Botulinum toxin injection for childhood constipation is safe and can be effective regardless of anal sphincter dynamics

Zar-Kessler, Claire; Kuo, Braden; Belkind‐Gerson, Jaime

doi:10.1016/j.jpedsurg.2017.12.007

Cited by 43 publications

(32 citation statements)

References 24 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…Current practice describes administration of intra-sphincteric botulinum toxin (BT) injections as a second step in treatment of obstructive symptoms after surgery, in order to obtain temporary relaxation of the internal anal sphincter, which subsequently improves faecal passage. We know from patients with childhood constipation and chronic anal fissures, that BT can be beneficial in treating constipation, regardless of sphincter dynamics[4], suggesting comparable beneficial effects for patients with Hirschsprung disease. Langer was the first to introduce treatment with BT injections for patients with Hirschsprung disease in 1997, as an alternative to myotomy of the anal sphincter and to use it as a predictive tool to assess necessity of sphincter myotomy[5].…”

Section: Introductionmentioning

confidence: 99%

Botulinum toxin injections after surgery for Hirschsprung disease: Systematic review and meta-analysis

Roorda¹,

Abeln²,

Oosterlaan³

et al. 2019

WJG

View full text Add to dashboard Cite

BACKGROUND A large proportion of patients with Hirschsprung disease experience persistent obstructive symptoms after corrective surgery. Persistent obstructive symptoms may result in faecal stasis that can develop into Hirschsprung-associated enterocolitis, a potential life-threatening condition. Important treatment to improve faecal passage is internal anal sphincter relaxation using botulinum toxin injections. AIM To give an overview of all empirical evidence on the effectiveness of botulinum toxin injections in patients with Hirschsprung disease. METHODS A systematic review and meta-analysis was done by searching PubMed, EMBASE and the Cochrane Library, using entry terms related to: (1) Hirschsprung disease; and (2) Botulinum toxin injections. 14 studies representing 278 patients met eligibility criteria. Data that were extracted were proportion of patients with improvement of obstructive symptoms or less enterocolitis after injection, proportion of patients with adverse effects and data on type botulinum toxin, mean dose, average age at first injection and patients with associated syndromes. Random-effects meta-analysis was used to aggregate effects and random-effects meta-regression was used to test for possible confounding factors. RESULTS Botulinum toxin injections are effective in treating obstructive symptoms in on average 66% of patients [event rate (ER) = 0.66, P = 0.004, I 2 = 49.5, n = 278 patients]. Type of botulinum toxin, average dose, average age at first injections and proportion of patients with associated syndromes were not predictive for this effect. Mean 7 duration of improvement after one botulinum toxin injections was 6.4 mo and patients needed on average 2.6 procedures. There was a significant higher response rate within one month after botulinum toxin injections compared to more than one month after Botulinum toxin injections (ER = 0.79, vs ER = 0.46, Q = 19.37, P < 0.001). Botulinum toxin injections were not effective in treating enterocolitis (ER 0.58, P = 0.65, I 2 = 71.0, n = 52 patients). There were adverse effects in on average 17% of patients (ER = 0.17, P < 0.001, I 2 = 52.1, n = 187 patients), varying from temporary incontinence to mild anal pain. CONCLUSION Findings from this systematic review and meta-analysis indicate that botulinum toxin injections are effective in treating obstructive symptoms and that adverse effects were present, but mild and temporary.

show abstract

Section: Introductionmentioning

confidence: 99%

Botulinum toxin injections after surgery for Hirschsprung disease: Systematic review and meta-analysis

Roorda¹,

Abeln²,

Oosterlaan³

et al. 2019

WJG

View full text Add to dashboard Cite

show abstract

“…40 About one-third of patients with chronic constipation have abnormal anal sphincter dynamics on AMAN, such as abnormal sphincter thickness, frequency, and amplitude of internal anal sphincter contraction, 41,42 possibly due to the constant stimulus of stool in the rectum. 43 Also internal anal sphincter achalasia (ISA) could be present, defined by an incomplete rectoanal inhibitory reflex (RAIR), upon rectal distention with normal rectal biopsy 44 and/or high resting pressure, and increased baseline pressures (>45 mm Hg). 45 Botulinum toxin A is a neurotoxic protein that acts as a muscle relaxant of the anal sphincter by binding of nerve terminals.…”

Section: Injection Of Botulinum Toxin Into the Anal Sphinctersmentioning

confidence: 99%

“…Two-thirds of the patients resolved their symptoms with only one injection and only one-third of the patients needed additional injections (range: 3-7). 44 Basson et al also published a review on children who underwent botulinum toxin injection with good results in 72% of patients; however, the study did not specific whether validated tools were used to measure the outcomes. 50 More than one-third of patients had recurrence of symptoms and eventually 25% needed a surgical procedures (ACE or stoma).…”

Section: Injection Of Botulinum Toxin Into the Anal Sphinctersmentioning

confidence: 99%

Surgical Interventions for Functional Constipation: An Update

Vilanova-Sánchez

Levitt

2020

Eur J Pediatr Surg

View full text Add to dashboard Cite

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.

show abstract

“…There is some data to suggest that it may be useful in children irrespective of anorectal dynamics. 69 (evidence levellow) • Transanal irrigation (TAI) -TAI involves a large-volume water irrigation of the rectum and colon performed by introducing a catheter through the anus. Recent studies using TAI in children have reported success, both in clinical bowel outcomes and in improvement of quality of life.…”

Section: The Management Options In a Child With Refractory Constipatimentioning

confidence: 99%

Paediatric constipation for general paediatricians: Review using a case‐based and evidence‐based approach

Bolia

Safe

Southwell

et al. 2020

J Paediatrics Child Health

View full text Add to dashboard Cite

Constipation is a common problem in childhood. The most common type of constipation is functional, accounting for 90–95% of all cases. The aim of this review is to provide clinical scenarios with treatment using evidence‐based information, and management strategies and a clinical algorithm to guide the management of constipation in children. Recent guidelines and online information sites are detailed. Clinical red flags and organic causes of constipation are included. Four clinical scenarios are presented: case (1) 4‐month‐old child with constipation since birth and likely Hirschsprung disease; case (2) 6‐month‐old infant with infant dyschezia; case (3) 4‐year old with functional constipation; and; case (4) 9‐year old with treatment resistant constipation. Children with functional constipation need a thorough history and physical exam to rule out the presence of any ‘red flags’ but do not require laboratory investigations. Management includes education and demystification, disimpaction followed by maintenance therapy with oral laxatives, dietary counselling and toilet training. Treatment options differ between infants and children. Disimpaction and maintenance regimens for common laxatives are presented. On treatment failure or on suspicion of organic disease the patient should be referred for further evaluation. The radionuclide intestinal transit study (scintigraphy) is a useful modality for evaluation and planning of management in treatment‐resistant children. Treatment options for treatment‐resistant patients are presented. High‐level evidence (meta‐analyses) for pharmalogical and non‐pharmalogical treatment modalities are reviewed and an algorithm for assessment and treatment are presented.

show abstract

Botulinum toxin injection for childhood constipation is safe and can be effective regardless of anal sphincter dynamics

Cited by 43 publications

References 24 publications

Botulinum toxin injections after surgery for Hirschsprung disease: Systematic review and meta-analysis

Botulinum toxin injections after surgery for Hirschsprung disease: Systematic review and meta-analysis

Surgical Interventions for Functional Constipation: An Update

Paediatric constipation for general paediatricians: Review using a case‐based and evidence‐based approach

Contact Info

Product

Resources

About