Efficacy of Non-pharmacologic Auxiliary Treatments in Improving Defecation Function in Children With Chronic Idiopathic Constipation: A Systematic Review and Network Meta-analysis

Background: Non-pharmacologic auxiliary treatments have been considered crucial therapies for treating chronic idiopathic constipation (CIC) during the past decades worldwide. Several treatment patterns are available, but their relative efficacy is obscure because there are no head-to-head randomized controlled trials, especially in children. We conducted this network meta-analysis to evalute the effectiveness of these therapies in improving defecation function based on their direct comparisons with standard medical care.Methods: Medline, Embase, and Cochrane Central were searched for randomized controlled trials (RCTs) published in English from inception to October 2020, assessing the efficacy of auxiliary therapies (behavior therapy, physiotherapy, biofeedback, or anorectal manometry) in children with CIC. We extracted data for endpoints, risk of bias, and evidence quality. Eligible studies in the meta-analysis reported the data of a dichotomous assessment of overall response to treatment (response or not) or defecation frequency per week after treatment. The hierarchical Bayesian network meta-analysis was used in the study. We chose a conservative methodology, random effects model, to pool data which could handle the heterogeneity well. The relative risk (RR) with 95% confidence intervals (CIs) was calculated for dichotomous outcomes. For continuous results, weighted mean difference (WMD) with related CIs was calculated. The included treatments were ranked to define the probability of being the best treatment.Results: Seven RCTs (838 patients) met inclusion and endpoint criteria. Based on an endpoint of the absence of constipation (Rome criteria) with laxatives allowed, physiotherapy plus standard medical care (SMC) had the highest probability (84%) to bethe most effective therapy. When the treatment response was defined as an absence of constipation with not laxatives allowed, biofeedback plus SMC ranked first (probability 52%). Physiotherapy plus SMC ranked first when the endpoint was based on defecation frequency per week with laxatives allowed (probability 86%).Conclusion: Almost all auxiliary therapies are effective complementary therapies for treating CIC, but they needed to be used simultaneously with SMC. Nevertheless, because of the small number of eligible studies and their small sample sizes, the differences in treatment duration and the endpoints, large sample RCTs with long-term follow-up are required for further investigation.

Perineal Fistula With High Dilated Colon: One of a Special Type of Anorectal Malformations

Background The perineal fistula with high dilated colon is a rare anomalous in the spectrum of anorectal malformations. The aim of this study is to explore the diagnosis and treatment of this special type of perineal fistula (SPF), and to avoid the severe consequence due to misdiagnosis.Methods From March 2012 to January 2019, 7 patients who suffered from perineal fistula with high dilated colon were retrospectively reviewed. Three were operated on primarily by our department, and 4 cases were re-operated after a perineal anoplasty repair performed elsewhere. Four were operated by laparoscopic anorectoplasty (LARP), and 3 cases were repaired by posterior sagittal anorectoplasty (PSARP). The follow-up outcomes were compared with 71 cases of normal perineal fistula (NPF) in the same period.Results 7 cases have been followed up for 0.5-4 years (M=2.57±1.26) after definitive surgery. Their bowel function score (BFS) was lower than normal perineal fistula (SPF=12, rang:5-18; NPF=18.5, rang:18-20). Four cases underwent anorectomanometry. The incidence of rectoanal inhibitory reflex (RAIR) was lower in the special type group. (p=0.14). Three cases of barium enema angiography: 2 cases of colorectal dilatation and thickening changes, 1 case showed no obvious abnormalities.Conclusions Anorectal perineal fistula should be examined by distal colostogram at preoperation. Select appropriate surgical approach is essential for children’s defecation function, and blind surgery can seriously affect long-term defecation function.

Application of laparoscopic total mesorectal excision combined with sphincter-preserving surgery in low or ultralow rectal cancer

This study aimed to investigate the influence of laparoscopic total mesorectal excision combined with sphincter-preserving surgery on the postoperative defecation function, urinary function and sexual function in low or ultralow rectal cancer. A retrospective study was undertaken on 107 patients (65 laparoscopic resection and 42 laparoctomic resection) with rectal cancer undergoing laparoscopic or open laparoscopic total mesorectal excision combined with sphincter-preserving surgery from April 2009 to April 2013. The quality of life outcomes of all patients, including defection, urinary and sexual function, were assessed at 6, 12 and 24 months after operation. Gastrointestinal quality of life index (GQOLI) was used to evaluate the fecal incontinence and bowel dysfunction. Urinary and sexual functions were studied by means of questionnaires on the basis of the international prostatic symptom score (IPSS) and international index of erectile function (IIEF), respectively. In laparoscopic surgery group, there were two cases of anastomotic leakage, three cases of anastomotic stricture, seven cases of local recurrence, ten cases of hepatic metastasis and five cases of lung metastasis. The satisfaction rates of patients about their defecation function reached 60.3% (35/58, 84.5% (49/58) and 91.3% (53/58) at 6, 12, and 24 months follow-up, respectively. The assessment after one year showed that the overall incidence of urinary dysfunction was 10.7% (7/65); Among male patients, 18.4% (7/36) suffered from erectile dysfunction and 27.8% (10/36) suffered from ejaculatory dysfunction; 65.5% (19/29) female patients investigated were satisfied with their postoperative sexual life. In open surgery group, there were two cases of anastomotic leakage, two cases of anastomotic stricture, nine cases of local recurrence, ten cases of hepatic metastasis and seven cases of lung metastasis. The satisfaction rates of patients about their defecation function were 56.4% (22/39), 82.1% (32/39) and 94.8% (37/39) at 6, 12, and 24 months follow-up, respectively. The assessment after one year showed that the overall incidence of urinary dysfunction was 11.9% (5/42); 25% (4/16) male patients suffered from erectile dysfunction and 31.3% (5/16) suffered from ejaculatory dysfunction; 69.2% (19/26) female patients investigated were satisfied of their postoperative sexual life. There was no statistic difference in the two groups. Laparoscopic total mesorectal excision combined with sphincter-preserving surgery in low or ultralow rectal carcinoma is safe and practicable. It can be helpful for enhancing the probability of anus reservation, and obtains satisfactory defecation, sexual and urinary functions.

MULTIDISCIPLINARY APPROACH TO CHRONIC CONSTIPATION ASSOCIATED WITH FECAL INCONTINENCE IN CHILDREN

Constipation is a common symptom in clinical practice. Definition include abnormal transit difficulty during defecation and abnormal stool consistency. Limited diagnostic methods and the many diseases that lead to symptoms, leading to more cases of drug resistance. Treatment includes dietary and behavioral approaches, pharmacological therapy and surgery in carefully selected cases. Surgery is recommended in patients with severe constipation resistant to conservative treatment. Confirmation of indication for surgical treatment requires colonic transit studies, defecation function and conducting anorectal manometry. Therefore, a close collaboration between pediatric gastroenterologists and surgeon pediatricians is essential for the careful preoperative evaluation and gastrointestinal function. Postoperative complications include intestinal obstruction, abdominal pain, flatulence and diarrhea. The effectiveness of surgery and prevalence of postoperative complications are determined by a careful preoperative evaluation of the gastrointestinal function.