Case series with literature review: Surgical approach to megarectum and/or megasigmoid in children with unremitting constipation

Abstract

BackgroundThe role of surgery in treating children with functional constipation (FC) is controversial, because of the efficacy of bowel management programs. This case series is comprised of failures: 43 children, spanning 25 years' practice, who had megarectosigmoid (MRS) and unremitting constipation.PurposeTo determine whether these children were helped by surgery, and to contribute to formulating a standard of care for children with megarectum (MR) and/or redundancy of the sigmoid colon (MS) who fail medical management.MethodWe describe our selection criteria and the procedures we utilized – mucosal proctectomy and endorectal pull-through (MP) or sigmoidectomy (SE) with colorectal anastomosis at the peritoneal reflection. The internet (social media) allowed us to contact most of these patients and obtain extremely long follow-up data.Results30/43 patients had MP and 13/43 had SE. Follow-up was obtained in 83% MP and 70% SE patients. 60% of MP and 78% of SE patients reported regular evacuations and no soiling. 20% MP patients had occasional urgency or soiling or episodic constipation. 12% MP and 22% SE patients required antegrade continence enemas (ACE) or scheduled cathartics and/or stool softeners. 4% MP had no appreciable benefit, frequent loose stools and soiling, presumably from encopresis.ConclusionMR is characterized by diminished sensation, poor compliance and defective contractility. Patients with MR do better with MP, which effectively removes the entire rectum versus SE, where normal caliber colon is anastomosed to MR at the peritoneal reflection; furthermore, MP reliably preserves continence; whereas total proctectomy (trans-anal or trans-abdominal) may cause incontinence.

Megarrectosigmoides por constipación crónica idiopática, sigmoidectomía con robot en el paciente pediátrico. Primer caso en México

“…Los pacientes sometidos a estos procedimientos deben ser bien ser estudiados de manera prospectiva 12 . Según Glasser et al 13 , cuando el diagnóstico de megarrecto se ha establecido no existe justificación para postergar la cirugía, ya que su demora agrava los problemas sociales y emocionales del paciente. Por lo tanto, si el paciente se diagnostica en forma temprana, en ese momento debe considerarse la cirugía.…”

Transanal proximal rectosigmoidectomy. A new operation for severe chronic idiopathic constipation associated with megarectosigmoid

“…Complete rectal and sigmoid resection with coloanal anastomosis [9] resolved constipation and the risk of fecal impaction. However, these patients suffered true fecal incontinence after the surgery [10,11] (personal communication with authors from reference [8]). We believe the cause of this problem with this operation is the lack of a fecal reservoir, plus a more active bowel, compared with peristalsis of the megarectosigmoid, anastomosed with the anal canal.…”

Approach to the Adult Colorectal Patient with a History of Pediatric Abdominal Surgery

“…Segmental or subtotal colectomy; total proctocolectomy with ileal pouch anal anastomosis; and Swenson, Duhamel, and Soave procedures have all been described in the surgical treatment of chronic constipation. 78 79 80 81 82 83 84 Indications vary among these different surgical procedures for treatment of chronic constipation, and most datasets involve small sample sizes and retrospective reviews.…”