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Gould MJ, Marcon MA, Nguyen GC, Benchimol EI, Moineddin R, Swayze S, Kopp A, Ratcliffe EM, Merritt N, Davidson J, Langer JC, Mistry N, Lorenzo AJ, Temple M, Walsh CM. Impact of antegrade enema initiation on healthcare utilization in pediatric patients: A population-based cohort study. Neurogastroenterol Motil 2023; 35:e14495. [PMID: 36377812 DOI: 10.1111/nmo.14495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 10/24/2022] [Accepted: 11/01/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND When constipation is refractory to first-line interventions, antegrade enema use may be considered. We aimed to assess the impact of this intervention on healthcare utilization. METHODS We conducted a population-based, quasi-experimental study with pre-post comparison of the intervention group and a non-equivalent control group using linked clinical and health administrative data from Ontario, Canada. Subjects included children (0-18 years) who underwent antegrade enema initiation from 2007 to 2020 and matched controls (4:1) from the general population. To assess the change in healthcare utilization following antegrade enema initiation, we used negative binomial generalized estimating equations with covariates selected a priori. KEY RESULTS One hundred thirty-eight subjects met eligibility criteria (appendicostomy = 55 (39.9%); cecostomy tube = 83 (60.1%)) and were matched to 550 controls. There was no significant difference in the change in the rate of hospitalizations (rate ratio (RR) 1.05, 95% confidence interval (CI) 0.35-1.75), outpatient visits (RR 1.05, 95% CI 0.91-1.18), or same-day surgical procedures (RR 1.51, 95% CI 0.60-2.43) across cases in 2 years following antegrade enema initiation compared with controls. Cases had an increased rate of emergency department (ED) visits, which was not observed in controls (RR 1.52, 95% CI 1.11-1.79), driven in part by device-related complications. CONCLUSIONS AND INFERENCES Understanding healthcare utilization patterns following antegrade enema initiation allows for effective health system planning and aids medical decision-making. The observed increase in ED visits for device-related complications speaks to the need to improve preventive management to help mitigate emergency care after initiation of antegrade enemas.
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Affiliation(s)
- Michelle J Gould
- Division of Gastroenterology, Hepatology, and Nutrition, Hospital for Sick Children, Toronto, Canada.,Department of Paediatrics, University of Toronto, Toronto, Canada
| | - Margaret A Marcon
- Division of Gastroenterology, Hepatology, and Nutrition, Hospital for Sick Children, Toronto, Canada.,Department of Paediatrics, University of Toronto, Toronto, Canada
| | - Geoffrey C Nguyen
- Division of Gastroenterology, Mount Sinai Hospital, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada.,ICES, Toronto, Canada
| | - Eric I Benchimol
- Division of Gastroenterology, Hepatology, and Nutrition, Hospital for Sick Children, Toronto, Canada.,Department of Paediatrics, University of Toronto, Toronto, Canada.,ICES, Toronto, Canada
| | - Rahim Moineddin
- Department of Family and Community Medicine, Division of Biostatistics, University of Toronto, Toronto, Canada
| | | | | | - Elyanne M Ratcliffe
- Division of Pediatric Gastroenterology and Nutrition, McMaster Children's Hospital, Hamilton, Canada.,Department of Pediatrics, McMaster University, Hamilton, Canada
| | - Neil Merritt
- Division of Pediatric Surgery, London Health Sciences Center, London, Canada
| | - Jacob Davidson
- Division of Pediatric Surgery, London Health Sciences Center, London, Canada
| | - Jacob C Langer
- Division of General and Thoracic Surgery, Hospital for Sick Children, Toronto, Canada.,Department of Surgery, University of Toronto, Toronto, Canada
| | - Niraj Mistry
- Department of Paediatrics, University of Toronto, Toronto, Canada.,Division of Paediatric Medicine, Hospital for Sick Children, Toronto, Canada
| | - Armando J Lorenzo
- Department of Surgery, University of Toronto, Toronto, Canada.,Division of Urology, Hospital for Sick Children, Toronto, Canada
| | - Michael Temple
- Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, Canada.,Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Catharine M Walsh
- Division of Gastroenterology, Hepatology, and Nutrition, Hospital for Sick Children, Toronto, Canada.,Department of Paediatrics, University of Toronto, Toronto, Canada.,SickKids Research and Learning Institutes, Toronto, Canada
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2
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Jacobs SE, Tiusaba L, Bokova E, Russell TL, Al-Shamaileh T, Feng C, Badillo AT, Darbari A, Levitt MA. Functional constipation refractory to medical management: The colon is the problem. J Pediatr Surg 2023; 58:246-250. [PMID: 36411110 DOI: 10.1016/j.jpedsurg.2022.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 10/14/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Management of refractory constipation in children has not been standardized. We propose a protocolized approach which includes a contrast enema, anorectal manometry and exclusion of Hirschsprung disease (HD). For those without HD or with normal sphincters, an assessment of the colonic motility may be needed. The subgroups of dysmotility include (1) slow motility with contractions throughout, (2) segmental dysmotility (usually the sigmoid), or (3) a diffusely inert colon. We offered a Malone appendicostomy in all groups with the hope that this would avoid colonic resection in most cases. METHODS Patients with medically refractory constipation were reviewed at a single institution (2020 to 2021). For patients without HD or an anal sphincter problem, assessment of colonic motility using colonic manometry was performed followed by a Malone appendicostomy for antegrade flushes. RESULTS Of 196 patients evaluated for constipation refractory to medical management, 22 were felt to have a colonic motility cause. These patients underwent colonic manometry and Malone appendicostomy. 13 patients (59%) had a slow colon but with HAPCs throughout, 5 (23%) had segmental dysmotility, and 4 (18%) had a diffuse colonic dysmotility. 19 (86%) responded well to antegrade flushes with 17 reporting no soiling and 2 having occasional accidents. 3 patients (14%) failed flushes and underwent a colon resection within 6-month following Malone procedure. CONCLUSION We propose a protocol for medically refractory constipation which provides a collaborative framework to standardize evaluation and management of these patients with antegrade flushes, which aids in avoidance of colonic resection in most cases. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Shimon E Jacobs
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, 111 Michigan Avenue NW, Washington DC 20010, United States
| | - Laura Tiusaba
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, 111 Michigan Avenue NW, Washington DC 20010, United States
| | - Elizaveta Bokova
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, 111 Michigan Avenue NW, Washington DC 20010, United States
| | - Teresa L Russell
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, 111 Michigan Avenue NW, Washington DC 20010, United States
| | | | - Christina Feng
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, 111 Michigan Avenue NW, Washington DC 20010, United States
| | - Andrea T Badillo
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, 111 Michigan Avenue NW, Washington DC 20010, United States
| | - Anil Darbari
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, 111 Michigan Avenue NW, Washington DC 20010, United States
| | - Marc A Levitt
- Division of Colorectal and Pelvic Reconstruction, Children's National Hospital, 111 Michigan Avenue NW, Washington DC 20010, United States.
