's Hospital, Columbus, OH, USA
| | - E J Ambeba
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - V A Lane
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA.,Division of Pediatric Surgery, Department of Surgery, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Surgery, Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - D G Bates
- Department of Radiology, Nationwide Children's Hospital, Columbus, OH, USA
| | - P C Minneci
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA.,Division of Pediatric Surgery, Department of Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - K J Deans
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA.,Division of Pediatric Surgery, Department of Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - M A Levitt
- Division of Pediatric Surgery, Department of Surgery, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Surgery, Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - R J Wood
- Division of Pediatric Surgery, Department of Surgery, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Surgery, Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - M A Benninga
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital/Academic Medical Center, Amsterdam, The Netherlands
| | - C Di Lorenzo
- Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Surgery, Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - D Yacob
- Division of Pediatric Gastroenterology and Nutrition, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA.,Department of Surgery, Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| |
Collapse
|
35
|
King SK. Constipation—Surgical Aspects, Investigations, and Therapies. CURRENT PEDIATRICS REPORTS 2017. [DOI: 10.1007/s40124-017-0126-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
36
|
Kuizenga-Wessel S, Koppen IJN, Zwager LW, Di Lorenzo C, de Jong JR, Benninga MA. Surgical management of children with intractable functional constipation; experience of a single tertiary children's hospital. Neurogastroenterol Motil 2017; 29. [PMID: 27957788 DOI: 10.1111/nmo.13005] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 11/06/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND Children with intractable functional constipation (FC) may eventually require surgery. However, guidelines regarding the surgical management of children with intractable FC are lacking. The aim of this study was to describe the surgical management of FC in children. METHODS A retrospective chart review was performed of children with FC (according to the Rome III criteria) who underwent ileostomy, colostomy or (sub)total colectomy at a tertiary hospital. Treatment success was defined as no longer fulfilling the Rome III-FC-criteria or having a functional ostomy. In addition, a self-developed questionnaire was administered to parents by telephone to assess postsurgical satisfaction (yes-no question and rated on a scale of 1-10). KEY RESULTS Thirty-seven patients (68% female) were included; median age at first surgery was 12 years (range 1.6-17.6). The initial surgical procedure consisted of ileostomy (n=21), colostomy (n=10), sigmoid resection (n=5) and subtotal colectomy (n=1). Success criteria were fulfilled by 85% of the patients. Postsurgical satisfaction of parents was 91% with a median postoperative satisfaction score of 8 (range 2-10), and 97% would opt for the same procedure(s) if necessary. Thirty patients (81%) experienced stoma problems, with 12 patients (32%) requiring stoma-revisions. Other complications occurred in 16 patients (43%). CONCLUSIONS & INFERENCES Surgery can improve symptoms in children with intractable FC. Despite morbidity and complications, parental satisfaction is high. Prospective, high-quality research is necessary to develop guidelines for the diagnostic work-up and surgical management in children with intractable FC.
Collapse
Affiliation(s)
- S Kuizenga-Wessel
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital/Academic Medical Center, Amsterdam, The Netherlands
| | - I J N Koppen
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital/Academic Medical Center, Amsterdam, The Netherlands.,Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA
| | - L W Zwager
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital/Academic Medical Center, Amsterdam, The Netherlands
| | - C Di Lorenzo
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA
| | - J R de Jong
- Department of Pediatric Surgery, Emma Children's Hospital/Academic Medical Center, Amsterdam, The Netherlands
| | - M A Benninga
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital/Academic Medical Center, Amsterdam, The Netherlands
| |
Collapse
|
37
|
Koppen IJN, Yacob D, Di Lorenzo C, Saps M, Benninga MA, Cooper JN, Minneci PC, Deans KJ, Bates DG, Thompson BP. Assessing colonic anatomy normal values based on air contrast enemas in children younger than 6 years. Pediatr Radiol 2017; 47:306-312. [PMID: 27896373 PMCID: PMC5316394 DOI: 10.1007/s00247-016-3746-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 09/22/2016] [Accepted: 10/31/2016] [Indexed: 12/23/2022]
Abstract
BACKGROUND Contrast enemas with barium or water-soluble contrast agents are sometimes performed in children with severe intractable constipation to identify anatomical abnormalities. However there are no clear definitions for normal colonic size or abnormalities such as colonic dilation or sigmoid redundancy in children. OBJECTIVE To describe characteristics of colonic anatomy on air contrast enemas in children without constipation to provide normal values for colonic size ratios in children. MATERIALS AND METHODS We performed a retrospective chart review of children aged 0-5 years who had undergone air contrast enemas for intussusception. The primary outcome measures were the ratios of the diameters and lengths of predetermined colonic segments (lengths of rectosigmoid and descending colon; diameters of rectum, sigmoid, descending colon, transverse colon and ascending colon) in relation to the L2 vertebral body width. RESULTS We included 119 children (median age 2.0 years, range 0-5 years, 68% boys). Colonic segment length ratios did not change significantly with age, although the differences for the rectosigmoid/L2 ratio were borderline significant (P = 0.05). The ratios that involved the rectal and ascending colon diameters increased significantly with age, while diameter ratios involving the other colonic segments did not. Differences by gender and race were not significant. CONCLUSION These data can be used for reference purposes in young children undergoing contrast studies of the colon.
