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Swanson KA, Phelps HM, Chapman WC, Glasgow SC, Smith RK, Joerger S, Utterson EC, Shakhsheer BA. Surgery for chronic idiopathic constipation: pediatric and adult patients - a systematic review. J Gastrointest Surg 2024; 28:170-178. [PMID: 38445940 DOI: 10.1016/j.gassur.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 11/25/2023] [Accepted: 12/08/2023] [Indexed: 03/07/2024]
Abstract
BACKGROUND Chronic idiopathic constipation (CIC) is a substantial problem in pediatric and adult patients with similar symptoms and workup; however, surgical management of these populations differs. We systematically reviewed the trends and outcomes in the surgical management of CIC in pediatric and adult populations. METHODS A literature search was performed using Ovid MEDLINE, Embase, Scopus, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov between January 1, 1995 and June 26, 2020. Clinical trials and retrospective and prospective studies of patients of any age with a diagnosis of CIC with data of at least 1 outcome of interest were selected. The interventions included surgical resection for constipation or antegrade continence enema (ACE) procedures. The outcome measures included bowel movement frequency, abdominal pain, laxative use, satisfaction, complications, and reinterventions. RESULTS Adult patients were most likely to undergo resection (94%), whereas pediatric patients were more likely to undergo ACE procedures (96%) as their primary surgery. Both ACE procedures and resections were noted to improve symptoms of CIC; however, ACE procedures were associated with higher complication and reintervention rates. CONCLUSION Surgical management of CIC in pediatric and adult patients differs with pediatric patients receiving ACE procedures and adults undergoing resections. The evaluation of resections and long-term ACE data in pediatric patients should be performed to inform patients and physicians whether an ACE is an appropriate procedure despite high complication and reintervention rates or whether resections should be considered as an initial approach for CIC.
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Affiliation(s)
- Kerry A Swanson
- Department of Surgery, Washington University in St. Louis, St. Louis, Missouri, United States.
| | - Hannah M Phelps
- Department of Surgery, Washington University in St. Louis, St. Louis, Missouri, United States
| | - William C Chapman
- Department of Surgery, Washington University in St. Louis, St. Louis, Missouri, United States
| | - Sean C Glasgow
- James H. Quillen Veterans Affairs Medical Center, Mountain Home, Tennessee, United States; Eastern Tennessee State University, Johnson City, Tennessee, United States
| | - Radhika K Smith
- Advent Health Medical Center, Orlando, Florida, United States
| | - Shannon Joerger
- Division of Pediatric Gastroenterology, Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri, United States
| | - Elizabeth C Utterson
- Division of Pediatric Gastroenterology, Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri, United States
| | - Baddr A Shakhsheer
- Section of Pediatric Surgery, Department of Surgery, Comer Children's Hospital, The University of Chicago, Chicago, Illinois, United States
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Todhunter-Brown A, Booth L, Campbell P, Cheer B, Cowie J, Elders A, Hagen S, Jankulak K, Mason H, Millington C, Ogden M, Paterson C, Richardson D, Smith D, Sutcliffe J, Thomson K, Torrens C, McClurg D. Strategies used for childhood chronic functional constipation: the SUCCESS evidence synthesis. Health Technol Assess 2024; 28:1-266. [PMID: 38343084 PMCID: PMC11017632 DOI: 10.3310/pltr9622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2024] Open
Abstract
Background Up to 30% of children have constipation at some stage in their life. Although often short-lived, in one-third of children it progresses to chronic functional constipation, potentially with overflow incontinence. Optimal management strategies remain unclear. Objective To determine the most effective interventions, and combinations and sequences of interventions, for childhood chronic functional constipation, and understand how they can best be implemented. Methods Key stakeholders, comprising two parents of children with chronic functional constipation, two adults who experienced childhood chronic functional constipation and four health professional/continence experts, contributed throughout the research. We conducted pragmatic mixed-method reviews. For all reviews, included studies focused on any interventions/strategies, delivered in any setting, to