• Sotirios Siminas and Paul D Losty.
• *Department of Paediatric Surgery, Royal Manchester Children's Hospital, Manchester, UK †Department of Academic Paediatric Surgery, Institute of Child Health, University of Liverpool, Liverpool, UK ‡Department of Paediatric Surgery, Alder Hey Children's Hospital NHS Foundation Trust, Eaton Road, Liverpool, UK.
• Ann. Surg. 2015 Dec 1;262(6):925-33.

ObjectiveSurgery for pediatric idiopathic constipation (IC) is undertaken after failure of bowel management programs. Decisions are influenced by rectal biopsy, transit studies, megacolon/megarectum, degree of soiling/incontinence, and anorectal manometry profile(s). A systematic review of ALL published studies critically evaluates outcomes of surgery for IC.MethodsMEDLINE (PubMed), Google Scholar, and EMBase were searched for English-language articles only. Studies included (1) peer-review publications with 3 or more patients, and (2) clinical outcomes defined by authors.ResultsForty-five reports (1157 patients) met full inclusion criteria. Only 2 papers were randomized controlled trials. Many had small patient numbers (median n = 16; range: 3-114). Twenty-three described heterogenous populations with variant pathology. Follow-up was short (median = 1.5 years: range: 3 months-14 years). The antegrade continence enema operation (ACE)-[open/laparoscopic assisted, cecostomy, or "left sided" ACE]-was judged as successful in 82% of cases, although high morbidity and reoperations were reported. Colon resection and pull through operations had "good" outcome(s) in 79% of children with 17% reporting significant morbidity and a 10% incidence of revisional surgery. Anal dilatation did not improve outcome(s). Botulinum toxin injection scored equally effective compared to internal sphincter myectomy in short-term follow-up. Permanent colostomy was considered successful in 86% of refractory IC cases.ConclusionsSurgical management and outcome(s) for pediatric IC are based on low-quality evidence. No single operation was considered "best practice." This study crucially highlights that surgeons must develop better care strategies.

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