When Should Kids With Severe Functional Constipation Have Surgery?

Children with severe functional constipation are most often referred for surgery after failure of medical management. But there’s a problem with this process – no widely accepted definition for “failure of medical management” exists. Type of laxative or stool softener, dosage and length of treatment differ from provider to provider.

And once the referral is made, it’s not always clear which surgical intervention will be best for a patient. A child who is diagnosed with functional constipation and fecal impaction but does not soil needs a somewhat different surgical strategy from one who does soil. A pediatric gastroenterologist may not have enough knowledge of surgical approaches to realize that; a pediatric surgeon without specific colorectal expertise may not thoroughly understand the importance of motility testing and GI approaches to medical management.

A recent article from clinician-researchers at Nationwide Children’s Hospital offers a protocol for GI specialists and surgeons to follow that matches constipation diagnoses with surgical interventions, and actually allows many patients referred for surgery to avoid it altogether with “maximal medical therapy.”

“We have taken a chaotic situation and made order from it,” says Marc A. Levitt, MD, surgical director of the Center for Colorectal and Pelvic Reconstruction at Nationwide Children’s and senior author of the article. “It’s exceedingly common to see a patient who had a cecostomy who probably would have done well with the right dose of laxative. It’s also common to see a patient who has received a certain surgical intervention when motility testing would have shown another intervention would work better.”

The article’s authors, who also include Richard J. Wood, MD, pediatric surgeon at Nationwide Children’s and associate director of the Center for Colorectal and Pelvic Reconstruction, and Desale Yacob, MD, a gastroenterologist at Nationwide Children’s and medical director of the hospital’s Motility Center, represent the collaboration that allowed the protocol to be created, says Dr. Levitt.

“We put pediatric surgeons and gastroenterologists with motility expertise in the same room talking about patients with constipation,” he says. “That’s very rare in our field. Because of the marriage of ideas, we have come up with what we believe are much better plans.”

The article, published in Current Opinion in Pediatrics, first lays out a course of maximal medical management. Nationwide Children’s offers surgery only after a child has failed intensive, week-long bowel management guided by colorectal nurses, which includes stimulant laxatives such as senna and bisacodyl, water soluble fiber and imaging to evaluate evacuation of the colon.

Outside providers seem reluctant to use stimulant laxatives in some cases, but GI specialists and surgeons at Nationwide Children’s often find patients benefit from them enough to avoid surgery, according to Dr. Levitt.

If medical management still fails, the authors call for further testing. Transit studies, colonic manometry and anorectal manometry can help tease out which procedural interventions may work, again with crucial assistance from nurses with unique colorectal expertise. The Center for Colorectal and Pelvic Reconstruction then uses those tests and other evaluations to divide patients into six groups:

• Patients under 3 years of age with failure to thrive and diffuse colonic dysmotility, who are offered ileostomy
• Patients with internal anal sphincter achalasia, severe withholding or external anal sphincter dyssynergia, who often respond to anal Botox injection
• Patients with intractable fecal impaction without soiling, who are offered laparoscopic colonic resection
• Patients with intractable fecal impaction with soiling, who are offered laparoscopic colonic resection and an antegrade enema route (such as cecostomy)
• Patients who require enemas for colon emptying and have failed a laxative trial, who are offered an antegrade surgical route
• Patients who fail initial surgical treatment, who may be offered other options based on further testing

These novel surgical approaches were developed by Dr. Levitt and refined by Karen A. Diefenbach, MD, director of Minimally Invasive Surgery at Nationwide Children’s. Dividing patients into groups and offering different interventions for each group seems to work in practice, Dr. Levitt says. He and his colleagues in the Center for Colorectal and Pelvic Reconstruction are now tracking patients in hopes of proving the effectiveness of this protocol.

“Our experiences with these patients led us to divide the groups and procedures in these ways.” explains Dr. Levitt. “We need to see, long term, if our choices were correct. The ultimate goal is to have patients feeling better – no accidents, no bloating, no impaction.”

Reference:

Wood RJ, Yacob D, Levitt MA.  Surgical options for the management of severe functional constipation in children. Current Opinion in Pediatrics. 2016 Jun;28(3):370-9