Highlights
- •Treating refractory functional constipation requires a collaborative approach by surgeons and gastroenterologists.
- •The work-up should include a contrast enema, anorectal manometry for assessment of the sphincters, and a colonic motility evaluation.
- •Antegrade flushes are effective and colon resections can be avoided in most cases, regardless of underlying colonic dysmotility.
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
Keywords
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Article info
Publication history
Published online: October 21, 2022
Accepted:
October 14,
2022
Received:
October 5,
2022
Identification
Copyright
© 2022 Elsevier Inc. All rights reserved.