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Melanosis Coli Is Not Associated with Colonic Dysmotility Nor Severity of Pediatric Functional Constipation. Dig Dis Sci 2022; 67:3922-3928. [PMID: 34379221 DOI: 10.1007/s10620-021-07191-z] [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: 10/21/2020] [Accepted: 07/21/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND Sennosides are commonly used for the treatment of constipation and associated with melanosis coli. In the present study, we evaluated the utility of melanosis coli as a marker of severity and its association with colonic motility in children with functional constipation. METHODS Prospective study includes pediatric patients undergoing colonic manometry and colonic biopsies. Demographic data, medication history, surgical history, colonic manometry results (gastrocolonic response to a meal, high-amplitude propagating contractions, and nonpropagating contractions), colonic manometry catheter position, and pathologic results were collected and analyzed. We compared those variables with outcome (need for surgery) between both patient groups (presence or absence of melanosis coli). RESULTS A total of 150 patients were included, median age was 9.9 years (range 2.1-18) and 77 (51.3%) were female, 17 had melanosis. Patients who took sennosides had higher rates of melanosis coli compared to those who did not (adjusted OR 13.88; 95% CI 4.05-47.57; P < 0.001), and we did not find an association between melanosis coli and use of other medications (osmotic laxatives, bisacodyl, lubiprostone), age, gender, weight, and height. We found no significant difference in the results colonic manometry between patients with and without melanosis coli. The rates of surgery for constipation between patients with and without melanosis coli were not statistically different. (OR 3.00; 95% CI 0.45-20.07; P = 0.257). CONCLUSIONS Melanosis coli is associated with sennosides use, but it does not influence colonic motility nor is associated with increased subsequent need for surgery in pediatric functional constipation.
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Abstract
Constipation is a common challenge in pediatrics. Abdominal radiographs are frequently taken in the pediatric emergency department for diagnosis despite their inadequate reliability to detect the pathology or the degree of constipation. Misdiagnosis of constipation may cause multiple vague physician visits, deployment of emergency medical services, use of radiation, unnecessary laboratory tests, and even surgical procedures. The primary evidence-based suggestions are based on published guidelines that include management of constipation in children divided into three stages of therapy: (1) disimpaction, (2) maintenance therapy, and (3) behavior modification, and special care should be given to neonates and to children with pre-existing medical problems.
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Corsetti M, Brown S, Chiarioni G, Dimidi E, Dudding T, Emmanuel A, Fox M, Ford AC, Giordano P, Grossi U, Henderson M, Knowles CH, O'Connell PR, Quigley EMM, Simren M, Spiller R, Whelan K, Whitehead WE, Williams AB, Scott SM. Chronic constipation in adults: Contemporary perspectives and clinical challenges. 2: Conservative, behavioural, medical and surgical treatment. Neurogastroenterol Motil 2021; 33:e14070. [PMID: 33522079 DOI: 10.1111/nmo.14070] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 12/05/2020] [Accepted: 12/13/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Chronic constipation is a prevalent disorder that affects quality of life of patients and consumes resources in healthcare systems worldwide. In clinical practice, it is still considered a challenge as clinicians frequently are unsure as to which treatments to use and when. Over a decade ago, a Neurogastroenterology and Motility journal supplement devoted to the investigation and management of constipation was published (Neurogastroenterol Motil 2009;21(Suppl 2):1). In October 2018, the 3rd London Masterclass, entitled "Contemporary management of constipation" was held. The faculty members of this symposium were invited to write two reviews to present a collective synthesis of talks presented and discussions held during this meeting. The first review addresses epidemiology, diagnosis, clinical associations, pathophysiology, and investigation. PURPOSE The present is the second of these reviews, providing contemporary perspectives and clinical challenges regarding behavioral, conservative, medical, and surgical treatments for patients presenting with constipation. It includes a management algorithm to guide clinical practice.
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Affiliation(s)
- Maura Corsetti
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK.,School of Medicine, University of Nottingham and Nottingham Digestive Diseases Centre, University of Nottingham, Nottingham, UK
| | - Steven Brown
- Department of Surgery, University of Sheffield, Sheffield, UK
| | - Giuseppe Chiarioni
- Division of Gastroenterology, University of Verona, AOUI Verona, Verona, Italy.,Center for Functional GI and Motility Disorders, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Eirini Dimidi
- Department of Nutritional Sciences, King's College London, London, UK
| | | | | | - Mark Fox
- Division of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland.,Digestive Function: Basel, Laboratory and Clinic for Motility Disorders and Functional Gastrointestinal Diseases, Centre for Integrative Gastroenterology, Klinik Arlesheim, Arlesheim, Switzerland
| | - Alexander C Ford
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK.,Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, UK
| | - Pasquale Giordano
- Department of Colorectal Surgery, Barts health NHS Trust, London, UK
| | - Ugo Grossi
- Tertiary Referral Pelvic Floor and Incontinence Centre, Regional Hospital Treviso, University of Padua, Padua, Italy
| | - Michelle Henderson
- Durham Bowel Dysfunction Service, Old Trust Headquarters, University Hospital of North Durham, Durham, UK
| | - Charles H Knowles
- National Bowel Research Centre and GI Physiology Unit, Centre for Neuroscience, Surgery & Trauma, Blizard Institute, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - P Ronan O'Connell
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - Eamonn M M Quigley
- Lynda K and David M Center for Gastrointestinal Disorders, Houston Methodist Hospital and Weill Cornell Medical College, Houston, Texas, USA
| | - Magnus Simren
- Center for Functional GI and Motility Disorders, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Robin Spiller
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK.,School of Medicine, University of Nottingham and Nottingham Digestive Diseases Centre, University of Nottingham, Nottingham, UK
| | - Kevin Whelan
- Department of Nutritional Sciences, King's College London, London, UK
| | - William E Whitehead
- Center for Functional GI and Motility Disorders, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - S Mark Scott
- National Bowel Research Centre and GI Physiology Unit, Centre for Neuroscience, Surgery & Trauma, Blizard Institute, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London, UK
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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.