Collapse
Affiliation(s)
- Ilan J. N. Koppen
- Division of Pediatric Gastroenterology and Nutrition, Nationwide Children’s Hospital, Columbus, OH USA ,Department of Pediatric Gastroenterology and Nutrition, Emma Children’s Hospital/Academic Medical Center, H7-250, PO Box 22700, 1100DD Amsterdam, The Netherlands
| | - Desale Yacob
- Division of Pediatric Gastroenterology and Nutrition, Nationwide Children’s Hospital, Columbus, OH USA
| | - Carlo Di Lorenzo
- Division of Pediatric Gastroenterology and Nutrition, Nationwide Children’s Hospital, Columbus, OH USA
| | - Miguel Saps
- Division of Pediatric Gastroenterology and Nutrition, Nationwide Children’s Hospital, Columbus, OH USA
| | - Marc A. Benninga
- Department of Pediatric Gastroenterology and Nutrition, Emma Children’s Hospital/Academic Medical Center, H7-250, PO Box 22700, 1100DD Amsterdam, The Netherlands
| | - Jennifer N. Cooper
- Center for Surgical Outcomes Research, Research Institute Nationwide Children’s Hospital, Columbus, OH USA
| | - Peter C. Minneci
- Center for Surgical Outcomes Research, Research Institute Nationwide Children’s Hospital, Columbus, OH USA ,Division of Pediatric Surgery, Department of Surgery, Nationwide Children’s Hospital, Columbus, OH USA
| | - Katherine J. Deans
- Center for Surgical Outcomes Research, Research Institute Nationwide Children’s Hospital, Columbus, OH USA ,Division of Pediatric Surgery, Department of Surgery, Nationwide Children’s Hospital, Columbus, OH USA
| | - D. Gregory Bates
- Department of Radiology, Nationwide Children’ Hospital, Columbus, OH USA
| | | |
Collapse
|
38
|
De La Torre L, Cogley K, Calisto J, Nace G, Correa C. Primary sigmoidectomy and appendicostomy for chronic idiopathic constipation. Pediatr Surg Int 2016; 32:767-72. [PMID: 27372298 DOI: 10.1007/s00383-016-3913-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/18/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE To present our experience in patients with chronic idiopathic constipation complicated by megarectosigmoid and fecal incontinence who underwent a primary sigmoidectomy and appendicostomy. METHODS We reviewed eight patients referred to the Colorectal Center from 2014 to 2016 with chronic idiopathic constipation and undergoing a sigmoidectomy and appendicostomy. We analyzed the previous medical treatment, indications for the surgical procedure, and outcomes. RESULTS Age at operation was 5-19 years. Time with constipation was 4-15 years. All patients received multiple laxatives, mainly polyethylene glycol, and all had severe social problems. Four patients have autism. The indication for surgery was an unsuccessful laxative trial, refusal to continue with rectal enemas or both, and social fear of continued fecal incontinence. Post-operatively, all patients were having daily bowel movements without fecal accidents. CONCLUSION Selected patients with chronic idiopathic constipation complicated by megarectosigmoid and fecal incontinence can obtain great benefit from primary sigmoidectomy and appendicostomy.
Collapse
Affiliation(s)
- Luis De La Torre
- Colorectal Center for Children at Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, One Children's Hospital Drive, 4401 Penn Avenue, Faculty Pavilion Suite 7135, Pittsburgh, PA, 15224, USA.
| | - Kimberly Cogley
- Colorectal Center for Children at Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, One Children's Hospital Drive, 4401 Penn Avenue, Faculty Pavilion Suite 7135, Pittsburgh, PA, 15224, USA
| | - Juan Calisto
- Colorectal Center for Children at Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, One Children's Hospital Drive, 4401 Penn Avenue, Faculty Pavilion Suite 7135, Pittsburgh, PA, 15224, USA
| | - Gary Nace
- Colorectal Center for Children at Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, One Children's Hospital Drive, 4401 Penn Avenue, Faculty Pavilion Suite 7135, Pittsburgh, PA, 15224, USA
| | - Catalina Correa
- Colorectal Center for Children at Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, One Children's Hospital Drive, 4401 Penn Avenue, Faculty Pavilion Suite 7135, Pittsburgh, PA, 15224, USA
| |
Collapse
|