improve any outcomes in children (0-18 years) with a clinical diagnosis of chronic functional constipation (excluding studies of diagnosis/assessment) included. Dual reviewers applied inclusion criteria and assessed risk of bias. One reviewer extracted data, checked by a second reviewer. Scoping review: We systematically searched electronic databases (including Medical Literature Analysis and Retrieval System Online, Excerpta Medica Database, Cumulative Index to Nursing and Allied Health Literature) (January 2011 to March 2020) and grey literature, including studies (any design) reporting any intervention/strategy. Data were coded, tabulated and mapped. Research quality was not evaluated. Systematic reviews of the evidence of effectiveness: For each different intervention, we included existing systematic reviews judged to be low risk of bias (using the Risk of Bias Assessment Tool for Systematic Reviews), updating any meta-analyses with new randomised controlled trials. Where there was no existing low risk of bias systematic reviews, we included randomised controlled trials and other primary studies. The risk of bias was judged using design-specific tools. Evidence was synthesised narratively, and a process of considered judgement was used to judge certainty in the evidence as high, moderate, low, very low or insufficient evidence. Economic synthesis: Included studies (any design, English-language) detailed intervention-related costs. Studies were categorised as cost-consequence, cost-effectiveness, cost-utility or cost-benefit, and reporting quality evaluated using the consensus health economic criteria checklist. Systematic review of implementation factors: Included studies reported data relating to implementation barriers or facilitators. Using a best-fit framework synthesis approach, factors were synthesised around the consolidated framework for implementation research domains. Results Stakeholders prioritised outcomes, developed a model which informed evidence synthesis and identified evidence gaps. Scoping review 651 studies, including 190 randomised controlled trials and 236 primary studies, conservatively reported 48 interventions/intervention combinations. Effectiveness systematic reviews studies explored service delivery models (n = 15); interventions delivered by families/carers (n = 32), wider children's workforce (n = 21), continence teams (n = 31) and specialist consultant-led teams (n = 42); complementary therapies (n = 15); and psychosocial interventions (n = 4). One intervention (probiotics) had moderate-quality evidence; all others had low to very-low-quality evidence. Thirty-one studies reported evidence relating to cost or resource use; data were insufficient to support generalisable conclusions. One hundred and six studies described implementation barriers and facilitators. Conclusions Management of childhood chronic functional constipation is complex. The available evidence remains limited, with small, poorly conducted and reported studies. Many evidence gaps were identified. Treatment recommendations within current clinical guidelines remain largely unchanged, but there is a need for research to move away from considering effectiveness of single interventions. Clinical care and future studies must consider the individual characteristics of children. Study registration This study is registered as PROSPERO CRD42019159008. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 128470) and is published in full in Health Technology Assessment; Vol. 28, No. 5. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Alex Todhunter-Brown
- Nursing, Midwifery and Allied Health Professions (NMAHP) Research Unit, Glasgow Caledonian University, Glasgow, UK
| | - Lorna Booth
- Nursing, Midwifery and Allied Health Professions (NMAHP) Research Unit, Glasgow Caledonian University, Glasgow, UK
| | - Pauline Campbell
- Nursing, Midwifery and Allied Health Professions (NMAHP) Research Unit, Glasgow Caledonian University, Glasgow, UK
| | - Brenda Cheer
- ERIC, The Children's Bowel and Bladder Charity, Bristol, UK
| | - Julie Cowie
- Nursing, Midwifery and Allied Health Professions (NMAHP) Research Unit, Glasgow Caledonian University, Glasgow, UK
| | - Andrew Elders
- Nursing, Midwifery and Allied Health Professions (NMAHP) Research Unit, Glasgow Caledonian University, Glasgow, UK
| | - Suzanne Hagen
- Nursing, Midwifery and Allied Health Professions (NMAHP) Research Unit, Glasgow Caledonian University, Glasgow, UK
| | | | - Helen Mason
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Glasgow, UK
| | | | | | - Charlotte Paterson