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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.
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Mentessidou A, Livani A, Chrousos G, Mirilas P. Ileocecal Valve Removal Reverses the Constipating Effects of Loperamide in Rats. J Surg Res 2020; 255:371-377. [PMID: 32599457 DOI: 10.1016/j.jss.2020.05.002] [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: 12/09/2019] [Revised: 04/16/2020] [Accepted: 05/03/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Previous evidence associating ileocecal valve removal (ICVR) with a reduced risk of fecal impaction of the ileocecum in cystic fibrosis indicated possible benefits from ileocecal valve loss in disorders with inhibited proximal colon transit caused by fecal dehydration and hypoperistalsis. We aimed to investigate the ability of ICVR in reversing fecal impaction in a loperamide-induced model of a similar pattern of inhibited proximal colon transit in rats. MATERIALS AND METHODS Thirty pubertal Sprague-Dawley rats were rendered constipated with subcutaneous loperamide treatment (1 mg/kg/d) for 7 d. On day four, rats were allocated to groups: ICVR (n = 12), total colectomy (TC, n = 9), and sham operation (SO, n = 9). Fecal pellet number and consistency were assessed daily. On day seven, all rats were gavaged with barium. Two hours later, intestinal transit ratio (distance of barium head from the pylorus adjusted for small intestine length) and adjusted (for total intestine length) barium-to-anus distance were assessed. RESULTS ICVR showed higher transit ratio and shorter barium-to-anus distance, that is, faster transit, than SO (P < 0.0001); differences between ICVR and TC were not significant (P > 0.06). Furthermore, ICVR and TC showed similar reduction in hard feces, compared with SO (P < 0.0001). TC showed higher diarrhea rate than ICVR (P < 0.0001). CONCLUSIONS ICVR led to an effective, similar to TC, reversal of the constipating effects of loperamide and, unlike TC, was not associated with diarrhea. Our findings support the idea that ICVR might be beneficial in disorders with inhibited proximal colon transit resulting from fecal dehydration and hypoperistalsis, such as refractory cystic fibrosis-related intestinal obstruction. Potential clinical implications merit further study.
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Affiliation(s)
- Anastasia Mentessidou
- University Research Institute of Maternal & Child Health and Precision Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Anastasia Livani
- University Research Institute of Maternal & Child Health and Precision Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - George Chrousos
- University Research Institute of Maternal & Child Health and Precision Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Petros Mirilas
- University Research Institute of Maternal & Child Health and Precision Medicine, National and Kapodistrian University of Athens, Athens, Greece.
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8
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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.
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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
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9
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Kilpatrick JA, Zobell S, Leeflang EJ, Cao D, Mammen L, Rollins MD. Intermediate and long-term outcomes of a bowel management program for children with severe constipation or fecal incontinence. J Pediatr Surg 2020; 55:545-548. [PMID: 31837840 DOI: 10.1016/j.jpedsurg.2019.10.062] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 10/30/2019] [Indexed: 12/27/2022]
Abstract
PURPOSE We sought to examine the long-term clinical success rates of a bowel management program (BMP) for children with severe constipation or fecal incontinence. METHODS A single center review was conducted of children (≤18 years) enrolled in a BMP and followed in a colorectal specialty clinic (2011-2017). All patients who completed an initial week of the BMP were included. Patients enrolled in a BMP after 2018 were excluded. Success was defined as no accidents and <2 stool smears per week. RESULTS A total of 285 patients were reviewed. BMP was initiated at a median age of 7 years (9 months-17 years). Primary diagnoses included functional constipation (112), anorectal malformation (ARM) (104), Hirschsprung Disease (HD) (41), rectal prolapse (14), spina bifida (6), fecal incontinence (3) and other (5; 4 sacral coccygeal teratomas and a GSW to the buttocks). Initial bowel regimen included large volume enema in 54% and high dose stimulant laxative in 46%. The initial Bowel Management Week (BMW) was successful in 233 (87% of adherent patients) patients with 17 (6%) non-adherent. One hundred twenty-two patients had follow-up at 12 months (72% success amongst adherent patients, 7% of patient non-adherent) and 98 patients had follow-up at 24 months (78% success amongst adherent patients, 10% of patients non-adherent). 21/154 (14%) patients started on enemas were later successfully transitioned to laxatives and 13/132 (10%) patients started on laxatives subsequently required enemas in order to stay clean. Clinic phone contact occurred outside of scheduled visits for adjustment to the BMP in 44% of patients. 33% of patients had surgery to aid bowel management (antegrade colonic enema (ACE) = 81, resection + ACE = 13, diverting stoma = 4). Median follow up was 2.5 years (5 weeks-7 years). CONCLUSION Children who follow a structured BMP with readily available personnel to provide outpatient assistance can experience successful treatment of severe constipation or fecal incontinence long-term. A multi-institutional collaboration is necessary to identify factors which predict failure of a BMP and non-adherence. TYPE OF STUDY Single-center retrospective chart review. LEVEL OF EVIDENCE 3.
