Chapters Transcript Beyond Laxatives: Surgical and Multidisciplinary Approaches to Pediatric Constipation Dr. Zani-Ruttenstock provides an overview of surgical and multi disciplinary approaches to pediatric constipation. Before we start, just one quick question. Medicine, I, I see here an option even to take control over the slides. Sure, yeah, if you want to try, that'd be great. Should I do that? I say yes to take control and just see. Yes, I can move it myself. Perfect. That's great. Should I do that? Yeah? Mhm. OK. All right. Uh, good morning, everyone. Um, thank you so much for the invitation. It's a great pleasure and honor to, for me to be here with you, uh, today. I have nothing to disclose. Constipation, it's the #2 problem that's actually #1 in many pediatric clinics, and while we often joke about it, the burden on children and families is anything but funny. Today I'd like to talk about a condition that we see almost daily, yet often underestimate in its complexity, pediatric constipation. I'll start by briefly defining functional constipation, then highlight some key factors and trends in US children to show just how significant this problem is, and from there I'll introduce you to our colorectal program, where we take a multidisciplinary approach that brings. surgery, gastroenterology, nursing, psychology and physiotherapy to manage even the most challenging cases. Finally, we'll explore the surgical options available for children with refractory constipation and how a coordinated team approach can truly change outcomes and lives. The Rome 4 criteria are the standard tool that we use to diagnose functional constipation. I'm sure you all came across those. When the problem isn't, it's implemented and used when the problem isn't due to disease, but how the bowel functions. It looks at things like stool frequency, pain, size and stool withholding behaviors. Using this criteria allows clinicians and researchers around the world to report constipation prevalence consistently. Most cases of fecal incontinence in children, about 95%, are actually due to constipation with overflow that we call pseudo incontinence. True incontinence is much less common and usually related to structural or neuromuscular issues. In these children. We apply the same. Strategies that we also use for anorectal malformations to help those patients achieve social continence, often through mechanical approaches like antigrade or retrograde enemas to keep the colon empty and predictable. Let's have a look at some key factors. Constipation affects up to 1 in 5 children seen in US clinics. Across the Americas, about 1 in 10 children meets the Romeo criteria. Hospital data show that severe cases, those that are requiring hospital admissions, have almost doubled over the past decade. This tells us the burden is not only common but also growing in severity. This slide highlights the variability in children constipation rates across countries, from around 7% in China to 30 to even 46% in India and Russia. These differences likely reflect variation in dietary patterns, toilet training practices, and healthcare access rather than true biologic disparities. The key takeaway is that functional constipation remains a common global pediatric problem, emphasizing the need for early identification and standardized management across regions. About 50% of all constipation diagnoses occur before the age of 4, and it affects boys and girls equally. Fecal continence is seen in roughly 4% of children, but the vast majority, around 95%, also have underlying constipation, with boys more commonly affected. Overall, constipation accounts for about 5% of primary care visits and nearly a third of all pediatric GI consultations. But constipation is not just a physical problem, it's often closely tied to a child's emotional and family environment. Family stress, conflict, or parental mental health challenges can increase the risk, and rigid or anxious toilet training often leads to stool withholding. We also see higher rates in families with lower socioeconomic status, likely related to stress and diet factors. Emotional or behavioral conditions like anxiety or ADHD are common in these children, so treatment must go beyond laxatives. Addressing the emotional and family context is essential for lasting success. In children from stressful or broken homes, constipation can carry symbolic meaning, and I would like to introduce you to the hold on hypothesis that goes back to Sigmund Freud. On a psychological level, stool withholding may represent a child's attempt to maintain control, express distress, or avoid pain in an environment that feels unpredictable. Addressing these emotions roots, not just prescribing laxatives, is key to long-term recovery. Constipation isn't just about fiber, it's about family, feelings and flexibility. A balanced diet, emotional stability and supportive parenting together create the best defense against chronic constipation. Today I want to take you beyond laxatives to look at the emotional, behavioral and surgical sides of this condition and how our multidisciplinary approach can truly change outcomes. Our program takes a truly multidisciplinary approach because no single specialty can manage complex constipation alone. Our team includes pediatric gastroenterology, pediatric surgery, nurse practitioners, and stoma specialists, working closely with urology partners, dietitians, physiotherapists, and psychologists. Together we focus on every aspect of care, from mortality and anatomy