- Nursing, Midwifery and Allied Health Professions (NMAHP) Research Unit, University of Stirling, Stirling, UK
| | | | | | | | - Katie Thomson
- Nursing, Midwifery and Allied Health Professions (NMAHP) Research Unit, Glasgow Caledonian University, Glasgow, UK
- Department of Occupational Therapy, Human Nutrition and Dietetics, Glasgow Caledonian University, Glasgow, UK
| | - Claire Torrens
- Nursing, Midwifery and Allied Health Professions (NMAHP) Research Unit, University of Stirling, Stirling, UK
| | - Doreen McClurg
- Nursing, Midwifery and Allied Health Professions (NMAHP) Research Unit, Glasgow Caledonian University, Glasgow, UK
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Benson K, Bazier A, Schwartzkopf K, Waseem S, Gilbert E. Psychosocial factors impacting antegrade continence enema outcomes in pediatric patients. Neurogastroenterol Motil 2023; 35:e14644. [PMID: 37427680 DOI: 10.1111/nmo.14644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 06/18/2023] [Accepted: 06/26/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND Children with constipation and encopresis are often treated with medication and behavioral approaches. When constipation persists, surgical interventions such as antegrade continence enema (ACE) procedures are considered. Many children benefit from these procedures; however, some children continue to have incontinence, experience complications, or discontinue the use of the ACE stoma. There is some evidence in the literature to indicate that psychosocial factors can have an impact on ACE outcomes; however, standardized biopsychosocial guidelines related to ACE candidacy and surgery do not currently exist. PURPOSE The purpose of this review is to summarize the research to date on psychosocial factors related to ACE treatment outcomes and complications. Identifying what is known and what limitations remain can support future research to inform development of guidelines for pre-procedure evaluations. Psychosocial pre-procedure evaluations could help to inform eligibility for the procedure as well as interventions to enhance outcomes for children at increased risk for poor outcomes or complications from ACE. Age, psychiatric symptoms, and adherence to the ACE flush regimen were some of the factors identified in the literature as impacting ACE outcomes; however, there is limited research in this area.
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Affiliation(s)
- Kari Benson
- Indiana University School of Medicine, Indianapolis, Indiana, USA
- Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Ashley Bazier
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | - Shamaila Waseem
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Elaine Gilbert
- Indiana University School of Medicine, Indianapolis, Indiana, USA
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Bokova E, Svetanoff WJ, Levitt MA, Rentea RM. Pediatric Bowel Management Options and Organizational Aspects. CHILDREN 2023; 10:children10040633. [PMID: 37189882 DOI: 10.3390/children10040633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 03/20/2023] [Accepted: 03/22/2023] [Indexed: 03/30/2023]
Abstract
A bowel management program (BMP) to treat fecal incontinence and severe constipation is utilized for patients with anorectal malformations, Hirschsprung disease, spinal anomalies, and functional constipation, decreasing the rate of emergency department visits, and hospital admissions. This review is part of a manuscript series and focuses on updates in the use of antegrade flushes for bowel management, as well as organizational aspects, collaborative approach, telemedicine, the importance of family education, and one-year outcomes of the bowel management program. Implementation of a multidisciplinary program involving physicians, nurses, advanced practice providers, coordinators, psychologists, and social workers leads to rapid center growth and enhances surgical referrals. Education of the families is crucial for postoperative outcomes, prevention, and early detection of complications, especially Hirschsprung-associated enterocolitis. Telemedicine can be proposed to patients with a defined anatomy and is associated with high parent satisfaction and decreased patient stress in comparison to in-person visits. The BMP has proved to be effective in all groups of colorectal patients at a 1- and 2-year follow-up with social continence achieved in 70–72% and 78% of patients, respectively, and an improvement in the patients’ quality of life. A transitional care to adult program is essential to maintain the same quality of care, and continuity of care and to achieve desired long-term outcomes as the patient reaches adult age.