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Affiliation(s)
| | - Sarah Zobell
- Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, UT
| | | | - Duyen Cao
- University of Utah School of Medicine, Salt Lake City, UT
| | - Lija Mammen
- University of Utah School of Medicine, Salt Lake City, UT
| | - Michael D Rollins
- University of Utah School of Medicine, Salt Lake City, UT; Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, UT
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10
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Tamura R, Jaffray B. Outcomes of colonic resection for chronic idiopathic constipation in childhood. J Pediatr Surg 2020; 55:269-272. [PMID: 31727386 DOI: 10.1016/j.jpedsurg.2019.10.047] [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] [Received: 10/10/2019] [Accepted: 10/26/2019] [Indexed: 12/25/2022]
Abstract
AIMS The purpose of this study was to describe the outcomes of colonic resection for constipation in children. Three different types of resection are compared: pan-proctocolectomy with ileoanal pouch anastomosis (IPAA), total colectomy with ileorectal anastomosis (IR), and segmental resections and anastomosis (SR). PATIENTS AND METHODS All colonic resections were prospectively recorded and their outcomes tabulated. Outcomes were classified as Good: anal defecation with no soiling; Intermediate: anal defecation with occasional soiling or need for ACE; Poor: a permanent stoma. All complications were also recorded. RESULTS 22 children underwent colonic resection over a 20 year period. Mean follow up was 40 months. 18 had prior antegrade continent enema (ACE), and 12 had a prior stoma. 13 underwent IPAA, 6 IR, and 3 SR. 10 (45%) had a good outcome, 4 (18%) had an intermediate outcome, and 8 (36%) had a poor outcome. Resection restored 9/12 (75%) of children with a preexisting stoma to anal defecation. No procedure produced better outcome than the others in terms of results or complications. CONCLUSIONS There may be a role for colonic resection in selected constipated children, but parents should be warned that there remains a significant possibility of a permanent stoma. Our study suggests that around two-fifths will be left with a permanent stoma. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Ryo Tamura
- The Great North Children's Hospital, Newcastle upon Tyne, UK
| | - Bruce Jaffray
- The Great North Children's Hospital, Newcastle upon Tyne, UK.
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11
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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.
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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.
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12
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Vriesman MH, Koppen IJN, Camilleri M, Di Lorenzo C, Benninga MA. Management of functional constipation in children and adults. Nat Rev Gastroenterol Hepatol 2020; 17:21-39. [PMID: 31690829 DOI: 10.1038/s41575-019-0222-y] [Citation(s) in RCA: 181] [Impact Index Per Article: 45.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/26/2019] [Indexed: 02/06/2023]
Abstract
Functional constipation is common in children and adults worldwide. Functional constipation shows similarities in children and adults, but important differences also exist regarding epidemiology, symptomatology, pathophysiology, diagnostic workup and therapeutic management. In children, the approach focuses on the behavioural nature of the disorder and the initial therapeutic steps involve toilet training and laxatives. In adults, management focuses on excluding an underlying cause and differentiating between different subtypes of functional constipation - normal transit, slow transit or an evacuation disorder - which has important therapeutic consequences. Treatment of adult functional constipation involves lifestyle interventions, pelvic floor interventions (in the presence of a rectal evacuation disorder) and pharmacological therapy. When conventional treatments fail, children and adults are considered to have intractable functional constipation, a troublesome and distressing condition. Intractable constipation is managed with a stepwise approach and in rare cases requires surgical interventions such as antegrade continence enemas in children or colectomy procedures for adults. New drugs, including prokinetic and prosecretory agents, and surgical strategies, such as sacral nerve stimulation, have the potential to improve the management of children and adults with intractable functional constipation.
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Affiliation(s)
- Mana H Vriesman
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.
| | - Ilan J N Koppen
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Michael Camilleri
- C.E.N.T.E.R. Program, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Carlo Di Lorenzo
- Division of Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital, Columbus, OH, USA
| | - Marc A Benninga
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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13
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Xie XY, Sun KL, Chen WH, Zhou Y, Chen BX, Ding Z, Yu XQ, Wu YH, Qian Q, Jiang CQ, Liu WC. Surgical outcomes of subtotal colectomy with antiperistaltic caecorectal anastomosis vs total colectomy with ileorectal anastomosis for intractable slow-transit constipation. Gastroenterol Rep (Oxf) 2019; 7:449-454. [PMID: 31857907 PMCID: PMC6911993 DOI: 10.1093/gastro/goz014] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Revised: 09/02/2018] [Accepted: 10/22/2018] [Indexed: 12/16/2022] Open
Abstract
Background Few studies have compared the surgical outcomes of different surgical procedures currently used to treat refractory colonic slow-transit constipation (STC), despite the increase in the number of cases. This study aimed to analyse the long-term surgical outcomes of subtotal colectomy with antiperistaltic caecorectal anastomosis (SC-ACRA) vs total colectomy with ileorectal anastomosis (TC-IRA) for severe STC. Methods Between January 2005 and January 2015, we retrospectively collected clinical data of 55 patients who underwent TC-IRA (n = 35) or SC-ACRA (n = 20) for severe STC at our institution. The post-operative functional outcomes between the two groups were compared. Results There were no significant differences in age (P = 0.655), sex (P = 0.234), period of constipation (P = 0.105) and defecation frequency (P = 0.698) between the TC-IRA and SC-ACRA groups. During a median follow-up period of 72 months (range, 12–120 months), there were no significant differences between the TC-IRA and SC-ACRA groups regarding the median number of bowel movements per day [3 (1/6–7) vs 3 (1/6–5), P = 0.578], Cleveland Clinic Florida Constipation Score [2 (0–20) vs 2 (0–19), P = 0.454], Cleveland Clinic Incontinence Score [0 (0–5) vs 0 (0–2), P = 0.333] and Gastrointestinal Quality of Life Index [122 (81–132) vs 120 (80–132), P = 0.661]. Moreover, there was no significant difference in the incidence of post-operative complications between the two groups (37.1% vs 25.0%, P = 0.285). Conclusions Our findings indicate that both TC-IRA and SC-ACRA are effective treatments for severe STC, with similar long-term outcomes.