to diet, behavior, and family support. We're also very proud to collaborate with Rankin Jordan, ensuring our patients benefit from coordinated, comprehensive management. When we look at the children who need more specialized care, they often have underlying conditions like Hirschpru's disease. Anorectal malformations or severe chronic constipation requiring inpatient management. But we also see cases related to spina bifida, rectal or perineal trauma, and occasionally inflammatory bowel disease. The goals of treatment go beyond just stooling. We aim for symptom resolution, improvement in quality of life, and for children with true incontinence, achieving social continence so they can participate fully and confidently in daily life. These are some of the most common presentations we see referred to our program. Many of our patients come in with a history of delayed passage of meconium, raising concerns for underlying motility disorders. Others present with rectal bleeding, prolapse, or what families often describe as hemorrhoids. We also see children with severe constipation, abdominal distention or incontinence or overflow diarrhea, often misinterpreted. As diarrhea rather than stool leakage. Finally, some present with weight loss or poor growth reflecting the chronic nature and systemic impact of severe constipation. In clinic, our evaluation starts with a thorough physical examination. We palpate the abdomen for fecal masses, inspect the perineum for any abnormalities such as anterior positioned anus, and perform a limited rectal exam if indicated. It's also important to examine the lower back for signs of underlying spinal anomalies, such as sacro dimple or tuft of hair. And always review the growth chart since chronic constipation can impact nutrition and growth. Imaging, typically a KUB, can help assess the extent of the stool burden and guide us for further management. For children with refractory or complex constipation, our next step is targeted diagnostic workup. We begin with basic blood work, including a BMP, celiac screening, and including TTT IGA and total IgA levels, and functional thyroid function tests to rule out metabolic and endocrine causes. A contrast enema helps evaluate for anatomy abnormalities, assess the size and shape of the colon and, and can sometimes be both, not just diagnostic, but also therapeutic. For functional assessment, we utilize anorectal and colonic manometry to study motility patterns and sphincter function, along with colon transit studies to measure how stool moves through the bowel. Finally, when indicated, an MRI of the lumbar or sacral spine is obtained to exclude occult spinal dystrophism or shattered cord as contributing factors. Anorectal manometry evaluates the function and coordination of the internal and external sphincter. Rectal sensation and the director anal inhibitory reflex or so-called rare. It helps identify functional outlet obstruction or dysynergic defecation in children with refractory constipation. The colon transit time tests. Quantifies colonic motility by measuring the time required for markers to traverse the colon. It differentiates normal transit constipation from slow transit constipation and outlet obstruction. In our outpatient setting, we also have the opportunity to implement and teach effective other outpatient options like time toileting. Which is one of the simplest yet most effective behavioral interventions we can teach families. It's encouraging the child to sit on the toilet at regular times, usually after meals when the gastrocolic reflex is active, and it really helps retain the bowel and establish predictable habits. Furthermore, proper positioning is just as important that the feet should be supported with knees slightly above the hip level. That squatty potty position straightens the anorectal angle and makes dual passage easier and less painful. Small changes like these can make a big difference in reducing stool withholding and promoting long term continence. We are also able to offer teaching on a variety of different retrograde enema options. Retrograde enemas are highly effective outpatient management options for children with severe refractory constipation and fecal incontinence. They work by mechanically emptying the distal colon, helping to maintain predictable bowel movements and social continence. We can use several delivery systems, from a simple Foley catheter with a balloon to cone systems or more advanced systems like the Pistine system, which allows to control irrigation and independence at home. When properly taught and supported, these methods can really significantly improve the quality of life and reduce hospital admissions for cleanouts. When it comes to pharmacologic management of constipation, we often use stimulant laxatives like biscodil and Senna, which increase the colonic motility and enhance propulsive contractions, while osmotic agents such as lactulose, MiraLax, and milk of magnesia draw water into the bowel to soften the stool. We like to play with both of those. Rectal stimulants provide rapid low collection and irrigations or enemas, typically normal saline with or without additives we like to use, um, and they are reserved for refractory or neurogenic cases. Together, these therapies support regular, pain-free bowel habits when combined with the dietary and behavioral measurements. Beyond medication, a multidisciplinary approach can make a huge difference. Pelvic floor physiotherapy and biofeedback training help children relearn