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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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Peeraully R, Langley J, Hayes N, Storry K, Richardson L, Burridge D, More B. Transition and reversal: long-term experience of the MACE procedure in children. Pediatr Surg Int 2022; 38:883-889. [PMID: 35394166 DOI: 10.1007/s00383-022-05122-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/30/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Analysis of outcomes and follow-up of children who underwent the Malone antegrade continence enema (MACE) procedure in a UK tertiary paediatric surgery unit. METHODS Children who underwent a MACE procedure from 1998 to 2020 were identified. Demographic and clinical data were obtained from contemporaneous records. Outcomes were categorised as full (success), partial or failure. RESULTS Ninety-five children were identified for inclusion (chronic idiopathic constipation (CIC, 59), anorectal malformations (ARM, 23) and Hirschsprung's disease (HD, 13)). Mean age at surgery was 9.4 years (3-19 years) and mean follow-up time was 6 years (0.3-16.8 years). Outcomes were successful in 69% of CIC patients, 78% in ARM and 69% in HD. Twenty (21%) underwent MACE reversal after developing independent continence, with a significant difference between groups (CIC 19%, ARM 9%, HD 54%, p = 0.0047). 50% of patients > 16 years old were transitioned to adult services. CONCLUSION We report a success rate of 72% for MACE procedures in our unit, with a significant difference in reversal rate between diagnostic groups. Long term, a fifth of patients no longer required their MACE. When these patients reach adolescence, those who require ongoing support outside of the paediatric surgery setting should be safely transitioned to adult services.
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Affiliation(s)
| | | | | | - Kate Storry
- Queen's Medical Centre, Nottingham, NG7 2UH, UK
| | | | | | - Bharat More
- Queen's Medical Centre, Nottingham, NG7 2UH, UK
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Vilanova-Sanchez A, Levitt MA. Surgical Interventions for Functional Constipation: An Update. Eur J Pediatr Surg 2020; 30:413-419. [PMID: 32987436 DOI: 10.1055/s-0040-1716729] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Chronic idiopathic constipation, also known as functional constipation, is defined as difficult and infrequent defecation without an identifiable organic cause. Medical management with laxatives is effective for the majority of constipated children. However there is a subset of patients who may need evaluation by a surgeon. As constipation progresses, it can lead to fecal retention and rectal and sigmoid distension, which impairs normal colorectal motility. Surgical interventions are influenced by the results of: a rectal biopsy, transit studies, the presence of megacolon/megarectum on contrast enema, the degree of soiling/incontinence, anorectal manometry findings, and colonic motility evaluation. In this review, we describe the different surgical options available (intestinal diversion, antegrade enemas, sacral nerve stimulation, colonic resections, and Botulinum toxin injection) and provide guidance on how to choose the best procedure for a given patient.
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Affiliation(s)
- Alejandra Vilanova-Sanchez
- Deparment of Pediatric Surgery, Urogenital and Colorectal Unit, La Paz University Hospital Children Hospital, Madrid, Comunidad de Madrid, Spain
| | - Marc A Levitt
- Department of Pediatric Surgery, Children's National Medical Center, Washington, District of Columbia, United States
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Vriesman MH, Wang L, Park C, Diefenbach KA, Levitt MA, Wood RJ, Alpert SA, Benninga MA, Vaz K, Yacob D, Di Lorenzo C, Lu PL. Comparison of antegrade continence enema treatment and sacral nerve stimulation for children with severe functional constipation and fecal incontinence. Neurogastroenterol Motil 2020; 32:e13809. [PMID: 32017325 PMCID: PMC7507175 DOI: 10.1111/nmo.13809] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 12/12/2019] [Accepted: 01/06/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND To compare antegrade continence enema (ACE) treatment and sacral nerve stimulation (SNS) in children with intractable functional constipation (FC) and fecal incontinence (FI). METHODS We performed a retrospective review of children 6-18 years old with FC and FI treated with either ACE or SNS at our institution. We recorded symptoms at baseline, 6 months, 12 months, 24 months, and their most recent visit after starting treatment. We compared improvement in FI, bowel movement (BM) frequency, abdominal pain, laxative use, and complications. Patients were contacted to evaluate perceived benefit using the Glasgow Children's Benefit Inventory. KEY RESULTS We included 23 patients treated with ACE (52% female, median age 10 years) and 19 patients treated with SNS (74% female, median age 10 years). Improvement in FI was greater with SNS than ACE at 12 months (92.9% vs 57.1%, P = .03) and 24 months (100% vs 57.1%, P = .02). Improvement in BM frequency was greater with ACE, and children were more likely to discontinue laxatives at all follow-up time points (all P < .05). Improvement in abdominal pain was greater with ACE at the most recent visit (P < .05). Rate of complications requiring surgery was similar between groups (26.3% vs 21.7%). Benefit was reported in 83.3% and 100% of ACE and SNS groups, respectively (NS). CONCLUSIONS AND INFERENCES Although both ACE and SNS can lead to durable improvement in children with FC and FI, SNS appears more effective for FI and ACE more effective in improving BM frequency and abdominal pain and in discontinuation of laxatives.