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Affiliation(s)
- Xiao-Yu Xie
- Department of Colorectal and Anal Surgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, P. R. China.,Clinical Center of Intestinal and Colorectal Diseases of Hubei Province, Wuhan, Hubei, P. R. China.,Key Laboratory of Intestinal and Colorectal Diseases of Hubei Province, Wuhan, Hubei, P. R. China
| | - Kong-Liang Sun
- Department of Colorectal and Anal Surgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, P. R. China
| | - Wen-Hao Chen
- Department of Colorectal and Anal Surgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, P. R. China
| | - Yan Zhou
- Department of Colorectal and Anal Surgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, P. R. China.,Clinical Center of Intestinal and Colorectal Diseases of Hubei Province, Wuhan, Hubei, P. R. China.,Key Laboratory of Intestinal and Colorectal Diseases of Hubei Province, Wuhan, Hubei, P. R. China
| | - Bao-Xiang Chen
- Department of Colorectal and Anal Surgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, P. R. China
| | - Zhao Ding
- Department of Colorectal and Anal Surgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, P. R. China
| | - Xue-Qiao Yu
- Department of Colorectal and Anal Surgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, P. R. China
| | - Yun-Hua Wu
- Department of Colorectal and Anal Surgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, P. R. China
| | - Qun Qian
- Department of Colorectal and Anal Surgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, P. R. China.,Clinical Center of Intestinal and Colorectal Diseases of Hubei Province, Wuhan, Hubei, P. R. China.,Key Laboratory of Intestinal and Colorectal Diseases of Hubei Province, Wuhan, Hubei, P. R. China.,Colorectal and Anal Disease Research Center, Medical School of Wuhan University, Wuhan, Hubei, P. R. China.,Quality Control Center of Colorectal and Anal Surgery, Health Commission of Hubei Province, Wuhan, Hubei, P. R. China
| | - Cong-Qing Jiang
- Department of Colorectal and Anal Surgery, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, P. R. China.,Clinical Center of Intestinal and Colorectal Diseases of Hubei Province, Wuhan, Hubei, P. R. China.,Quality Control Center of Colorectal and Anal Surgery, Health Commission of Hubei Province, Wuhan, Hubei, P. R. China
| | - Wei-Cheng Liu
- Key Laboratory of Intestinal and Colorectal Diseases of Hubei Province, Wuhan, Hubei, P. R. China.,Colorectal and Anal Disease Research Center, Medical School of Wuhan University, Wuhan, Hubei, P. R. China
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14
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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.
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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
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15
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Abstract
Most clinicians will agree that chronic constipation is characterized by abnormal bowel movement consistency and/or frequency plus or minus evacuation symptoms, but patient perception of constipation varies widely and includes symptoms that may or may not meet official defining criteria. Although intermittent constipation is extremely common, only a small minority of patients seek care for their symptoms. Among these patients, dissatisfaction with the currently available laxative options is not uncommon, and many patients will require specialized care for severe or refractory symptoms-especially those with abdominal pain, irritable bowel syndrome overlap, bloating or distention, and psychological comorbidities. This review outlines a physiological assessment of the patient with refractory constipation, exploring treatment options among patients with slow transit, rectal evacuation disorders, and normal transit. In addition, we explore nonlaxative approaches to normal-transit patients bothered by ongoing symptoms, with an emphasis on the biopsychosocial model of functional gastrointestinal disease and treatment of visceral hypersensitivity using neuromodulators. Finally, we propose a comprehensive evaluation algorithm for the management of patients with refractory slow-transit constipation considering surgery and examine surgical options including colectomy and cecostomy using an antegrade continent enema.
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16
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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.
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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
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17
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Abstract
BACKGROUND Chronic constipation is described as a common complication determined by difficult and/or rare passage of stool or both. The difference in definition of constipation has led to a wide range of reported prevalence (i.e., between 1% and 80%). Various factors are involved in the pathogenesis of the disease, including type of diet, genetic predisposition, colonic motility, absorption, social economic status, daily behaviors, and biological and pharmaceutical factors. Diagnostic and therapeutic options play a key role in the treatment of chronic constipation. There are still debates about the timing of these diagnostic and therapeutic algorithms. METHODS A systematic and comprehensive search will be performed using MEDLINE, PubMed, EMBASE, AMED, the Cochrane Library and Google Scholar. Better understanding of the pathophysiology of chronic constipation and efficacy of pharmacological agent can help physicians for treating and managing symptoms.In this study, some of the old and new therapies in the treatment of chronic constipation have been studied based on the controlled studies and strong evidence. We are trying to address some of the controversial issues to manage the disease and to provide appropriate diagnostic options in an efficient and cost-effective way. RESULTS The results of this systematic review will be published in a peer-reviewed journal. CONCLUSION To our knowledge, our study will provide an overall estimate of chronic constipation to assess controversial issues, available diagnostic and therapeutic strategies of chronic constipation. ETHICS AND DISSEMINATION Ethical approval and informed consent are not required, as the study will be a literature review and will not involve direct contact with patients or alterations to patient care.
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Affiliation(s)
- Mojgan Forootan
- Department of Gastroenterology, Gastrointestinal, and liver Diseases Research Center (RCGLD)
| | - Nazila Bagheri
- Department of Nephrology, Taleghani Educational Hospital, Shahid Beheshti University of Medical Sciences
| | - Mohammad Darvishi
- Department of Aerospace and Subaquatic Medicine, Infectious Diseases and Tropical Medicine Research Center (IDTMRC), AJA University of Medical Sciences, Tehran, Iran
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18
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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: 5] [Impact Index Per Article: 0.8] [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.
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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
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19
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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.
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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
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20
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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.
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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
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21
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Koppen IJN, Di Lorenzo C, Saps M, Dinning PG, Yacob D, Levitt MA, Benninga MA. Childhood constipation: finally something is moving! Expert Rev Gastroenterol Hepatol 2016; 10:141-55. [PMID: 26466201 DOI: 10.1586/17474124.2016.1098533] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Recent developments in the evaluation and treatment of childhood constipation are likely to influence the way we deal with pediatric defecation disorders in the near future. Innovations in both colonic and anorectal manometry are leading to novel insights into functional defecation disorders in children. Promising results have been achieved with innovative therapies such as electrical stimulation and new drugs with targets that differ from conventional pharmacological treatments. Also, new surgical approaches, guided by manometric findings, have led to improvement in patient outcome. Finally, utilization of non-pharmacological interventions such as fiber and probiotics has been a field of particular interest in recent years. The aim of this article is to provide an update on these and other novel diagnostic and therapeutic tools related to childhood constipation.
