Transanal rectosigmoid resection for severe intractable idiopathic constipation

doi:10.1016/j.jpedsurg.2009.02.049

Journal of Pediatric Surgery

Volume 44, Issue 6, June 2009, Pages 1285-1291

https://doi.org/10.1016/j.jpedsurg.2009.02.049 Get rights and content

Abstract

Introduction

Idiopathic constipation is a source of significant morbidity in children. A subset of patients is refractory to medical therapy and requires surgical intervention. We present a novel surgical technique for the management of these patients.

Methods

We reviewed the records of 288 patients with severe idiopathic constipation and soiling. Patients who were refractory to medical management and had a megarectosigmoid underwent a transanal full-thickness rectosigmoid resection with a primary colo-anal anastomosis.

Results

Fifteen patients underwent a transanal rectosigmoid resection. The preoperative contrast enema demonstrated an enormously dilated rectosigmoid in 14. An average of 43 cm (range, 8-98 cm) of rectosigmoid was resected. Of 14 patients with more than 3 months of follow-up, the preoperative laxative dose was 68 mg of senna/d (range, 52-95 mg), which decreased to 8.6 mg postoperatively (P < .001). Nine patients are clean without soiling, 1 is more prone to diarrhea, but is clean. Two patients soil occasionally, but are noncompliant, and 2 were lost to follow-up.

Conclusion

Transanal rectosigmoid resection for medically intractable idiopathic constipation resulted in a dramatic reduction or elimination in laxatives use while preserving continence. It is a useful alternative to surgical options such as other colonic resections, antegrade enemas, and stomas.

Section snippets

Materials and methods

We reviewed the records of all patients who were referred to us with severe idiopathic constipation and soiling over a 20-year period. All patients were previously seen by a pediatrician or a pediatric gastroenterologist and were considered unmanageable. The vast majority were referred for surgical consultation to evaluate for Hirschsprung's disease, and no patient turned out to have Hirschsprung's. Patients first received a thorough history and physical examination and then were subjected to

Results

Two hundred eighty-eight patents were referred to our care with severe idiopathic constipation over a 20-year period. Two hundred fifty-six (89%) patients were medically managed and did not require operative intervention. No referred patient in this group had Hirschsprung's disease. In all patients, soiling was eliminated after the laxative regimen was implemented. The intractable patients (32 patients, 11%) were offered surgery (Table 1). Seventeen received a sigmoid resection only (previously

Discussion

A subset of patients with severe idiopathic constipation, refractory to medical therapy, will benefit from surgical intervention. In this study we present our experience with a transanal full-thickness rectosigmoid resection and a primary colo-anal anastomosis. Patients had a significant reduction or elimination in laxative requirement, were continent postoperatively, and had an improved quality of life. We believe this approach is a novel minimally invasive alternative to treat this patient

References (27)

ClarkeM.C. et al.
Quality of life in children with slow transit constipation
J Pediatr Surg
(2008)
VerneG.N. et al.
Long-term response to subtotal colectomy in colonic inertia
J Gastrointest Surg
(2002)
KingS.K. et al.
The antegrade continence enema successfully treats idiopathic slow-transit constipation
J Pediatr Surg
(2005)
KeshtgarA.S. et al.
Botulinum toxin, a new treatment modality for chronic idiopathic constipation in children: long-term follow-up of a double-blind randomized trial
J Pediatr Surg
(2007)
De la Torre-MondragonL. et al.
Transanal endorectal pull-through for Hirschsprung's disease
J Pediatr Surg
(1998)
BelizonA. et al.
Rectal prolapse following posterior sagittal anorectoplasty for anorectal malformations
J Pediatr Surg
(2005)
PenaA. et al.
Megasigmoid: a source of pseudoincontinence in children with repaired anorectal malformations
J Pediatr Surg
(1993)
HalderS.L. et al.
Impact of functional gastrointestinal disorders on health-related quality of life: a population-based case-control study
Aliment Pharmacol Ther
(2004)
YoussefN.N. et al.
Chronic childhood constipation is associated with impaired quality of life: a case-controlled study
J Pediatr Gastroenterol Nutr
(2005)
LevittM.A. et al.
Pediatric fecal incontinence

ScarpaM. et al.

Ileostomy for constipation: long-term postoperative outcome

Colorectal Dis

(2005)

GladmanM.A. et al.

Systematic review of surgical options for idiopathic megarectum and megacolon

Ann Surg

(2005)

LevittM.A. et al.

Surgery and constipation: when, how, yes, or no?