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Affiliation(s)
- Mana H. Vriesman
- Division of Gastroenterology, Hepatology and NutritionDepartment of PediatricsNationwide Children's HospitalColumbusOHUSA,Department of Pediatric Gastroenterology and NutritionEmma Children's HospitalAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Lyon Wang
- Division of Gastroenterology, Hepatology and NutritionDepartment of PediatricsNationwide Children's HospitalColumbusOHUSA,The Ohio State University College of MedicineColumbusOHUSA
| | - Candice Park
- Division of Gastroenterology, Hepatology and NutritionDepartment of PediatricsNationwide Children's HospitalColumbusOHUSA,The Ohio State University College of MedicineColumbusOHUSA
| | | | - Marc A. Levitt
- Department of SurgeryNationwide Children's HospitalColumbusOHUSA
| | - Richard J. Wood
- Department of SurgeryNationwide Children's HospitalColumbusOHUSA
| | - Seth A. Alpert
- Department of UrologyNationwide Children's HospitalColumbusOHUSA
| | - Marc A. Benninga
- Department of Pediatric Gastroenterology and NutritionEmma Children's HospitalAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Karla Vaz
- Division of Gastroenterology, Hepatology and NutritionDepartment of PediatricsNationwide Children's HospitalColumbusOHUSA
| | - Desale Yacob
- Division of Gastroenterology, Hepatology and NutritionDepartment of PediatricsNationwide Children's HospitalColumbusOHUSA
| | - Carlo Di Lorenzo
- Division of Gastroenterology, Hepatology and NutritionDepartment of PediatricsNationwide Children's HospitalColumbusOHUSA
| | - Peter L. Lu
- Division of Gastroenterology, Hepatology and NutritionDepartment of PediatricsNationwide Children's HospitalColumbusOHUSA
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Tube cecostomy versus appendicostomy for antegrade enemas in the management of fecal incontinence in children: A systematic review. J Pediatr Surg 2020; 55:1196-1200. [PMID: 32037219 DOI: 10.1016/j.jpedsurg.2020.01.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 01/13/2020] [Accepted: 01/20/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Few studies have directly compared between cecostomy and appendicostomy for the management of fecal incontinence in pediatric population. This systematic review of the literature describes outcomes and complications following both procedures. We also reviewed studies reporting impact on quality of life and patient satisfaction. METHODS MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), and Google Scholar were searched for chronic constipation pediatric patients who underwent cecostomy or appendicostomy. Two reviewers independently screened studies, extracted data, and assessed quality. RESULTS An initial literature search retrieved 633 citations. After review of all abstracts, 40 studies were included in the final analysis, assessing a total of 2086 patients. The overall rate of complications was lower in the cecostomy group compared to the appendicostomy group (16.6% and 42.3%, respectively). Achievement of fecal continence and improvement in patient quality of life were found to be similar in both groups, however the need for revision of surgery was approximately 15% higher in the appendicostomy group. CONCLUSION Cecostomy has less post procedural complications, however rates of patient satisfaction and impact on quality of life were similar following both procedures. LEVEL OF EVIDENCE III.
