Multi-disciplinary collaboration key in any approach to refractory functional constipation
For the last several years, the physicians, advance practice providers, and nurses within the Division of Colorectal and Pelvic Reconstruction at Children’s National Hospital have sought to establish standardized protocols for diagnosing and treating children with severe constipation unresponsive to medical management. Their work seeks to create a collaborative approach that brings gastroenterologists with motility expertise and colorectal surgeons together from the start to streamline testing, analysis, and to avoid unnecessary surgical procedures.
To that end, the team has published several studies that make the case for such a protocol based on their experiences managing this unique population.
What it means
In a 2022 study, the team conducted a retrospective review of children referred for retractable functional constipation to the Division of Colorectal and Pelvic Reconstruction at Children’s National. A unique algorithm for assessment and treatment was created based on the data analysis.
The resulting proposed protocol for medically refractory constipation provided a collaborative framework to standardize the work-up and treatment. This protocol led to the use of antegrade flushes via appendicostomy to empty the colon and was able to in most cases avoid a colonic resection, something done much more commonly in the past
A 2023 study further reiterated the importance of these collaborative approaches, stating, “It is vitally important to recognize that constipation exists on a spectrum of severity with multiple potential etiologic factors and therefore treatment must be customized based on the individual’s symptom, anatomic and manometric findings.”
The 2023 study also introduced an enhanced standardized algorithm to evaluate and treat refractory constipation, with the central idea being a consolidation of evaluation and initiation of treatment into a single combined procedure. This means collaboration between gastroenterology and colorectal surgery in the operating room by including anorectal manometry at the start to rule out anatomic anomalies as the cause of the constipation and to test motility.
Why it matters
In the 2023 study, the authors wrote, “While algorithms for initial evaluation and treatment of functional constipation in children have been described, most articles in the pediatric literature lack details about the work-up and management of those refractory symptoms and the approaches described for such patients vary widely among clinicians.”
That means that children with functional constipation for whom medical treatment has failed face a drastically lower quality of life. Functional constipation and encopresis, or stool soiling, correlates with a higher prevalence of low self-esteem, social withdrawal, and depression. It is critical to correctly diagnose and efficiently treat these conditions and work together to do it quickly.
Children’s National leads the way
As one of the nation’s leaders in pediatric colorectal and pelvic reconstructive surgery, Children’s National, led by Division Chief Marc Levitt, M.D., receives more referrals asking for a surgical solution for severe pediatric constipation than any other center in the world.
Caring for such a large population positions the team to analyze evidence and establish protocols based on statistically relevant numbers of patients. The studies outlined above are the result of the innovative design of the Division of Colorectal and Pelvic Reconstruction, in which multiple divisions involved in the care of these patients, from Gastroenterology to Urology and beyond, experience an unprecedented ability to work together, including in the operating room. It is a fully integrated program with experts in colorectal surgery, GI motility, and colorectal nursing embedded into the same team.
While most children with functional constipation will respond to medical treatment, for those who need further help that includes surgical assessments, the evidence-based algorithms developed in these studies can truly be life-changing for these children and their families.
Read the studies in the Journal of Pediatric Surgery:
