Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
J Pediatr Surg. 2010 Jan;45(1):213-9; discussion 219. doi: 10.1016/j.jpedsurg.2009.10.034.
Intractable constipation in children is an uncommon but debilitating condition. When medical therapy fails, surgery is warranted; but the optimal surgical approach has not been clearly defined. We reviewed our experience with operative management of intractable constipation to identify predictors of success and to compare outcomes after 3 surgical approaches: antegrade continence enema (ACE), enteral diversion, and primary resection.
A retrospective review of pediatric patients undergoing ACE, diversion, or resection for intractable, idiopathic constipation from 1994 to 2007 was performed. Satisfactory outcome was defined as minimal fecal soiling and passage of stool at least every other day (ACE, resection) or functional enterostomy without abdominal distension (diversion).
Forty-four patients (range = 1-26 years, mean = 9 years) were included. Sixteen patients underwent ACE, 19 underwent primary diversion (5 ileostomy, 14 colostomy), and 9 had primary colonic resections. Satisfactory outcomes were achieved in 63%, 95%, and 22%, respectively. Of the 19 patients diverted, 14 had intestinal continuity reestablished at a mean of 27 months postdiversion, with all of these having a satisfactory outcome at an average follow-up of 56 months. Five patients underwent closure of the enterostomy without resection, whereas the remainder underwent resection of dysmotile colon based on preoperative colonic manometry studies. Of those undergoing ACE procedures, age younger than 12 years was a predictor of success, whereas preoperative colonic manometry was not predictive of outcome. Second manometry 1 year post-ACE showed improvement in all patients tested. On retrospective review, patient noncompliance contributed to ACE failure.
Antegrade continence enema and enteral diversion are very effective initial procedures in the management of intractable constipation. Greater than 90% of diverted patients have an excellent outcome after the eventual restoration of intestinal continuity. Colon resection should not be offered as initial therapy, as it is associated with nearly 80% failure rate and the frequent need for additional surgery.
儿童难治性便秘是一种不常见但使人虚弱的疾病。当药物治疗无效时，需要手术治疗；但最佳手术方法尚未明确。我们回顾了我们治疗难治性便秘的手术经验，以确定手术成功的预测因素，并比较 3 种手术方法（顺行灌肠、肠内分流和结肠切除术）的结果。
对 1994 年至 2007 年期间因难治性特发性便秘接受顺行灌肠、分流或切除手术的儿科患者进行回顾性研究。满意的结果定义为粪便污染最少，排便至少每两天一次（顺行灌肠、结肠切除术）或功能性肠造口术而无腹胀（分流术）。
共纳入 44 例患者（年龄 1-26 岁，平均 9 岁）。16 例行顺行灌肠，19 例行原发性分流术（5 例回肠造口术，14 例结肠造口术），9 例行结肠切除术。分别有 63%、95%和 22%的患者获得满意的结果。在分流的 19 例患者中，14 例在分流后平均 27 个月重建肠道连续性，所有患者在平均 56 个月的随访中均获得满意的结果。5 例患者未行结肠切除术而行肠造口关闭术，其余患者则根据术前结肠测压研究行动力性结肠切除术。在接受顺行灌肠术的患者中，年龄小于 12 岁是成功的预测因素，而术前结肠测压术不能预测结果。在顺行灌肠后 1 年进行第二次测压时，所有接受测试的患者均显示出改善。回顾性分析发现，患者不依从是导致顺行灌肠术失败的原因。
顺行灌肠和肠内分流术是治疗难治性便秘的非常有效的初始治疗方法。超过 90%的分流患者在最终恢复肠道连续性后获得良好的结果。结肠切除术不应作为初始治疗方法，因为其失败率接近 80%，且经常需要额外的手术。