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10
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Arruda VPD, Bellomo‐Brandão MA, Bustorff‐Silva JM, Lomazi EA. Refractory functional constipation: clinical management or appendicostomy? JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2020. [DOI: 10.1016/j.jpedp.2018.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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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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Arruda VPAD, Bellomo-Brandão MA, Bustorff-Silva JM, Lomazi EA. Refractory functional constipation: clinical management or appendicostomy? J Pediatr (Rio J) 2020; 96:210-216. [PMID: 30352206 PMCID: PMC9432165 DOI: 10.1016/j.jped.2018.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Revised: 08/17/2018] [Accepted: 09/04/2018] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVE To compare the clinical evolution in patients with refractory functional constipation undergoing different therapeutic regimens: oral laxatives and antegrade enemas via appendicostomy or clinical treatment with oral laxatives and rectal enemas. METHODS Analysis of a series of 28 patients with a mean age of 7.9 years (2.4-11), followed-up in a tertiary outpatient clinic. Refractory functional constipation was defined as continuous retentive fecal incontinence after at least a 12-month period of consensus therapy. After the diagnosis of refractory condition, appendicostomy was proposed and performed in 17 patients. OUTCOMES (1) persistence of retentive fecal incontinence despite the use of enemas, (2) control of retentive fecal incontinence with enemas, and (3) control of retentive fecal incontinence, spontaneous evacuations, with no need for enemas. RESULTS Six and 12 months after the therapeutic option, control of retentive fecal incontinence was observed only in patients who underwent surgery, 11/17 and 14/17, p=0.001 and p=0.001, respectively. At 24 months, control of retentive fecal incontinence was also more frequent in operated patients: 13/17 versus 3/11 with clinical treatment, p=0.005. In the final evaluation, the median follow-up times were 2.6 and 3 years (operated vs. clinical treatment, p=0.40); one patient in each group was lost to follow-up and 9/16 operated patients had spontaneous bowel movements vs. 3/10 in the clinical treatment group, p=0.043. Surgical complications, totaling 42 episodes, were observed 14/17 patients. CONCLUSION Appendicostomy, although associated with a high frequency of complications, controlled retentive fecal incontinence earlier and more frequently than clinical treatment. The choice of one of the methods should be made by the family, after adequate information about the risks and benefits of each alternative.
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Affiliation(s)
- Vanesca P A de Arruda
- Universidade Estadual de Campinas (Unicamp), Faculdade de Ciências Médicas, Campinas, SP, Brazil
| | - Maria A Bellomo-Brandão
- Universidade Estadual de Campinas (Unicamp), Faculdade de Ciências Médicas, Departamento de Pediatria, Campinas, SP, Brazil
| | - Joaquim M Bustorff-Silva
- Universidade Estadual de Campinas (Unicamp), Faculdade de Ciências Médicas, Departamento de Cirurgia, Campinas, SP, Brazil
| | - Elizete Aparecida Lomazi
- Universidade Estadual de Campinas (Unicamp), Faculdade de Ciências Médicas, Departamento de Pediatria, Campinas, SP, Brazil.
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Scientific and Clinical Abstracts From WOCNext 2019. J Wound Ostomy Continence Nurs 2019. [DOI: 10.1097/won.0000000000000530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ayub SS, Zeidan M, Larson SD, Islam S. Long-term outcomes of antegrade continence enema in children with chronic encopresis and incontinence: what is the optimal flush to use? Pediatr Surg Int 2019; 35:431-438. [PMID: 30426223 DOI: 10.1007/s00383-018-4416-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/02/2018] [Indexed: 12/16/2022]
Abstract
PURPOSE Severe constipation and encopresis are significant problems in the pediatric population. Medical management succeeds in 50-70%; however, surgical considerations are necessary for the remainder such as the antegrade continence enema (ACE). The purpose of this study is to assess the long-term outcomes following the ACE procedure. METHODS All patients undergoing an ACE over a 14-year period were included. Data on clinical conditions, treatments, and outcomes were collected. A successful outcome was defined as remaining clean with ≤ 1 accident per week. Comparative data were analyzed using the Fisher's exact test, Mann-Whitney U test, or Student's t test. RESULTS There were 42 ACE patients, and overall, 79% had improvement in their bowel regimens. Encopresis rates decreased from 79 to 5% (P < 0.001). Admissions for cleanouts decreased from 52 to 19% (P = 0.003). All cases of Hirschsprung's, functional constipation and spina bifida were successful. Rates of success varied for other diseases such as slow-transit constipation (60%) and cerebral palsy (33%). A majority (85%) required a change in the enema composition for improvement. CONCLUSION In our study, ACE reduced soiling, constipation, and need for fecal disimpaction. Higher volume saline flushes used once a day was the optimal solution and most preferred option. LEVEL OF EVIDENCE Level 4 (retrospective case series or cohort).