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Affiliation(s)
- Ilan J N Koppen
- a Department of Pediatric Gastroenterology and Nutrition , Emma Children's Hospital/Academic Medical Center , Amsterdam , The Netherlands.,b Division of Pediatric Gastroenterology, Hepatology, and Nutrition , Nationwide Children's Hospital , Columbus , OH , USA
| | - Carlo Di Lorenzo
- b Division of Pediatric Gastroenterology, Hepatology, and Nutrition , Nationwide Children's Hospital , Columbus , OH , USA
| | - Miguel Saps
- b Division of Pediatric Gastroenterology, Hepatology, and Nutrition , Nationwide Children's Hospital , Columbus , OH , USA
| | - Phil G Dinning
- c Departments of Gastroenterology & Surgery , Flinders Medical Centre, Flinders University , South Australia , Australia
| | - Desale Yacob
- b Division of Pediatric Gastroenterology, Hepatology, and Nutrition , Nationwide Children's Hospital , Columbus , OH , USA
| | - Marc A Levitt
- d Center for Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Department of Surgery , The Ohio State University , Columbus , OH , USA
| | - Marc A Benninga
- a Department of Pediatric Gastroenterology and Nutrition , Emma Children's Hospital/Academic Medical Center , Amsterdam , The Netherlands
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22
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Abstract
PURPOSE OF REVIEW Constipation is a very common problem in pediatrics with both the severity of presentations and treatments varying across a broad spectrum. The majority of children with functional constipation are managed successfully without the need for specialized testing and surgical intervention. Those who present with intractable constipation, with or without fecal soiling, require referrals for motility testing that helps determine both medical and surgical management, and interventions. The literature was reviewed for publications on surgical approaches to children with severe constipation, including assessing the quality and levels of evidence and the use of objective measures to determine outcomes. RECENT FINDINGS There is very little in the way of recent studies evaluating surgical indications or treatment approaches for functional constipation, apart from one systematic review and one recent expert review. Although the systematic review was published in the last year, most of the studies it analyzes are older. The vast majority of studies comprise level 4 and 5 evidence. SUMMARY The indication for most surgical procedures is 'failed' medical management, yet no standardized definition for this exists. Many surgical procedures are proposed with little evidence to show outcomes. We recommend that the surgical evaluation and treatment of children with constipation needs to be protocolized and studied in a prospective manner using validated outcomes measures. Our center's current protocol is described.
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Wan S, Liu W, Tian C, Ren X, Ding Z, Qian Q, Jiang C, Wu Y. Differential Proteomics Analysis of Colonic Tissues in Patients of Slow Transit Constipation. BIOMED RESEARCH INTERNATIONAL 2016; 2016:4814702. [PMID: 27239471 PMCID: PMC4867068 DOI: 10.1155/2016/4814702] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 04/11/2016] [Indexed: 11/17/2022]
Abstract
Objective. To investigate and screen the different expression of proteins in STC and normal group with a comparative proteomic approach. Methods. Two-dimensional electrophoresis was applied to separate the proteins in specimens from both 5 STC patients and 5 normal controls. The proteins with statistically significant differential expression between two groups were identified by computer aided image analysis and matrix assisted laser desorption ionization tandem time of flight mass spectrometry (MALDI-TOF-MS). Results. A total of 239 protein spots were identified in the average gel of the normal control and 215 in patients with STC. A total of 197 protein spots were matched and the mean matching rate was 82%. There were 14 protein spots which were expressed with statistically significant differences from others. Of those 14 protein spots, the expression of 12 spots increased markedly, while that of 2 spots decreased significantly. Conclusion. The proteomics expression in colonic specimens of STC patients is statistically significantly different from that of normal control, which may be associated with the pathogenesis of STC.
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Affiliation(s)
- Songlin Wan
- Zhongnan Hospital of Wuhan University, Department of Colorectal & Anal Surgery, Clinical Center of Intestinal and Colorectal Diseases of Hubei Province, Key Laboratory of Intestinal & Colorectal Diseases of Hubei Province, Wuhan University, No. 169, Donghu Road, Wuchang District, Wuhan, Hubei 430071, China
| | - Weicheng Liu
- Zhongnan Hospital of Wuhan University, Department of Colorectal & Anal Surgery, Clinical Center of Intestinal and Colorectal Diseases of Hubei Province, Key Laboratory of Intestinal & Colorectal Diseases of Hubei Province, Wuhan University, No. 169, Donghu Road, Wuchang District, Wuhan, Hubei 430071, China
| | - Cuiping Tian
- Zhongnan Hospital of Wuhan University, Department of Colorectal & Anal Surgery, Clinical Center of Intestinal and Colorectal Diseases of Hubei Province, Key Laboratory of Intestinal & Colorectal Diseases of Hubei Province, Wuhan University, No. 169, Donghu Road, Wuchang District, Wuhan, Hubei 430071, China
| | - Xianghai Ren
- Zhongnan Hospital of Wuhan University, Department of Colorectal & Anal Surgery, Clinical Center of Intestinal and Colorectal Diseases of Hubei Province, Key Laboratory of Intestinal & Colorectal Diseases of Hubei Province, Wuhan University, No. 169, Donghu Road, Wuchang District, Wuhan, Hubei 430071, China
| | - Zhao Ding
- Zhongnan Hospital of Wuhan University, Department of Colorectal & Anal Surgery, Clinical Center of Intestinal and Colorectal Diseases of Hubei Province, Key Laboratory of Intestinal & Colorectal Diseases of Hubei Province, Wuhan University, No. 169, Donghu Road, Wuchang District, Wuhan, Hubei 430071, China
| | - Qun Qian
- Zhongnan Hospital of Wuhan University, Department of Colorectal & Anal Surgery, Clinical Center of Intestinal and Colorectal Diseases of Hubei Province, Key Laboratory of Intestinal & Colorectal Diseases of Hubei Province, Wuhan University, No. 169, Donghu Road, Wuchang District, Wuhan, Hubei 430071, China
