Effectiveness of an organized bowel management program in the management of severe chronic constipation in children

Strategies used for childhood chronic functional constipation: the SUCCESS evidence synthesis

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.

Decreasing Radiation Exposure to the Abdomen in Children with Chronic Constipation

Background

Bowel management for children with chronic constipation may include repeated single-view abdomen radiographs (AXR) to monitor treatment success. Only one image of the abdomen is needed to include most of the colon, but technologists often make a second (or even third) exposure to be sure they have imaged the entire abdomen. Our quality improvement project aimed to reduce radiation exposure by decreasing the frequency of >1 exposure performed for AXR orders in children with chronic constipation from 27% to <10% by December 2022 and sustain.

Methods

We counted baseline (01/2020-11/2020) and intervention (12/2020-5/2023) examinations with >1 exposure. Initial interventions were a structured communication to technologists and an article in the monthly department newsletter and later, a technologist education module. Additional interventions included communication to radiologists, project updates and encouragement to all technologists, and individual technologist feedback. A statistical process control chart tracked data to study process changes over time.

Results

During the baseline and intervention periods, 525/1944 and 1329/8334 examinations, respectively, had >1 exposure performed for AXR orders. Interventions created 2 centerline shifts. Overall, examinations with >1 exposure decreased from 27% to 13.5%.

Conclusions

Frequency of >1 exposure performed for AXR orders in children with chronic constipation decreased from 27% to 13.5% through education and communication. This was sustained. We plan to assign training modules for all new technologists, policy reminders (annual training in odd years) for all technologists, and continue individualized learning opportunities.

Radiologically supervised bowel management program outcome in patients with chronic idiopathic constipation

PURPOSE

This study aimed to analyze our radiologically supervised bowel management program (RS-BMP) outcomes in patients with chronic idiopathic constipation (CIC).

METHODS

A retrospective study was conducted. We included all patients with CIC who participated in our RS-BMP at Children´s Hospital Colorado from July 2016 to October 2022.

RESULTS

Eighty patients were included. The average time with constipation was 5.6 years. Before our RS-BMP, 95% had received non-radiologically supervised treatments, and 71% had attempted two or more treatments. Overall, 90% had tried Polyethylene Glycol and 43% Senna. Nine patients had a history of Botox injections. Five underwent anterograde continence procedure, and one a sigmoidectomy. Behavioral disorders (BD) were found in 23%. At the end of the RS-BMP, 96% of patients had successful outcomes, 73% were on Senna, and 27% were on enemas. Megarectum was detected in 93% of patients with successful outcomes and 100% with unsuccessful outcomes (p = 0.210). Of the patients with BD, 89% had successful outcomes, and 11% had unsuccessful.

CONCLUSION

Our RS-BMP has been proven to be effective in treating CIC. The radiologically supervised use of Senna and enemas was the appropriate treatment in 96% of the patients. BD and megarectum were associated with unsuccessful outcomes.

State of the Art Bowel Management for Pediatric Colorectal Problems: Functional Constipation

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.

Pediatric Bowel Management Options and Organizational Aspects

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.

The presence of a neurodiverse disorder is associated with increased use of antegrade enema therapy in children with severe constipation: A study from the Pediatric Colorectal and Pelvic Learning Consortium (PCPLC)

INTRODUCTION

Children with severe constipation and a neurodiverse disorder (Autism and/or developmental delay) represent a challenging bowel management group. Treatment outcomes with laxative or enema therapy remain limited and are often complicated by patient/caregiver compliance. We hypothesized that children with neurodiverse disorders and severe constipation would benefit from a bowel management program (BMP) that includes early use of antegrade enemas.

MATERIALS AND METHODS

Children requiring BMP in the Pediatric Colorectal and Pelvic Learning Consortium (PCPLC) registry with diagnosis of constipation and/or constipation with pseudo-incontinence were reviewed. Those with Hirschsprung disease and/or Anorectal Malformation were excluded. BMP needs in patients with a neurodiverse diagnosis were compared to those without to evaluate differences in BMP's.

RESULTS

372 patients requiring a BMP were identified. 95 patients (58 autism spectrum, 54 developmental delay) were neurodiverse, and 277 patients were not. Neurodiverse patients had a higher prevalence of enema therapy 62.1% (59/95) vs. 54.9% (152/273) and use of antegrade enema therapy 33.7% (32/95) vs. 21.2% (58/273), p = 0.126. Neurodiverse patients were older 37.9% (36/95) > 12 years vs. 23.1% (63/273), p = 0.001 and 47.6% (10/21) were changed from laxative to enema therapy over time. 80% (8/10) of those changed from laxatives to enemas used antegrade therapy. 67.3% (35/52) of neurodiverse patients followed over time were on enema therapy at the most recent visit with 80% (28/35) requiring antegrade therapy.