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Affiliation(s)
- Suniah S Ayub
- Department of Surgery, Division of Pediatric Surgery, University of Florida College of Medicine, 1600 SW Archer Rd, Room 6130, PO Box 100119, Gainesville, FL, 32610-0287, USA
| | - Michelle Zeidan
- Department of Surgery, Division of Pediatric Surgery, University of Florida College of Medicine, 1600 SW Archer Rd, Room 6130, PO Box 100119, Gainesville, FL, 32610-0287, USA
| | - Shawn D Larson
- Department of Surgery, Division of Pediatric Surgery, University of Florida College of Medicine, 1600 SW Archer Rd, Room 6130, PO Box 100119, Gainesville, FL, 32610-0287, USA
| | - Saleem Islam
- Department of Surgery, Division of Pediatric Surgery, University of Florida College of Medicine, 1600 SW Archer Rd, Room 6130, PO Box 100119, Gainesville, FL, 32610-0287, USA.
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The Role of Bowel Management in Children with Bladder and Bowel Dysfunction. CURRENT BLADDER DYSFUNCTION REPORTS 2018. [DOI: 10.1007/s11884-018-0458-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Meenakshi-Sundaram B, Coco CT, Furr JR, Dubow BP, Aston CE, Lewis J, Slobodov G, Kropp BP, Frimberger DC. Analysis of Factors Associated with Patient or Caregiver Regret following Surgery for Fecal Incontinence. J Urol 2017; 199:274-279. [PMID: 28728991 DOI: 10.1016/j.juro.2017.07.040] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE Malone antegrade continence enema has been a successful and widely used procedure for achieving fecal continence in children. We present data on the previously uninvestigated issue of patient and caregiver regret following surgery for intractable constipation and fecal incontinence. MATERIALS AND METHODS We reviewed all patients undergoing antegrade continence enema or cecostomy creation at a single institution between 2006 and 2016. Patients and caregivers were assessed for decisional regret using the Decisional Regret Scale. Results were correlated with demographics, surgical outcomes and complications. RESULTS A total of 81 responses (49 caregivers and 32 patients) were obtained. Mean followup was 49 months. Decisional regret was noted in 43 subjects (53%), including mild regret in 38 (47%) and moderate to severe regret in 5 (6%). No statistical difference in regret was noted based on gender, complications or performance of concomitant procedures. On regression analysis incontinence was strongly associated with decisional regret (OR 4.4, 95% CI 1.1-18.1, p <0.001) and regret increased as age at surgery increased, particularly when patients were operated on at age 13 to 15 years (OR 2.6, 95% CI 1.0-6.4 for age 13 years; OR 2.9, 95% CI 1.1-7.8 for age 14 years; OR 3.1, 95% CI 1.1-8.8 for age 15 years). CONCLUSIONS This is the first known study describing decisional regret following surgery for fecal incontinence. Surgical factors aimed at achieving continence may be effective in decreasing postoperative regret. The finding of increased regret in teenage patients compared to younger children should be shared with families since it may impact the age at which surgery is pursued.
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Affiliation(s)
| | - Caitlin T Coco
- Department of Urology, Children's Hospital at OU Medical Center, Oklahoma City, Oklahoma
| | - James R Furr
- Department of Urology, Children's Hospital at OU Medical Center, Oklahoma City, Oklahoma
| | - Byron P Dubow
- Department of Urology, Children's Hospital at OU Medical Center, Oklahoma City, Oklahoma
| | - Christopher E Aston
- Department of Pediatrics, Children's Hospital at OU Medical Center, Oklahoma City, Oklahoma
| | - Jennifer Lewis
- Department of Urology, Children's Hospital at OU Medical Center, Oklahoma City, Oklahoma
| | - Gennady Slobodov
- Department of Urology, Children's Hospital at OU Medical Center, Oklahoma City, Oklahoma
| | - Bradley P Kropp
- Department of Urology, Children's Hospital at OU Medical Center, Oklahoma City, Oklahoma
| | - Dominic C Frimberger
- Department of Urology, Children's Hospital at OU Medical Center, Oklahoma City, Oklahoma
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King SK. Constipation—Surgical Aspects, Investigations, and Therapies. CURRENT PEDIATRICS REPORTS 2017. [DOI: 10.1007/s40124-017-0126-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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