J Pediatr Gastroenterol Nutr

(2005)

Cited by (47)

Intermediate and long-term outcomes of a bowel management program for children with severe constipation or fecal incontinence
2020, Journal of Pediatric Surgery
We sought to examine the long-term clinical success rates of a bowel management program (BMP) for children with severe constipation or fecal incontinence.
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.
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).
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.
Single-center retrospective chart review.
3
Outcomes of colonic resection for chronic idiopathic constipation in childhood
2020, Journal of Pediatric Surgery
Citation Excerpt :
Among children left with a permanent stoma, 82% were deemed to have had successful treatment [17]; by our criteria all these children would be categorized as failed treatments. Levitt reported 60% of 15 children who underwent transanal rectosigmoid resection to be clean on follow up, broadly similar to our success rate of 64% [15]. The same authors subsequently reported a series of 31 children who underwent a combination of segmental resection and ACE surgery as definitive treatment [18].
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).
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.
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.
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 IV.
Functional Constipation and Fecal Incontinence
2020, Pediatric Gastrointestinal and Liver Disease, Sixth Edition
Constipation and fecal incontinence represent common problems in children. Beyond the neonatal period, only a minority of children have an organic cause for their constipation, and the etiology remains not well understood. Constipation rarely leads to life-threatening complications but can cause emotional and physical distress and concerns for children and their families, ultimately impairing health-related quality of life. The hallmarks of constipation are infrequent painful defecation and fecal incontinence often accompanied by abdominal pain. In less than 15% of cases, children have fecal incontinence without a history and physical examination that indicates underlying constipation. These latter children are classified as having functional nonretentive fecal incontinence (FNRFI) according to the Rome IV criteria. The aims of this chapter are to describe functional defecation disorders in children: functional constipation associated with or without fecal incontinence and FNRFI. The chapter will also describe diagnostic approaches and treatment regimens for this disorder and will report on treatment outcomes.
Transanal proximal rectosigmoidectomy. A new operation for severe chronic idiopathic constipation associated with megarectosigmoid
2019, Journal of Pediatric Surgery
At the severe end of the idiopathic constipation spectrum exist patients with chronic idiopathic constipation associated with an enormous megarectosigmoid, among whom few require surgery. We performed transanal proximal rectosigmoidectomy, involving preservation of a 5 cm rectal reservoir, to ameliorate inconsistent and unpredictable outcomes and fecal incontinence occurring in some patients operated on with other techniques.
We retrospectively observed patients with chronic idiopathic constipation with megarectosigmoid who underwent transanal proximal rectosigmoidectomy during July 2017–May 2018. We analyzed sex, age, operation indication, complications, functional outcome, and time of follow-up. We statistically compared the dosage of laxative before and after the procedure.
Thirteen patients were included in the study. Median age during surgery was 8 years. In 9 cases, the indication for surgery was chronic intake of a daily high dose of Senna with failed weaning trials, and 4 had persistent fecal impaction with laxative-intolerance and refusal of rectal enemas. No intra/postoperative complications occurred. Currently, all 13 patients have daily voluntary bowel movements and no fecal accidents. Laxative dosage was significantly reduced (p = 0.007). Follow-up ranged 6–16 months.
Preliminary results suggest transanal proximal rectosigmoidectomy as an adequate alternative for patients requiring surgery for chronic idiopathic constipation with megarectosigmoid.
Clinical research.
Level III.
Surgical treatment of idiopathic megarectum in constipated children
2019, Journal of Pediatric Surgery
Citation Excerpt :
The data obtained with ultrasound examination correlate with morphological findings. A previous study reported that idiopathic megarectum occurs infrequently and was present in only 11% of patients referred to a pediatric colorectal center for surgical treatment of chronic constipation [11]. This low prevalence may explain the lag in acceptance of idiopathic megarectum as an indication for transanal rectosigmoid resection.
Chronic constipation in children is associated with primary megarectum. This study investigated outcomes of surgical treatment of idiopathic megarectum in children.
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.
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).
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.
Treatment study.
Level III, retrospective comparative study.
Functional constipation in children: Is there a place for surgical treatment
2019, Journal of Pediatric Surgery

View all citing articles on Scopus

View full text

AAP PaperTransanal rectosigmoid resection for severe intractable idiopathic constipation

Abstract

Introduction

Methods

Results

Conclusion

Section snippets

Materials and methods

Results

Discussion

J Pediatr Surg

J Gastrointest Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

Impact of functional gastrointestinal disorders on health-related quality of life: a population-based case-control study

Aliment Pharmacol Ther

Chronic childhood constipation is associated with impaired quality of life: a case-controlled study

J Pediatr Gastroenterol Nutr

Pediatric fecal incontinence

Ileostomy for constipation: long-term postoperative outcome

Colorectal Dis

Systematic review of surgical options for idiopathic megarectum and megacolon

Ann Surg

Surgery and constipation: when, how, yes, or no?

J Pediatr Gastroenterol Nutr

AAP Paper
Transanal rectosigmoid resection for severe intractable idiopathic constipation