CONCLUSION

A large portion of patients with a neurodiverse disorder who fail laxative therapy use antegrade enemas to achieve effective bowel management. Early consideration of an antegrade conduit may simplify treatment in this group of children.

LEVEL OF EVIDENCE

III.

Multi-institutional review of bowel management strategies in children with anorectal malformations

BACKGROUND/RATIONALE

To describe current bowel management program (BMP) strategies in anorectal malformation (ARM) patients based on patient-level predictors using data from a multi-institutional consortium.

MATERIALS/METHODS

Patient bowel function and BMP were reviewed from Pediatric Colorectal and Pelvic Learning Consortium (PCPLC) data. The PCPLC is comprised of multidisciplinary specialists researching colorectal and pelvic disorders. Seven US institutions submitted de-identified clinical data on ARM patients into a centralized patient registry.

RESULTS

The primary ARM of 624 patients was categorized into Mild (45.2%), Moderate (40.4%) or Complex (14.2%) anomaly classifications. Patient-specific BMP were examined based on age and on the presence of spinal cord/sacral anomalies. 418 (67%) enrolled patients were prescribed BMP (<5 yo 56.4%; ≥5-<12 yo 86.7%; ≥12 81.5%). Constipation was the primary chief complaint (80.2%). Forty percent of patients on a BMP were toilet trained and approximately one-half (48.5%) reported daytime stool accidents. Secondary surgical interventions for antegrade continence enemas (ACE) were examined; 14.5% of patients employed ACE strategies and utilization increased with age and varied based on anatomic anomalies.

CONCLUSIONS

This is the first report on BMP strategies for patients with ARM from the Pediatric Colorectal and Pelvic Learning Consortium. Individual patient characteristics are explored for their impact on bowel management strategy utilization.

LEVEL OF EVIDENCE

IV.

Medications for constipation in 2020

PURPOSE OF REVIEW

Chronic constipation is a common problem that substantially impacts the quality of life of patients and families, healthcare professionals, and resources. The purpose of this review is to discuss the medications that are available for management of chronic constipation, including medications that have been approved by the FDA for adults, other been studied in pediatrics now, and might become available within the upcoming years.

RECENT FINDINGS

Recent developments in the evaluation of childhood constipation are providing a better understanding into defecation disorders in children and not only new therapies are becoming available, including medications, but also other therapies, such as biofeedback for treatment of functional defecation disorders, electrical stimulation, and surgeries. The aim of this article is to provide an update on the medications that are available for management of chronic constipation, especially with the development and study of newer medications, such as Linaclotide and Lubiprostone with promising results in both adult and pediatric patients.

SUMMARY

This review will help us identify and have a better understanding regarding what medications are available for use and the indications, so that we can better manage patients with chronic constipation. VIDEO ABSTRACT.

Intermediate and long-term outcomes of a bowel management program for children with severe constipation or fecal incontinence

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.

Quality of life in children with pseudoincontinence after implementing a bowel management program in Egypt

AIM OF THE STUDY

The aim of this study was to evaluate the impact of implementing a Bowel Management Program (BMP) on the quality of life (QOL) in children with pseudoincontinence.

METHOD

Children aged 2.5-13 years with pseudoincontinence were included. Evaluations were performed before and after BMP implementation. Perceptions from parents about QOL were assessed by a QOL questionnaire, and the severity of fecal incontinence (FI) was assessed using the fecal incontinence index (FII) of the Wexner scale.

RESULTS

115 children (mean age of 7.54 ± 2.48) were studied over a 3-12 month period (mean duration 4.36 months). QOL improved from 2.45 ± 1.57 to 14.36 ± 1.37, P˂0.05. There was a significant improvement of the FII: 18.65 ± 1.25 versus 0.13 ± 0.39, P˂ 0.05. There was a significant inverse correlation between the final scores of QOL (14.36 ± 1.37) and FII (0.13 ± 0.39) after implementation of the BMP (r = -0.53; P ˂ 0.05).

CONCLUSION

This is the largest case series examining QOL in pseudoincontinent children. It demonstrates that BMP significantly improves the QOL of these children in the short and midterm. In addition, it is feasible to apply the FII in assessing incontinence in children. To our knowledge, this is the first study of its kind in our region.

LEVEL OF EVIDENCE

Level IV.

A Comparison of the Efficacy of Enema Solutions in Pediatric Emergency Department Patients

BACKGROUND

Children presenting to pediatric emergency departments (EDs) are frequently given enemas for relief of constipation symptoms; there is very little literature guiding solution selection.

OBJECTIVE

Our aim was to assess and compare the efficacy of the various enema solutions used in a pediatric ED, including the "pink lady," a previously unreported compounded combination of docusate, magnesium citrate, mineral oil, and sodium phosphate.

