What You Need to Know About Surgical Treatment for Children With Functional Constipation

Pediatric surgeons are often consulted by pediatricians, emergency physicians or pediatric gastroenterologists to assist treating children with severe cases of constipation, fecal impaction and fecal incontinence. Pediatric surgeons perform the following procedures that help improve these conditions:

• Antegrade continence enema (ACE) procedure, also called a Malone appendicostomy
• Cecostomy
• Neo-appendicostomy
• Colon resection

An antegrade continence enema (ACE) procedure, also known as a Malone procedure, is a surgical procedure that involves constructing a tube from the appendix through the belly button through which an enema can be given.  This provides an alternative route for the enema, and can more easily be performed by the patient, promoting their independence.

This operation is usually recommended for patients who are capable of being more independent, as it allows the administration of the enema without parental assistance. It should ideally be performed in patients for whom bowel management has been successful. However, for children who cannot tolerate rectal enemas, this procedure is also beneficial as a bridge to continence, enabling the training of the sphincter muscles while the patient tries to hold onto the flush. 

Malone Appendicostomy Procedure:

In patients in whom both a Malone appendicostomy and a similar tube construction for the bladder and urinary system are needed, there are various strategies that may be employed to share the appendix, which depends on whether the appendix is a certain length: 

In cases where there is no appendix, creating a tube from a flap of the intestine is an option to make a “new” appendix. A triangular skin flap is created at the umbilical site (as in the Malone procedure). The procedure produces basically the same result as a Malone appendicostomy.

In a cecostomy, the healthcare provider puts a tube (catheter) into the large intestines (cecum) located in the lower right abdomen, also for access to place an enema used to empty the colon. 

Sometimes “skin-level” devices which are soft, flexible, non-latex tubes, similar to a gastrostomy feeding tube are used. These tubes may be placed through the abdominal wall directly into the cecum using minimally invasive techniques. The benefits of a skin-level device include the avoidance of daily catheterization and elimination of certain risks. This option is ideal for children with sensory processing disorders in whom intermittent catherization is impractical.

In cases in which a child requires long-term bowel management and the colon is difficult to empty, a segmental colon resection may be performed to reduce either their daily laxative intake or the needed daily enema volume. It is recommended to perform a colon resection in children only after they have had a thorough motility assessment. The procedure does not cure the constipation, but rather will assist in subsequent bowel management, making it easier to empty the colon, either by laxatives or flushes.

Bowel management is considered successful when a child can wear normal underwear and stay totally clean for 24 hours. This is achievable in the majority of children with anorectal malformations, Hirschsprung's disease or severe functional constipation.  

Regardless of the underlying disorder, bowel management plans often require modification over time. Careful follow-up is a key component to a successful program. Specialists caring for children with severe constipation or fecal incontinence must be committed to finding the right program that works for the individual.