proper coordination of the pelvic muscles during defecation. Behavioral therapy addresses stool withholding behaviors and toileting anxiety, while at home techniques such as scheduled toilet sitting, which we discussed, positive reinforcement and posture correction support long-term success. These strategies remain underutilized and often underappreciated unfortunately. Yet when timed appropriately, especially in our younger children, they can be pirotal in restoring normal bowel habits and preventing chronic dysfunction. For many children, a structured bowel management program with retrograde animmas, laxatives, and behavioral strategies can achieve excellent results, but in some severe or complex cases where medical, behavioral and irrigation therapies have failed, we start to consider surgical options. These are typically children with underlying motility dysfunction, refractory constipation, or true incontinence, where maintaining bowel control isn't possible without surgical support. The goal, even then, remains the same to help the child achieve predictable bowel emptying, avoid accidents, and regain quality of life. When we move to the surgical management of constipation, our first step is always to reassess anatomy, and we do that in a, uh, you know, exam under anesthesia. We ensure that the anus is correctly positioned, that there is good sphincter tone, and that the perineum appears normal. I like to use an electrostimulator also for those patients to evaluate the sphincter complex to confirm that the anus is completely encircled by functional muscle, a critical factor in determining whether a child has the potential for continence. A rectal biopsy remains the gold standard to rule out Hirschprung's disease in children with refractory constipation. For those without ganglionosis but persistent outlet dysfunction, Botox injections into the internal sphincter can help by relaxing the muscle and improving stool passage. Recent data from our group supports its safety and effectiveness in children with defecation disorders, especially those with dysynergic defecation or sphincter akalasia. Children post pull for Hirschprung's disease or post PA often need continued surgical input to optimize the function. In case of colonic hypermortality, a subtotal colectomy with ileor rectal anastomosis may be indicated in some cases. Antigrade continence options like a mace or ACE are excellent tools when built on a stable retrograde program. Helping achieve reliable bowel control and independence. Both the mace or malone appendicostomy and the cystostomy provide antegrade access for colonic irrigation. The mace uses the appendix as a catherizable channel while a cycostomy places the tube directly into the cecum, typically chosen when the appendix isn't available, or might be needed for future interventions also by urology. Both are effective options for achieving predictable bowel emptying and improving continence. So which option is better, the cytostomy or the appendicostomy? This systematic review looked at over 2000 patients across 40 studies and found that both approaches achieved similar outcomes in terms of fecal continence, about 88%, and quality of life improvement around 90%. However, complication rates were higher, with appendicostomies at around 42% compared to 16% for sycostomies, and the need for surgical revision was also more frequent. In summary, both work well. The choice often comes down to anatomy, prior surgeries, and the surgeon's experience with them, but yostomy tends to have fewer complications overall. While antigrade continence procedures can be very effective, they are not always successful. Failure can occur for several reasons. It can be a dilated right colon, which makes effective irrigation difficult. Or pelvic floor to synergy where this child cannot relax during the actual evacuation of the stool, wound or stoma complications can also limit the use and sometimes the problem isn't surgical at all, but a lack of comprehensive bowel management, including medication, diet, and behavioral support. These cases remind us that success depends as much on the team and follow-up as it does on the operation itself. So in conclusion, constipation remains a significant burden, not only for our patients and their families, but also for the healthcare system as a whole. The causes in children are brought from functional constipation to structural and neurogenic disorders, so there's no one size fits it all approach. Recognising alarm symptoms and high risk features early is key, and these children should be referred to specialized centers with pediatric gastroenterology and colorectal expertise. Ultimately, our goal goes far beyond stool frequency. It's about restoring comfort, confidence and quality of life. And for those with complex conditions such as Hirschsprung disease, anorectal malformations, or severe chronic constipation, outcomes are best when managed within a multidisciplinary colorectal program. By working together across specialties, we help these children not just move their bowels but move forward in their lives. Before I close, I want to give a big thank you to my colorectal team for their dedication, collaboration and compassion in caring for these children and their families every single day. This work truly takes a team, and I'm grateful to be part of one of the teams that never stops striving and make life better for our patients. Thank you. Created by Presenters Elke M. Zani-Ruttenstock, MD Pediatric Surgery View full profile