METHODS

We identified all children who received any enema over a 5-year period in an urban, quaternary care pediatric ED for inclusion in the study via electronic record review. Physician investigators retrospectively reviewed routine visit documentation to confirm the type and dosage of enema and assess comorbidities, indications, efficacy, and side effects. Subjective descriptions of output were classified as none, small, medium, or large by reviewer consensus.

RESULTS

There were 768 records included. Median age was 6.2 years (interquartile range 3.3-10.3 years). Solutions used were sodium phosphate (n = 396), pink lady (n = 198), soap suds (n = 160), and other (n = 14). There was no significant difference in output by solution type (p = 0.88). Volume delivered was highest for pink lady, with no significant association between volume delivered and output (p = 0.48). Four percent of patients had side effects. Soap suds had a significantly higher rate of side effects (10.6%; p = 0.0003), primarily abdominal pain.

CONCLUSIONS

There was no significant difference in reported stool output produced by sodium phosphate, soap suds, and pink lady enemas in children treated in an ED. Further study via randomized controlled trials would be beneficial in guiding selection of enema solution.

Development of a Patient-reported Experience and Outcome Measures in Pediatric Patients Undergoing Bowel Management for Constipation and Fecal Incontinence

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.

Surgical treatment of idiopathic megarectum in constipated children

BACKGROUND

Chronic constipation in children is associated with primary megarectum. This study investigated outcomes of surgical treatment of idiopathic megarectum in children.

METHODS

This retrospective comparative study included 52 children with idiopathic megarectum (mean age, 9.4 ± 1.7 years) treated from 2007 to 2016. Patients were divided into 2 groups. Group 1 included 23 patients who underwent a Soave pull-through operation. Group 2 included 29 children who underwent laparoscopic low anterior resection with endorectal stapled anastomosis using laparoscopic ultrasound guidance. All patients had clinical and laboratory evaluations with anorectal manometry, colonoscopy and contrast enema studies.

RESULTS

Six patients (26.1%) in Group 1 and one (3.5%) in Group 2 experienced anastomosis leakage requiring colostomy (χ² = 3.867, P = 0.049). In long-term follow-up, 3 children (13.1%) in Group 1 and 2 (6.9%) in Group 2 had ongoing constipation; this difference was not significant. Frequent loose stools with soiling were significantly more common in Group 1 (14 patients; 60.9%) than in Group 2 (4 patients; 13.8%) (χ² = 10.566, P = 0.001).

CONCLUSIONS

Our experience shows that laparoscopic video-assisted low anterior resection of the colon with endorectal stapled anastomosis under laparoscopic ultrasound guidance to determine the level of colon resection is the better operation then Soave for children with idiopathic megarectum and chronic constipation. This approach provides good functional results and reduces complications.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Can fecal continence be predicted in patients born with anorectal malformations?

PURPOSE

The purpose of this study was to identify factors associated with attaining fecal continence in children with anorectal malformations (ARM).

METHODS

We performed a multi-institutional cohort study of children born with ARM in 2007-2011 who had spinal and sacral imaging. Questions from the Baylor Social Continence Scale were used to assess fecal continence at the age of ≥4 years. Factors present at birth that predicted continence were identified using multivariable logistic regression.

RESULTS

Among 144 ARM patients with a median age of 7 years (IQR 6-8), 58 (40%) were continent. The rate of fecal continence varied by ARM subtype (p = 0.002) with the highest rate of continence in patients with perineal fistula (60%). Spinal anomalies and the lateral sacral ratio were not associated with continence. On multivariable analysis, patients with less severe ARM subtypes (perineal fistula, recto-bulbar fistula, recto-vestibular fistula, no fistula, rectal stenosis) were more likely to be continent (OR = 7.4, p = 0.001).

CONCLUSION

Type of ARM was the only factor that predicted fecal continence in children with ARM. The high degree of incontinence, even in the least severe subtypes, highlights that predicting fecal continence is difficult at birth and supports the need for long-term follow-up and bowel management programs for children with ARM.

TYPE OF STUDY

Prospective Cohort Study.

LEVEL OF EVIDENCE

II.

A structured bowel management program for patients with severe functional constipation can help decrease emergency department visits, hospital admissions, and healthcare costs

BACKGROUND

Published health-care costs related to constipation in children in the USA are estimated at $3.9 billion/year. We sought to assess the effect of a bowel management program (BMP) on health-care utilization and costs.

METHODS

At two collaborating centers, BMP involves an outpatient week during which a treatment plan is implemented and objective assessment of stool burden is performed with daily radiography. We reviewed all patients with severe functional constipation who participated in the program from March 2011 to June 2015 in center 1 and from April 2014 to April 2016 in center 2. ED visits, hospital admissions, and constipation-related morbidities (abdominal pain, fecal impaction, urinary retention, urinary tract infections) 12 months before and 12 months after completion of the BMP were recorded.