| | - Congqing Jiang
- Zhongnan Hospital of Wuhan University, Department of Colorectal & Anal Surgery, Clinical Center of Intestinal and Colorectal Diseases of Hubei Province, Key Laboratory of Intestinal & Colorectal Diseases of Hubei Province, Wuhan University, No. 169, Donghu Road, Wuchang District, Wuhan, Hubei 430071, China
| | - Yunhua Wu
- Zhongnan Hospital of Wuhan University, Department of Colorectal & Anal Surgery, Clinical Center of Intestinal and Colorectal Diseases of Hubei Province, Key Laboratory of Intestinal & Colorectal Diseases of Hubei Province, Wuhan University, No. 169, Donghu Road, Wuchang District, Wuhan, Hubei 430071, China
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Chan DSY, Delicata RJ. Meta-analysis of antegrade continence enema in adults with faecal incontinence and constipation. Br J Surg 2016; 103:322-7. [PMID: 26830062 DOI: 10.1002/bjs.10051] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2015] [Revised: 07/24/2015] [Accepted: 10/07/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND Faecal incontinence and constipation affects up to 20 per cent of the general population, and can be a significant source of distress. The antegrade continence enema (ACE) procedure has been shown to be an effective alternative treatment option for children, but its use in adults requires clarification. A systematic review and meta-analysis was performed to determine outcomes of the ACE procedure in adults with faecal incontinence and constipation. METHODS PubMed, MEDLINE and the Cochrane Library (from January 1990 to January 2015) were searched for studies that reported outcomes of ACE in adults with faecal incontinence and constipation. The primary outcome measure was successful use of ACE in the management of symptoms, as determined by continued use at follow-up. RESULTS Seventeen observational studies involving 426 patients (265 female patients; median age 42 (range 17-84) years) with faecal incontinence (165 patients), constipation (209) or both (52), who had undergone the ACE procedure, were analysed. At a median follow-up of 39 months, the pooled success rate was 74·3 (95 per cent c.i. 66·1 to 82·6) per cent (P < 0·001). For patients with faecal incontinence the pooled success rate was 83·6 (75·0 to 92·1) per cent, compared with 67·7 (55·1 to 80·3) per cent in patients with constipation (both P < 0·001). CONCLUSION The ACE procedure is an effective long-term treatment option in patients with faecal incontinence and constipation, and should be considered before performing a definitive colostomy. Patients with faecal incontinence appear to respond better than those with constipation.
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Affiliation(s)
- D S Y Chan
- Department of Surgery, Nevill Hall Hospital, Abergavenny, NP7 7EG, UK
| | - R J Delicata
- Department of Surgery, Nevill Hall Hospital, Abergavenny, NP7 7EG, UK
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Liu W, Zhang Q, Li S, Li L, Ding Z, Qian Q, Fan L, Jiang C. The Relationship Between Colonic Macrophages and MicroRNA-128 in the Pathogenesis of Slow Transit Constipation. Dig Dis Sci 2015; 60:2304-15. [PMID: 25749934 DOI: 10.1007/s10620-015-3612-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 02/25/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND Recent evidence suggests that colonic macrophages and microRNAs play important roles in motor activity in the gastrointestinal tract. However, there are almost no data concerning colonic macrophages and microRNAs in slow transit constipation. AIM The purpose of this study was to investigate colonic macrophages and microRNA-128 expression in the pathogenesis of slow transit constipation in colon tissues. METHODS Full-thickness colonic specimens from patients undergoing surgery for slow transit constipation, due to refractoriness to other therapeutic interventions (n = 25), were compared to controls (n = 25), and the number of colonic macrophages (as evaluated by specific monoclonal antibodies) was counted. Gene expression analysis of microRNA-128 was performed by microRNA microarray and qRT-PCR. Lastly, bioinformatics analysis, coupled with luciferase reporter assays, was used to investigate the mRNA transcript(s) targeted by microRNA-128. RESULTS Compared to controls, 20 of 25 slow transit constipation patients (80 %) had significantly higher numbers of macrophages in colonic specimens, coupled with down-regulation of microRNA-128. Linear regression analyses showed a significant negative correlation between macrophage number and microRNA-128 expression level. Among 83 bioinformatically predicated candidates, mitogen-activated protein kinase 14 (p38α) was validated to be a direct target of microRNA-128 in human intestinal epithelial cells. CONCLUSIONS This study presents evidence for the negative correlation of macrophage number and microRNA-128 expression, in slow transit constipation patients, representing a possible mechanism of impaired gastrointestinal motility.
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Affiliation(s)
- Weicheng Liu
- Department of Colorectal Surgery, Clinical Center of Intestinal and Colorectal Diseases of Hubei Province, Key Laboratory of Intestinal & Colorectal Diseases of Hubei Province, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuchang District, Wuhan, 430071, People's Republic of China,
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Pescatori M, Podzemny V, Pescatori LC, Dore MP, Bassotti G. The PNEI holistic approach in coloproctology. Tech Coloproctol 2015; 19:269-73. [PMID: 25820513 DOI: 10.1007/s10151-015-1277-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 01/27/2015] [Indexed: 12/17/2022]
Abstract
The psycho-neuroendocrine-immune approach relies on the concept of considering diseases from a holistic point of view: the various components (psyche, nervous system, endocrine system, and immune system) control the diseased organ/apparatus and in turn are influenced by a feedback mechanism. In this article, we will consider the psycho-neuroendocrine-immune approach to coloproctological disorders, by providing clinical cases and discussing them in light of this approach.
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Affiliation(s)
- M Pescatori
- Coloproctology Unit, Parioli Clinic, Rome, Italy,
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Bassotti G, Blandizzi C. Understanding and treating refractory constipation. World J Gastrointest Pharmacol Ther 2014; 5:77-85. [PMID: 24868488 PMCID: PMC4023327 DOI: 10.4292/wjgpt.v5.i2.77] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Revised: 01/20/2014] [Accepted: 02/19/2014] [Indexed: 02/06/2023] Open
Abstract
Chronic constipation is a frequently encountered disorder in clinical practice. Most constipated patients benefit from standard medical approaches. However, current therapies may fail in a proportion of patients. These patients deserve better evaluation and thorough investigations before their labeling as refractory to treatment. Indeed, several cases of apparent refractoriness are actually due to misconceptions about constipation, poor basal evaluation (inability to recognize secondary causes of constipation, use of constipating drugs) or inadequate therapeutic regimens. After a careful re-evaluation that takes into account the above factors, a certain percentage of patients can be defined as being actually resistant to first-line medical treatments. These subjects should firstly undergo specific diagnostic examination to ascertain the subtype of constipation. The subsequent therapeutic approach should be then tailored according to their underlying dysfunction. Slow transit patients could benefit from a more robust medical treatment, based on stimulant laxatives (or their combination with osmotic laxatives, particularly over the short-term), enterokinetics (such as prucalopride) or secretagogues (such as lubiprostone or linaclotide). Patients complaining of obstructed defecation are less likely to show a response to medical treatment and might benefit from biofeedback, when available. When all medical treatments prove to be unsatisfactory, other approaches may be attempted in selected patients (sacral neuromodulation, local injection of botulinum toxin, anterograde continence enemas), although with largely unpredictable outcomes. A further although irreversible step is surgery (subtotal colectomy with ileorectal anastomosis or stapled transanal rectal resection), which may confer some benefit to a few patients with refractoriness to medical treatments.
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Gardiner A, Wallace E. Identifying patient problems and devising care pathways with the neurogenic bowel dysfunction score. ACTA ACUST UNITED AC 2014. [DOI: 10.12968/gasn.2014.12.sup2.s17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Angela Gardiner
- Senior Lecturer, Department of Health Technology and Perioperative Practice, University of Hull, East Yorkshire, UK
| | - Eva Wallace
- Clinical Nurse Manager 2, National Rehabilitation Hospital, Dún Laoghaire, Dublin, Republic of Ireland
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A modified total colonic exclusion for elderly patients with severe slow transit constipation. Tech Coloproctol 2014; 18:629-34. [PMID: 24435473 DOI: 10.1007/s10151-013-1108-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Accepted: 12/09/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND The aim of this study was to evaluate outcomes of total colonic exclusion with antiperistaltic ileorectal anastomosis (TCE-AIA) for elderly patients with slow transit constipation (STC). METHODS Elderly patients (defined as age >65) who underwent TCE-AIA for severe idiopathic STC between 2009 and 2012 at our institution were identified. Postoperative outcomes and routine follow-up were assessed using the Wexner constipation score (WCS), gastrointestinal quality of life index (GIQLI) and four-point postoperative satisfaction scales. RESULTS A total of 13 elderly patients were met the inclusion criteria. Five patients (38.5%) were male, and eight patients (61.5%) were female. The mean age of this population was 74 years (range 63-82 years). The mean operative time was 55 min (range 28-32), and blood loss was minimal. The mean postoperative hospital stay was 6.7 days (range 5-12 days). The mean time until the first postoperative bowel movement was 4 days (range 2-8 days). There was no procedure-related mortality and no major in-hospital complications. The median duration of follow-up was 12.4 months (range 6-29 months). None of the 13 patients had fecal incontinence or recurrence of constipation at the follow-up end point. However, eight patients underwent colonoscopy during follow-up, and four patients presented with diversion colitis. The patients' preoperative WCS was 22.8 ± 3.3, and it had significantly improved to 5.4 ± 2.1 on 6 months after operation (p < 0.05). The preoperative GIQLI of 93.6 ± 20.5 had significantly increased to 120.8 ± 13.0 on 6 months after surgery (p < 0.05). Patient satisfaction at 6 months was very high in 11 patients and high in two patients. CONCLUSIONS TCE-AIA is a relatively simple procedure. It might be an effective surgical intervention for the selected elderly patients with STC.
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Barthel ER, Levin DE, Speer AL, Sala FG, Torashima Y, Hou X, Grikscheit TC. Human tissue-engineered colon forms from postnatal progenitor cells: an in vivo murine model. Regen Med 2013; 7:807-18. [PMID: 23164081 DOI: 10.2217/rme.12.91] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
AIM Loss of colon reservoir function after colectomy can adversely affect patient outcomes. In previous work, human fetal intestinal cells developed epithelium without mesenchyme following implantation in mice. However, for humans, postnatal tissue would be the preferred donor source. We generated tissue-engineered colon (TEC) from postnatal human organoid units. MATERIALS & METHODS Organoid units were prepared from human colon waste specimens, loaded onto biodegradable scaffolds and implanted into immunocompromised mice. After 4 weeks, human TEC was harvested. Immunofluorescence staining confirmed human origin, identified differentiated epithelial cell types and verified the presence of supporting mesenchyme. RESULTS Human TEC demonstrated a simple columnar epithelium. Immunofluorescence staining demonstrated human origin and the three differentiated cell types of mature colon epithelium. Key mesenchymal components (smooth muscle, intestinal subepithelial myofibroblasts and ganglion cells) were seen. CONCLUSION Colon can form from human progenitor cells on a scaffold in a mouse host. This proof-of-concept experiment is an important step in transitioning TEC to human therapy.
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Affiliation(s)
- Erik R Barthel
- Children's Hospital Los Angeles, Keck School of Medicine of the University of Southern California, Division of Pediatric Surgery, 4650 Sunset Boulevard Mailstop #35, Los Angeles, CA 90027, USA
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Beyond hematoxylin and eosin: the importance of immunohistochemical techniques for evaluating surgically resected constipated patients. Tech Coloproctol 2011; 15:371-5. [PMID: 21766200 DOI: 10.1007/s10151-011-0721-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2011] [Accepted: 06/30/2011] [Indexed: 12/18/2022]
Abstract
Chronic constipation requiring surgical ablation for intractability is often a frustrating condition from the pathologist's point of view. In fact, limiting the histological examination to only hematoxylin-eosin staining usually yields only the information that there are no abnormalities. By employing some simple and widely available immunohistochemical methods, discussed in this review, it is possible to gather data that may help in explaining the pathophysiological basis of constipation in these patients.
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