RESULTS

One hundred eighty-four patients were included (center 1 = 96, center 2 = 88). Sixty-three (34.2%) patients had at least one unplanned visit to the ED before treatment. ED visits decreased to 23 (12.5%) or by 64% (p < 0.0005). Unplanned hospital admissions decreased from 65 to 28, i.e., a 56.9% reduction (p < 0.0005).

CONCLUSION

In children with severe functional constipation, a structured BMP decreases unplanned visits to the ED, hospital admissions, and costs for constipation-related health care.

LEVEL OF EVIDENCE

3.

Surgical Management of Idiopathic Constipation in Pediatric Patients

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.

Reducing hospital admissions of healthy children with functional constipation: a quality initiative

Functional constipation (FC) is a common medical problem in children, with minimal risk of long-term complications. We determined that a large number of children were being admitted to our children’s hospital for FC in which there was no neurological or anatomical cause. Our hospital experienced a patient complication in which a patient died after inpatient treatment of FC. Subsequently, we developed a standardised approach to determine when paediatric patients needed hospitalisation for FC, as well as to develop a regimented outpatient therapeutic approach for such children to prevent hospitalisation. Our quality improvement initiative resulted in a large decrease in the number of children with FC admitted into the hospital as well as a decrease in the number of children needing faecal disimpaction in the operating room. Our quality improvement process can be used to decrease hospitalisations, decrease healthcare costs and improve patient care for paediatric FC.

Case series with literature review: Surgical approach to megarectum and/or megasigmoid in children with unremitting constipation

Background

The role of surgery in treating children with functional constipation (FC) is controversial, because of the efficacy of bowel management programs. This case series is comprised of failures: 43 children, spanning 25 years' practice, who had megarectosigmoid (MRS) and unremitting constipation.

Purpose

To determine whether these children were helped by surgery, and to contribute to formulating a standard of care for children with megarectum (MR) and/or redundancy of the sigmoid colon (MS) who fail medical management.

Method

We describe our selection criteria and the procedures we utilized – mucosal proctectomy and endorectal pull-through (MP) or sigmoidectomy (SE) with colorectal anastomosis at the peritoneal reflection. The internet (social media) allowed us to contact most of these patients and obtain extremely long follow-up data.

Results

30/43 patients had MP and 13/43 had SE. Follow-up was obtained in 83% MP and 70% SE patients. 60% of MP and 78% of SE patients reported regular evacuations and no soiling. 20% MP patients had occasional urgency or soiling or episodic constipation. 12% MP and 22% SE patients required antegrade continence enemas (ACE) or scheduled cathartics and/or stool softeners. 4% MP had no appreciable benefit, frequent loose stools and soiling, presumably from encopresis.

Conclusion

MR is characterized by diminished sensation, poor compliance and defective contractility. Patients with MR do better with MP, which effectively removes the entire rectum versus SE, where normal caliber colon is anastomosed to MR at the peritoneal reflection; furthermore, MP reliably preserves continence; whereas total proctectomy (trans-anal or trans-abdominal) may cause incontinence.

•

Intestinal peristalsis stagnates in a dilated segment.

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Megarectosigmoid (MRS) may present during infancy or later in life.

•

It may occur in association with anorectal malformations or as an isolated abnormality.

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Unlike dilatation secondary to outlet dysfunction, MRS persists even after a diverting colostomy.

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MRS does not respond to bowel management programs.

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Intestinal peristalsis improves following extirpation of MRS.

Surgical options for the management of severe functional constipation in children

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.

Impact of the Bowel Management Program on the quality of life in children with fecal incontinence

PURPOSE

Evaluate the impact of implementing Bowel Management Program (BMP) on quality of life (QoL) in children with fecal incontinence (FI).

METHODS

Children 3-12 years referred to the Children's Treatment Center of FI were included and categorized accordingto the tendency to constipation (dilated colon; group 1) or diarrhea (non-dilated colon; group 2). Evaluations were performed before and after 3 months of BMP implementation. Perceptions from parents and children about QoL were assessed by the instrument PedsQL4.0 and the severity of FI by the fecal incontinence index (FII) of Wexner scale.

RESULTS

43 children (mean age of 7.7 ± 3.1) were studied. 32 (74.4 %) belonged to group 1 and 11 (25.6 %) to group 2. After 3 months of BMP, it was noticed a significant improvement of the FII (14.5 ± 3.7 versus 2.8 ± 2.5; p < 0.001) in both groups. QoL perception by the parents and children increased on PedsQL4.0 evaluation (p < 0.001). There was a medium inverse statistically significant correlation of the FII and the total PedsQL4.0 score among children and parents (r = -0.47, p = 0.009 and r = -0, 39, p = 0.03, respectively).

CONCLUSION

The BMP applied by a multidisciplinary dedicated team significantly improves the QoL of children with FI in the short-term period.